Complex Spine Surgery Research Articles

Utilizing Artificial Intelligence and Chat Generative Pretrained Transformer to Answer Questions About Clinical Scenarios in Neuroanesthesiology.

We tested the ability of chat generative pretrained transformer (ChatGPT), an artificial intelligence chatbot, to answer questions relevant to scenarios covered in 3 clinical guidelines, published by the Society for Neuroscience in Anesthesiology and Critical Care (SNACC), which has published management guidelines: endovascular treatment of stroke, perioperative stroke (Stroke), and care of patients undergoing complex spine surgery (Spine). Four neuroanesthesiologists independently assessed whether ChatGPT could apply 52 high-quality recommendations (HQRs) included in the 3 SNACC guidelines. HQRs were deemed present in the ChatGPT responses if noted by at least 3 of the 4 reviewers. Reviewers also identified incorrect references, potentially harmful recommendations, and whether ChatGPT cited the SNACC guidelines. The overall reviewer agreement for the presence of HQRs in the ChatGPT answers ranged from 0% to 100%. Only 4 of 52 (8%) HQRs were deemed present by at least 3 of the 4 reviewers after 5 generic questions, and 23 (44%) HQRs were deemed present after at least 1 additional targeted question. Potentially harmful recommendations were identified for each of the 3 clinical scenarios and ChatGPT failed to cite the SNACC guidelines. The ChatGPT answers were open to human interpretation regarding whether the responses included the HQRs. Though targeted questions resulted in the inclusion of more HQRs than generic questions, fewer than 50% of HQRs were noted even after targeted questions. This suggests that ChatGPT should not currently be considered a reliable source of information for clinical decision-making. Future iterations of ChatGPT may refine algorithms to improve its reliability as a source of clinical information.

Our C-Arm-Free Minimally Invasive Technique for Spinal Surgery: The Thoracolumbar and Lumbar Spine-Based on Our Experiences.

Background and Objectives: The implementation of intraoperative imaging in the procedures performed under the guidance of the same finds its history dating back to the early 1990s. This practice was abandoned due to many deficits and practicality. Later, fluoroscopy-dependent techniques were developed and have been used even in the present time, albeit with several disadvantages. With the recent advancement of several complex surgical techniques, which demand higher accuracy and are in conjunction with the existence of radiation exposure hazard, C-arm-free techniques were introduced. In this review study, we aim to demonstrate the various types of these techniques performed in our hospital. Materials and Methods: We have retrospectively analyzed and collected imaging data of C-arm-free, minimally invasive techniques performed in our hospital. The basic steps of the procedures are described, following with a discussion, along with the literature of findings, enlisting the merits and demerits. Results: MIS techniques of the thoracolumbar and lumbar spine that do not require the use of the C-arm can offer excellent results with high precision. However, several disadvantages may prevail in certain circumstances such as the navigation accuracy problem where in the possibility of perioperative complications comes a high morbidity rate. Conclusions: The accustomedness of performing these techniques requires a steep learning curve. The increase in accuracy and the decrease in radiation exposure in complex spinal surgery can overcome the burden hazards and can prove to be cost-effective.

Perioperative Management for Complex Spine Fusion Surgery.

Complex spine surgeries performed worldwide continue to increase in number, as do the age and comorbidity of patients undergoing these operations. Perioperative care protocols related to blood management, postoperative pain control, and intraoperative measures to mitigate morbidity may improve clinical workflows and patient outcomes.

Plastic surgeon closure is comparable to orthopedic closure when a perioperative optimization protocol is instituted for pediatric patients with neuromuscular scoliosis

Background ContextSince 2015, plastic multilayer closure (PMC) has been gaining attraction due to improved wound healing outcomes for medically complex patients. Plastic multilayer closure has been readily used for complex spine surgery closures in patients susceptible to wound healing issues (ie, dehiscence, surgical site infection [SSI]). However, PMC requires extensive soft tissue manipulation compared with standard orthopedic spine surgeon closure (SOC) and can result in extended operative times, increased transfusion rates, and more frequent returns to the operating room. PurposeFrom 2016 to 2019, our institution implemented a perioperative protocol designed to decrease postoperative complication rates in NMS patients. A retrospective cohort study was performed to determine if PMC imparted advantages over SOC above and beyond that from the perioperative protocol. Study Design/SettingRetrospective study at a single academic institution. Patient SampleEighty-one pediatric patients with neuromuscular scoliosis undergoing spinal fixation surgery. Outcome MeasuresPostoperative wound complications such as surgical site infection, hematoma, and superficial/deep dehiscence were the main outcome measures. Respiratory and neuromuscular complications along with duration of surgery were also recorded. MethodsA retrospective review was conducted of NMS patients undergoing spinal fixation at a single academic pediatric hospital over 4 years. Cases were labeled as SOC (n=41) or PMC (n=40) based on the closure technique applied. Reported 90-day complications were evaluated as the primary outcome. ResultsOf the 81 reviewed patients, 45 reported complications, roughly equal between the study groups. While we found no statistically significant differences in rates of postoperative complications or SSIs, SOC cases were 30 minutes shorter on average with fewer returns to the operating room for additional surgery. ConclusionsWith the implementation of our perioperative protocol for NMS patients, PMC did not result in fewer complications than SOC but the surgeries did take longer.

A 10-Year Retrospective Review on the Use of Prophylactic Spinal Reconstruction in Spinal Surgery Involving High-Risk Patients.

