Ocular Neovascular Conversion and Systemic Bleeding Complications in Patients with Age-Related Macular Degeneration on Anticoagulants.

PURPOSE: Conversion to neovascular disease in patients with non-neovascular age-related macular degeneration (AMD) initiated on direct oral anticoagulants (DOACs) compared with matched patients treated with warfarin. DESIGN: Retrospective cohort study. PARTICIPANTS: The study included 20 300 patients and 13 387 patients with non-neovascular AMD initiated on DOACs or warfarin, respectively, before propensity score matching (PSM). METHODS: TriNetX was used to identify patients diagnosed with non-neovascular AMD stratified by treatment with DOACs or warfarin with at least 6 months of follow-up. Propensity score matching was performed to control for baseline demographics and medical comorbidities. MAIN OUTCOME MEASURES: Relative risk (RR) of developing neovascular AMD, macular hemorrhage (MH), vitreous hemorrhage (VH), and requiring an ocular intervention (intravitreal anti-VEGF therapy or pars plana vitrectomy [PPV]) within 6 months and 1 year. Patients with chronic atrial fibrillation (AF) on anticoagulation were separately evaluated for the same measures within 5 years after initiating therapy. RESULTS: Treatment with warfarin was associated with a higher risk of developing neovascular AMD at 6 months (RR, 1.24, 95% confidence interval [CI], 1.12-1.39; P < 0.001) and 1 year (RR, 1.26, 95% CI, 1.14-1.40; P < 0.001) when compared with matched patients treated with DOACs. There was an increased risk of requiring intravitreal anti-VEGF therapy (6 months: RR, 1.30; 95% CI, 1.13-1.49; P < 0.001; 1 year: RR, 1.31, 95% CI, 0.72-2.05; P < 0.001) and PPV (6 months: RR, 2.13; 95% CI, 1.16-3.94; P = 0.01; 1 year: RR, 2.29, 95% CI, 1.30-4.05; P = 0.003). Among patients with AMD and AF treated with warfarin, there was an increased risk of ocular complications (neovascular AMD: RR, 1.25; 95% CI, 1.14-1.38; P < 0.001; MH: RR, 1.86; 95% CI, 1.47-2.35; P < 0.001; VH: RR, 2.22; 95% CI, 1.51-3.26; P < 0.001) and need for intravitreal anti-VEGF therapy (RR, 1.34; 95% CI, 1.18-1.52; P < 0.001) over an extended 5-year period. There was no significant difference in the development of major systemic hemorrhagic events between the 2 cohorts over 5 years. CONCLUSIONS: Patients with non-neovascular AMD treated with warfarin were more likely to develop neovascular disease and require ocular intervention for hemorrhagic complications when compared with matched patients initiated on DOACs. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Comparative Effects of GLP-1 Receptor Agonists and Metformin on Glaucoma Risk in Type 2 Diabetes Patients.

PURPOSE: To compare effects of glucagon-like peptide-1 (GLP-1) receptor agonists and metformin on the risk of primary open-angle glaucoma (POAG), ocular hypertension, and the need for first-line glaucoma treatments in patients with type 2 diabetes. DESIGN: A retrospective cohort study was conducted using electronic medical records (EMR) data from the from an international electronic health record network, covering a period from May 2006 to May 2024. PARTICIPANTS: Patients diagnosed with type 2 diabetes mellitus (T2DM) who were treated with either GLP-1 receptor agonists or metformin. METHODS: Data from 120 healthcare organizations across 17 countries were analyzed. Patient outcomes were assessed at 1, 2, and 3 years. Propensity score matching (PSM) was used to balance covariates such as demographics, comorbidities, and medication usage. Risk ratios (RR) with 95% confidence intervals (CI) were calculated. MAIN OUTCOME MEASURES: Incidence of POAG, ocular hypertension, and the need for first-line treatments including beta-blockers, prostaglandin analogues, brimonidine, brinzolamide, dorzolamide, netarsudil, and laser trabeculoplasty. RESULTS: After PSM, both groups included 61,998 patients at the 1-year follow-up, 27,414 at the 2-year follow-up, and 14,100 at the 3-year follow-up. Patients treated with GLP-1 receptor agonists had a significantly decreased risk of developing POAG compared to those on metformin at 1 year (RR 0.59, 95% CI 0.39-0.88), 2 years (RR 0.50, 95% CI 0.32-0.78), and 3 years (RR 0.59, 95% CI 0.37-0.94). Similar protective effects were observed for ocular hypertension with risk reductions of 56% at 1 year (RR 0.44, 95% CI 0.31-0.62), 57% at 2 years (RR 0.43, 95% CI 0.30-0.62), and 49% at 3 years (RR 0.51, 95% CI 0.34-0.75). The risk of first-line therapy initiation was also lower in the GLP-1 receptor agonists group at 1 year (RR 0.63, 95% CI 0.53-0.74), 2 years (RR 0.71, 95% CI 0.59-0.85), and 3 years (RR 0.75, 95% CI 0.62-0.91). CONCLUSIONS: GLP-1 receptor agonists are associated with a significantly lower incidence of POAG, ocular hypertension, and the need for first-line glaucoma treatments compared to metformin in patients with type 2 diabetes. These findings highlight the potential ocular benefits of GLP-1 receptor agonists and their expanding role in the clinical management of diabetic patients.

COMPREHENSIVE MOLECULAR PROFILING OF UVEAL MELANOMA EVALUATED WITH GENE EXPRESSION PROFILING, PREFERENTIALLY EXPRESSED ANTIGEN IN MELANOMA EXPRESSION, AND NEXT-GENERATION SEQUENCING.

PURPOSE: To determine the association between gene-expression profiling (GEP), next-generation sequencing (NGS), preferentially expressed antigen in melanoma (PRAME) features, and metastatic risk in patients with uveal melanoma (UM). METHODS: A retrospective analysis of patients with UM treated by brachytherapy or enucleation by a single ocular oncologist was conducted from November 2020 and July 2022. Clinicopathologic features, patient outcomes, GEP classification, NGS, and PRAME results were recorded. RESULTS: Comprehensive GEP, PRAME, and NGS testing was performed on 135 UMs. The presence of eukaryotic translation initiation factor 1A, X-chromosomal and splicing factor 3B subunit 1 mutations was significantly associated with GEP class 1A and GEP class 1B, respectively. The presence of BRCA- associated protein-1 mutation was significantly associated with GEP class 2. The average largest basal diameter for tumors with eukaryotic translation initiation factor 1A, X-chromosomal mutations was significantly smaller than those with splicing factor 3B subunit 1 mutations and BRCA1-associated protein-1 mutations. Class 2 tumors metastasized sooner than GEP class 1 tumors. Tumors with splicing factor 3B subunit 1 and/or BRCA1-associated protein-1 mutations metastasized sooner compared with tumors that had either no driver mutation or no mutations at all. Tumors with splicing factor 3B subunit 1 did not have a significantly different time to metastasis compared with tumors with BRCA1-associated protein-1 (P value = 0.97). Forty tumors (30%) were PRAME positive, and the remaining 95 tumors (70%) were PRAME negative. Tumors with PRAME-positive status did not have a significantly different time to metastasis compared with tumors without PRAME-positive status (P value = 0.11). CONCLUSION: GEP, NGS, and PRAME expression analysis help determine different levels of metastatic risk in UM. Although other prognostic tests exist, the following study reports on the use of NGS for metastatic prognostication in UM. However, limitations of NGS exist, especially with small lesions that are technically difficult to biopsy.

Incidence of Tether Breakage in Anterior Vertebral Body Tethering.

BACKGROUND: Thoracic anterior vertebral body tethering (TAVBT) is an emerging treatment for adolescent idiopathic scoliosis. Tether breakage is a known complication of TAVBT with incompletely known incidence. We aim to define the incidence of tether breakage in patients with adolescent idiopathic scoliosis who undergo TAVBT. The incidence of tether breakage in TAVBT is hypothesized to be high and increase with time postoperatively. METHODS: All patients with right-sided, thoracic curves who underwent TAVBT with at least 2 and up to 3 years of radiographic follow-up were included. Tether breakage between 2 vertebrae was defined a priori as any increase in adjacent screw angle >5 degrees from the minimum over the follow-up period. The presence and timing of tether breakage were noted for each patient. A Kaplan-Meier survival analysis was performed to calculate expected tether breakage up to 36 months. χ 2 analysis was performed to examine the relationship between tether breakage and reoperations. Independent t test was used to compare the average final Cobb angle between cohorts. RESULTS: In total, 208 patients from 10 centers were included in our review. Radiographically identified tether breakage occurred in 75 patients (36%). The initial break occurred at or beyond 24 months in 66 patients (88%). Kaplan-Meier survival analysis estimated the cumulative rate of expected tether breakage to be 19% at 24 months, increasing to 50% at 36 months. Twenty-one patients (28%) with a radiographically identified tether breakage went on to require reoperation, with 9 patients (12%) requiring conversion to posterior spinal fusion. Patients with a radiographically identified tether breakage went on to require conversion to posterior spinal fusion more often than those patients without identified tether breakage (12% vs. 2%; P =0.004). The average major coronal curve angle at final follow-up was significantly larger for patients with radiographically identified tether breakage than for those without tether breakage (31 deg±12 deg vs. 26 deg±12 deg; P =0.002). CONCLUSIONS: The incidence of tether breakage in TAVBT is high, and it is expected to occur in 50% of patients by 36 months postoperatively. LEVEL OF EVIDENCE: Level IV.

Atypical Haemorrhagic Presentation of Neuro-Retinitis and Serous Retinal Detachment Secondary to Cat-Scratch Disease.

Cat-scratch disease (CSD) is a self-limited disease caused by Bartonella henselae, a fastidious gram-negative intracellular bacillus bacterium. Neuroretinitis, a form of optic neuropathy characterised clinically by optic disc swelling and a macular star, is an uncommon manifestation of CSD occurring in approximately 1-2% of cases. We report a case of a 14-year-old female who presented to the emergency department with a chief complaint of acute painless vision loss described as a large black spot in the centre of her right eye vision 2 weeks after being scratched by cats. Fundus examination revealed Frisen grade 5 disc oedema with an atypically diffuse disc and peripapillary haemorrhages with associated subretinal fluid and a macular star in the right eye. Optical coherence tomography (OCT) of the macula and retinal nerve fibre layer showed subretinal fluid involving the fovea, a serous retinal detachment of the nasal macula, and significant optic disc oedema in the right eye. The patient was admitted and treated with doxycycline, rifampin, and prednisone taper. After completing the treatment course, the patient's vision improved, fundus examination showed significantly improved disc oedema and haemorrhages, and OCT demonstrated resolution of the subretinal fluid in the right eye.

Isolation of Pseudomonas syringae pv. Tomato strains causing bacterial speck disease of tomato and marker-based monitoring for their virulence.

BACKGROUND: The bacterial speck disease of tomato caused by a bacterial pathogen Pseudomonas syringae pv. tomato is a most important disease causing severe crop losses. METHODS AND RESULTS: Present study was conducted to investigate and characterize the population diversity of P. syringae pv. tomato pathogen isolated from infected tomato plants from various regions of Egypt. Significant variation among the isolates was observed which demonstrated considerable virulence. All isolates were pathogenic and the CFU population recovered from inoculate tomato leaves by isolate Pst-2 was higher than other isolates. Genetic disparity among the isolates was investigated by PCR analysis by amplifying hrpZ gene using random amplified polymorphic DNA (RAPD), sequence-related amplified polymorphism (SRAP), and inter-simple sequence repeats (ISSR) markers. The amplified products for ITS1 were found to have 810 bp length whereas 536 bp length was observed for hrpZ gene using primer pairs (1406-f/23S-r) and (MM5-F, MM5-R) respectively. The restriction analysis of amplified regions "ITS" and hrpZ by using 5 and 4 endonucleases respectively demonstrated slight variation among the bacterial isolates. The results of RAPD, ISSR and SRAP showed higher polymorphism (60.52%) within the isolates which may assist for successful characterization by unique and specific markers based on geographical distribution, origin and virulence intensity. CONCLUSION: The results of present study suggested that the use of molecular approach may provide successful and valuable information to differentiate and classify P. syringae pv. tomato strains in future for the detection and confirmation of pathogenicity.

Do drains help reduce the risk of complications after thoracoplasties in posterior spinal fusions for adolescent idiopathic scoliosis?

PURPOSE: In adolescent idiopathic scoliosis (AIS), the rib prominence is a major cosmetic concern which can be improved using thoracoplasties. We sought to determine if the use of deep drains helps minimize the development of pleural effusions after thoracoplasties. METHODS: Retrospective study of 45 patients with AIS undergoing posterior spinal fusion (PSF) and thoracoplasties. RESULTS: Thirty six out of 45 patients (80.0%) required placement of a deep surgical drain, and 16 out of 45 (35.6%) developed pleural effusions after PSF with concomitant thoracoplasty. Of the 16 patients who developed pleural effusion, 12 of 36 (33.3%) required a placement of a deep drain (p > 0.05). Of the total 45 patients in this cohort, 3 patients (6.7%) required chest tubes, and 4 patients (8.9%) developed surgical site infections (SSIs). We found that deep drains were associated with a lower incidence of SSI (2.8% vs 33.3%; p = 0.021). Patients who had a pleural effusion had longer ICU stays (p = 0.037) and longer requirements of nasal oxygen (p = 0.025). DISCUSSION: The presence of a pleural effusion in patients with AIS undergoing PSF with thoracoplasty was associated with longer oxygen requirements and length of hospital ICU admission. Thirty six percent of patients with thoracoplasties developed pleural effusions, but deep subfascial drains did not significantly decrease the incidence of pleural effusions.

Risk factors for proximal junctional kyphosis after pediatric spinal deformity surgery with halo gravity traction.

PURPOSE: To determine risk factors for proximal junctional kyphosis (PJK) in pediatric patients with scoliosis undergoing halo gravity traction (HGT) prior to posterior spinal fusion (PSF). METHODS: Data from consecutive patients who underwent PSF after HGT with 2-year follow-up were retrospectively collected from a single center. Patients were divided into two groups: PJK vs. no PJK. RESULTS: Twenty-five patients (age 13.6 ± 3.1 years) underwent HGT for a mean of 42 ± 37 days. Eight patients (32%) developed radiographic PJK and 1 (4%) developed proximal junctional failure. PJK patients had greater loss of cervical lordosis (-17.4 ± 23.2 vs. 2.7 ± 16.2°, p < 0.05), greater increase in lumbar lordosis (9.3 ± 19.5 vs. -2.8 ± 12.8°; p = 0.034) during traction, and smaller overall major coronal curve angle correction (-16.8 ± 30.6 vs. -36.6 ± 16.4°; p = 0.026). From postoperative to last follow-up, PJK patients had a greater increase in upper end vertebrae (UEV) slope (3.3 ± 7.8 vs. -4.0 ± 7.7°; p = 0.004). Selection of UIV based on which vertebra was most level either pre-traction or in-traction was not associated with PJK development (p > 0.05). CONCLUSION: In-traction radiographic changes of decreased cervical lordosis, decreased major coronal curve, increased lumbar lordosis, and disruption of cervical sagittal balance at last follow-up may have implications for level selection and risk of PJK.

Efficacy of Care and Antibiotic Use for Chalazia and Hordeola.

OBJECTIVES: To evaluate whether use of an antibiotic improves the efficacy of care for a chalazion or hordeolum. METHODS: A cross-sectional retrospective review was performed. All patients treated for a newly diagnosed chalazion or hordeolum at the University of California, San Francisco from 2012 to 2018 were identified. Patients were excluded when clinical notes were inaccessible or there was inadequate documentation of treatment modality or outcome. Patient demographics, setting of initial presentation, treatment modalities, antibiotic use, and outcomes were analyzed. RESULTS: A total of 2,712 patients met inclusion criteria. Management with an antibiotic was observed in 36.5% of patients. An antibiotic was 1.53 times (95% confidence interval [CI], 1.06-2.22, P=0.025) more likely to be prescribed in emergency or acute care setting for a chalazion. Older age was associated with a higher risk of receiving an antibiotic for a hordeolum (adjusted RR 1.07 per decade, 95% CI, 1.05-1.11, P<0.001). The addition of an antibiotic to conservative measures for a chalazion (adjusted RR, 0.97, 95% CI, 0.89-1.04, P=0.393) or hordeolum (adjusted RR, 0.99, 95% CI, 0.96-1.02, P=0.489) was not associated with an increased likelihood of treatment success. CONCLUSION: Although frequently prescribed, an antibiotic is unlikely to improve the resolution of a chalazion or hordeolum.

Vertebral Body Tethering: Rationale, Results, and Revision.

Vertebral body tethering is a nonfusion technique for the surgical correction of adolescent idiopathic scoliosis. For skeletally immature patients for whom vertebral body tethering is indicated, it is an alternative option to the gold standard posterior spinal fusion (PSF) and may at least partially preserve motion in instrumented segments of the spine. Benefits of the procedure include the possibility of avoiding the long-term sequelae of PSF such as adjacent segment disease and proximal junctional kyphosis. Recent retrospective case series of vertebral body tethering have shown promising results with correction rates up to 70% but greater variability in outcomes compared with PSF. The complication profile of the procedure also appears to differ from PSF with tether breakage and overcorrection as primary concerns in addition to approach-related complications. Although early outcomes have been promising, additional studies to optimize surgical timing, long-term outcomes, and the possible role of tethering in the more skeletally mature patient are required.

Posterior-only Resection of Single Hemivertebrae With 2-Level Versus >2-Level Fusion: Can We Improve Outcomes?

BACKGROUND: The outcomes of congenital scoliosis (CS) patients undergoing hemivertebra (HV) resection surgery with a 2-level fusion versus a >2-level fusion are unclear. We hypothesized that CS patients undergoing HV resection and a >2-level fusion have decreased curve progression and reoperation rates compared with 2-level fusions. METHODS: Retrospective review of prospectively collected data from a multicenter scoliosis database. Fifty-three CS patients (average age 4.5, range 1.2 to 10.9 y) at index surgery were included. Radiographic and surgical parameters, complications, as well as revision surgery rates were tracked at a minimum of 2-year follow-up. RESULTS: Twenty-six patients had a 2-level fusion while 27 patients had a >2-level fusion with similar age and body mass index between groups. The HV was located in the lumbar spine for 69% (18/26) 2-level fusions and 30% (8/27) >2-level fusions ( P =0.006). Segmental HV scoliosis curve was smaller in 2-level fusions compared to >2-level fusions preoperatively (38 vs. 50 degrees, P =0.016) and at follow-up (25 vs. 34 degrees, P =0.038). Preoperative T2-T12 (28 vs. 41 degrees, P =0.013) and segmental kyphosis (11 vs. 23 degrees, P =0.046) were smaller in 2-level fusions, but did not differ significantly at postoperative follow-up (32 vs. 39 degrees, P =0.22; 13 vs. 11 degrees, P =0.64, respectively). Furthermore, the 2 groups did not significantly differ in terms of surgical complications (27% vs. 22%, P =0.69; 2-level fusion vs. >2-level fusion, respectively), unplanned revision surgery rate (23% vs. 22%, 0.94), growing rod placement or extension of spinal fusion (15% vs. 15%, P =0.95), or health-related quality of life per the EOS-Questionnaire 24 (EOSQ-24). Comparison of patients with or without the need for growing rod placement or posterior spinal fusion revealed no significant differences in all parameters analyzed. CONCLUSIONS: Two-level and >2-level fusions can control congenital curves successfully. No differences existed in curve correction, proximal junctional kyphosis or complications between short and long-level fusion after HV resection. Both short and long level fusions are viable options and generate similar risk of revision. The decision should be individualized by patient and surgeon.

Use of postoperative neurophysiological testing to help guide management in a case of delayed neurological injury.

Bimodal intraoperative neuromonitoring (IONM), combining transcranial motor-evoked potentials (tcMEP) and somatosensory-evoked potentials (SSEP), enables real-time detection and prevention of spinal cord injury during pediatric spinal deformity correction. Although rare, false-positive and false-negative signal alerts have been reported. However, no previously published accounts have described the use of postoperative neurophysiological testing to both identify new-onset neurological injury and guide reintervention. Here, we describe the case of an 18-year-old young man with achondroplasia, thoracolumbar kyphosis, and L2 wedge vertebra who underwent T12-L4 posterior spinal fusion with L2 vertebral column resection. Despite two intraoperative decreases in tcMEP amplitude, corrective measures on both occasions produced a return of IONM signal. Curiously, despite movement of the bilateral lower extremities upon waking, continued observation demonstrated minimal movement of the left lower extremity. Postoperative neurophysiological testing then identified limited muscle group activation below the left quadriceps, prompting operative reintervention. After cage removal and laminectomy lengthening, the patient recovered bilateral lower extremity function. He later returned to surgery for repeat cage placement at L2 via a retroperitoneal exposure, with no noted IONM changes and subsequent neurological improvement.

Crossing the cervicothoracic junction in complex pediatric deformity using anterior cervical discectomy and fusion: a case series.

PURPOSE: Proximal instrumentation failure is a challenge in posterior spinal fusions (PSFs) crossing the cervicothoracic junction. High rates of proximal junctional kyphosis (PJK) and loss of fixation have been reported. In this single-center retrospective cohort study, we evaluate the utility of anterior cervical discectomy and fusion (ACDF) in addition to traditional PSF crossing the cervicothoracic junction in order to mitigate implant-related complications. METHODS: All patients who underwent PSF across the cervicothoracic junction with ACDF with 2 years of follow-up data were reviewed. We analyzed clinical, surgical, and radiographic measures such as operative details, presence of PJK, complications, instrumentation migration, curve angles, and vertebral translation. Measurements were compared statistically using paired samples t-tests. RESULTS: Ten patients (6 girls, 4 boys) met inclusion criteria with a mean age at surgery of 12.8 ± 3.3 years and follow-up of 3.38 ± 0.9 years. All patients underwent ACDF (range 1-3 levels), and 8 (80%) underwent traction. The average number of levels fused posteriorly was 16.7 ± 4.7 and anteriorly was 2.4 ± 0.7. The major coronal curve averaged 48.8 ± 34.7° preoperatively and 23.3±13.3° postoperatively (p = 0.028). The average major sagittal curve was 83.5 ± 24.2° preoperatively, resolving to 53.9 ± 25.5° (p=0.001). One patient suffered rod breakage at T7, and another developed symptomatic PJK 19 months postoperatively. CONCLUSION: Our data suggest that ACDF procedures added to PSFs crossing the cervicothoracic junction offer promise for reducing risk for instrumentation-related complications. ACDF also significantly helps improve and maintain both coronal and sagittal correction over 2 years. LEVEL OF EVIDENCE: 4.

Congenital Scoliosis of the Pediatric Cervical Spine: Characterization of a 17-Patient Operative Cohort.

BACKGROUND: Congenital cervical scoliosis is rare, and there is a paucity of literature describing surgical outcomes. We report surgical outcomes in a 17-patient cohort with surgical correction for congenital cervical scoliosis and identify risk factors associated with complications. METHODS: Data were retrospectively collected from a single-center cohort of 17 consecutive patients (9 boys, 8 girls) receiving surgical deformity correction for congenital cervical scoliosis. The mean age at surgery was 7.1±3.4 years with an average follow-up of 3.6±1.1 years. RESULTS: There were 24 operations performed on 17 patients, and 4 complications (17%) were reported in the series, including one each of pressure ulcer, asystole, vertebral artery injury, and pseudarthrosis. The mean preoperative major curve angle was 36±20 degrees, which improved to 24±14 degrees (P=0.02). The mean operative time was 8±2 hours with a mean estimated blood loss of 298±690 mL. Halo-gravity traction was used in 5 patients and 6 cases were staged with anterior/posterior procedures. CONCLUSIONS: Congenital scoliosis of the cervical spine is a complex process. The spinal deformity of this nature can be managed successfully with carefully planned and executed surgical correction. LEVEL OF EVIDENCE: Level IV-retrospective review.

Preoperative SRS pain score is the primary predictor of postoperative pain after surgery for adolescent idiopathic scoliosis: an observational retrospective study of pain outcomes from a registry of 1744 patients with a mean follow-up of 3.4 years.

BACKGROUND: Traditionally, adolescent idiopathic scoliosis (AIS) has not been associated with back pain, but the increasing literature has linked varying factors between pain and AIS and suggested that it is likely underreported. PURPOSE: Our objective was to investigate factors associated with post-op pain in AIS. METHODS: A prospectively collected multicenter registry was retrospectively queried. Pediatric patients with AIS having undergone a fusion with at least 2 years of follow-up were divided into two groups: (1) patients with a postoperative SRS pain score ≤ 3 or patients having a reported complication specifically of pain, and (2) patients with no pain. Patients with other complications associated with pain were excluded. RESULTS: Of 1744 patients, 215 (12%) experienced back pain after postoperative recovery. A total of 1529 patients (88%) had no complaints of pain, and 171 patients (10%) had pain as a complication, with 44 (2%) having an SRS pain score ≤ 3. The mean time from date of surgery to the first complaint of back pain was 25.6 ± 21.6 months. In multivariate analysis, curve type (16% of Lenke 1 and 2 curves vs. 10% of Lenke 5 and 6, p = 0.002) and a low preoperative SRS pain score (no pain 4.15 ± 0.67 vs. pain 3.75 ± 0.79, p < 0.001) were significant. When comparing T2-4 as the upper instrumented vertebrae in a subgroup of Lenke 1 and 2 curves, 9% of patients had pain when fused to T2, 13% when fused to T3, and 18% when fused to T4 (p = 0.002). CONCLUSION: 12% of all AIS patients who underwent fusion had back pain after postoperative recovery. The most consistent predictive factor of increased postoperative pain across all curve types was a low preoperative SRS pain score. These slides can be retrieved under Electronic Supplementary Material.

Instrumented arthrodesis for non-traumatic craniocervical instability in very young children.

PURPOSE: Occipitocervical instrumentation is infrequently required for stabilization of the axial and subaxial cervical spine in very young children. However, when it is necessary, unique surgical considerations arise in children when compared with similar procedures in adults. METHODS: The authors reviewed literature describing fusion of the occipitocervical junction (OCJ) in toddlers and share their experience with eight cases of young children (age less than or equal to 4 years) receiving occiput to axial or subaxial spine instrumentation and fixation. Diagnoses and indications included severe or secondary Chiari malformation, skeletal dysplastic syndromes, Klippel-Feil syndrome, Pierre Robin syndrome, Gordon syndrome, hemivertebra and atlantal occipitalization, basilar impression, and iatrogenic causes. RESULTS: All patients underwent occipital bone to cervical spine instrumentation and fixation at different levels. Constructs extended from the occiput to C2 and T1 utilizing various permutations of titanium rods, autologous rib autografts, Mersilene sutures, and combinations of autografts with bone matrix materials. All patients were placed in rigid cervical bracing or halo fixation postoperatively. No postoperative neurological deficits or intraoperative vascular injuries occurred. CONCLUSION: Instrumented arthrodesis can be a treatment option in very young children to address the non-traumatic craniocervical instability while reducing the need for prolonged external halo vest immobilization. Factors affecting fusion are addressed with respect to preoperative, intraoperative, and postoperative decision-making that may be unique to the toddler population.

L3 translation predicts when L3 is not distal enough for an "ideal" result in Lenke 5 curves.

PURPOSE: Determining whether to fuse a Lenke 5 curve to L3 or to L4 is often a difficult decision. The purpose of this study was to determine preoperative variables predictive of an "ideal" or "less than ideal" outcome for Lenke 5 curves instrumented to L3. METHODS: A multicentre registry of adolescent idiopathic scoliosis patients was queried for surgically treated Lenke 5 curves with a lowest instrumented vertebra (LIV) of L3 and minimum 2 years of follow-up. Five seasoned surgeons qualitatively rated the 2-year postoperative images as "ideal" or "less than ideal" with respect to correction and alignment. Preoperative and postoperative radiographic variables were compared between the two groups. Multivariate regression analysis was performed to determine variables most predictive of a "less than ideal" outcome. RESULTS: One hundred and thirty-nine patients met criteria. Twenty-three were considered "less than ideal" by ≥ 3 surgeons; 81 were unanimously "ideal". Preoperatively, the "less than ideal" group had significantly stiffer curves, greater apical translation, and greater LIV angulation and translation. Multivariate regression found that preoperative L3 translation (p = 0.009) was the single most important predictor of a "less than ideal" outcome: < 3.5 cm consistently resulted in an "ideal" outcome, while > 3.5 cm risked a "less than ideal" result. CONCLUSION: While multiple variables are important in achieving an "ideal" outcome in Lenke 5 curves, this study found preoperative L3 translation was the most important predictor of success with an L3 translation < 3.5 cm being a potential threshold for selecting L3 as the LIV. These slides can be retrieved under Electronic Supplementary Material.

Systemic peptide-mediated oligonucleotide therapy improves long-term survival in spinal muscular atrophy.

The development of antisense oligonucleotide therapy is an important advance in the identification of corrective therapy for neuromuscular diseases, such as spinal muscular atrophy (SMA). Because of difficulties of delivering single-stranded oligonucleotides to the CNS, current approaches have been restricted to using invasive intrathecal single-stranded oligonucleotide delivery. Here, we report an advanced peptide-oligonucleotide, Pip6a-morpholino phosphorodiamidate oligomer (PMO), which demonstrates potent efficacy in both the CNS and peripheral tissues in severe SMA mice following systemic administration. SMA results from reduced levels of the ubiquitously expressed survival motor neuron (SMN) protein because of loss-of-function mutations in the SMN1 gene. Therapeutic splice-switching oligonucleotides (SSOs) modulate exon 7 splicing of the nearly identical SMN2 gene to generate functional SMN protein. Pip6a-PMO yields SMN expression at high efficiency in peripheral and CNS tissues, resulting in profound phenotypic correction at doses an order-of-magnitude lower than required by standard naked SSOs. Survival is dramatically extended from 12 d to a mean of 456 d, with improvement in neuromuscular junction morphology, down-regulation of transcripts related to programmed cell death in the spinal cord, and normalization of circulating insulin-like growth factor 1. The potent systemic efficacy of Pip6a-PMO, targeting both peripheral as well as CNS tissues, demonstrates the high clinical potential of peptide-PMO therapy for SMA.

Risk Factors for Wound Infections after Deformity Correction Surgery in Neuromuscular Scoliosis.

OBJECTIVE: This study aims to elucidate surgical risk factors in neuromuscular scoliosis (NMS) with respect to wound site infection after spinal fusion. METHODS: A retrospective review was performed of all patients treated surgically for NMS between January 2008 and December 2016 (minimum 6 months' follow-up). A sub-cohort of 60 patients with minimum 2 years of follow-up data was also analyzed. RESULTS: In 102 patients (53 boys and 49 girls), the mean age at surgery was 14.0 years (SD ±2.7). Mean follow-up was 2.53 years (±1.66), and mean time to presentation of infection was 2.14 months (±4.95). The overall perioperative complication rate was 26.5%, with 14.7% of patients developing deep wound infection. Gram-negative bacteria were responsible for 60% of infections; 20% were Gram positive, and 20% involved both types. Pulmonary comorbidities (p = 0.007), pre- to postoperative increase in weight (p = 0.010), exaggerated lumbar lordosis at follow-up (p = 0.008), history of seizures (p = 0.046), previous myelomeningocele repair (p = 0.046), and previous operations (p = 0.013) were significant risk factors for infection. CONCLUSION: Our data suggest that in the pediatric population treated surgically for NMS, wound infection is strongly associated with postoperative increase in body weight, residual lumbar lordosis, pulmonary comorbidity, history of myelomeningocele repair, seizures, and previous operations.