Spinal surgeries are being offered to a broader patient population who are both medically and surgically complex. History of prior spinal surgery, advanced age, and presence of comorbidities, such as obesity, malnutrition, steroid use, and tobacco use, are risk factors for postoperative complications. Prophylactic spinal reconstruction at the time of spinal surgery has been shown to have improved outcomes and decreased wound complications; however, outcomes focusing specifically on complex patients with a history of previous spinal surgery (or surgeries) have not been well described. This is a retrospective study performed at the University of Maryland Medical Center (Baltimore, MD) of high-risk patients who underwent complex spinal surgery with prophylactic spinal reconstruction from 2011 to 2022. One hundred forty-three consecutive surgeries from 136 patients were included in the study. Patients younger than 17 years or who had an incomplete medical record were excluded. Most patients were female (63.6%) versus male (31.5%). The average American Society of Anesthesiologists score was 3. All but 6 patients (11%) had a history of at least 1 spinal surgery, with nearly half of patients having had between 2 and 5 spinal surgeries. Reconstruction was performed with paraspinous flaps in most cases (n = 133 [93%]). The overall complication rate was 10.5%, with surgical site infection being the most common complication. Seventeen patients (12.5%) underwent reoperation within 90 days of initial surgery. Average length of follow-up was 4.18 months (range, 0.03-40.53 months). In appropriately selected patients, prophylactic spinal reconstruction offers improved outcomes with decreased wound complications compared with salvage. For large defects, paraspinous flaps are recommended over other reconstructive options. Prolonged drain placement is felt to be protective against complications.

Anterior Lumbar Interbody Fusion (ALIF) for Lumbar Hemivertebra in an Adult Using Three-Dimensional-Printed Patient-Specific Implants and Virtual Surgery Planning: A Technical Report

Introduction: Hemivertebrae are a common defect of vertebral formation, potentially resulting in debilitating congenital scoliosis and necessitating highly traumatic surgery. Virtual surgical planning (VSP) and 3D-printed patient-specific implants (PSIs) have increasingly been applied to complex spinal surgery, and offer a range of potential benefits. Research Question: We report the use of 3D-printed PSIs and VSP as part of a two-level anterior lumbar interbody fusion (ALIF) for the management of lateral hemivertebra and congenital scoliosis. Material and Methods: A 53-year-old male with chronic low-back pain, due to L4 hemivertebra and mild congenital scoliosis, presented with new-onset leg pain. CT revealed L4/5 and L5/S1 degeneration and foraminal stenosis. Given the complex anatomy and extensive multi-level osteophytosis, 3D-printed PSIs were designed, manufactured, and implanted as part of a two-level ALIF. Results: Excellent implant fit was achieved intraoperatively, confirmed via postoperative imaging. VSP assisted with navigating challenging bony and vascular anatomy. Three-month postoperative imaging demonstrated construct stability, early signs of bony fusion, with implant placement, spinal curvature, and disc height corrections closely matching the VSP. Clinically, the patient’s pain and functional impairment had effectively resolved by nine-month follow up, as demonstrated through subjective and objective measures. Discussion and Conclusions: Virtual surgical planning and 3D-printed PSIs can be useful surgical aids in the management of the often-complex cases involving hemivertebrae and congenital scoliosis. This case of congenital pathology adds to the growing reports of PSI application to a variety of complex spinal pathologies, with analyses showing a close match of the postoperative construct to the preoperative VSP.

Early Outcomes of Muscle Flap Closures in Posterior Thoracolumbar Fusions: A Propensity-Matched Cohort Analysis

Plastic surgery closure with muscle flaps after complex spinal reconstruction has become increasingly common. Existing evidence for this practice consists of small, uncontrolled, single-center cohort studies. We aimed to compare 30-day postoperative wound-related complication rates between flap closure and traditional closure after posterior thoracolumbar fusions (PTLFs) for non-infectious, non-oncologic pathologies using a national database. We performed a propensity-matched analysis using the 2012-2020 National Surgical Quality Improvement Program dataset to compare 30-day outcomes between PTLFs with flap closure versus traditional closure. A total of 100,799 PTLFs met our inclusion criteria. The use of flap closure with PTLF remained low but more than doubled from 2012 to 2020 (0.38% vs. 0.97%; P= 0.002). A higher proportion of flap closures had higher American Society of Anesthesiologists classifications and higher number of operated spine levels (all P < 0.001). We included 1907 PTLFs (630 for flap closure; 1257 for traditional closure) in the propensity-matched cohort. Unadjusted 30-day wound complication rates were 1.7% for flap and 2.1% for traditional closure (P= 0.76). After adjusting for operative time, wound complication, readmission, reoperation, mortality, and non-wound complication were not associated flap use (all P > 0.05). Plastic surgery closure was performed in patients with a higher comorbidity burden, suggesting consultation in sicker patients. Although higher rates of wound and non-wound complications were expected for the flap cohort, our propensity-matched cohort analysis of flap closure in PTLFs resulted in non-inferior odds of wound complications compared to traditional closure. Further study is needed to assess long-term complications in prophylactic flap closure in complex spine surgeries.

Spino-plastic surgery: A literature review of vascularized bone grafts and their uses in spine reconstruction

The role of plastic surgeons in the world of spine surgery is quickly evolving. The plastic surgeon now serves both a therapeutic and prophylactic role in addressing complications of complex and revision spine surgery. The field of Spino-plastic Surgery is characterized by the use of vascularized bone grafts (VBGs). VBGs are bone segments transferred on their corresponding muscular attachments without the inclusion of a named vessel. The bone graft is adequately vascularized through the connection of the tendon by Sharpey's fibers and their associated microvasculature. VBGs provide an autologous, pedicled tissue rearrangement option with osteoinductive properties and adequate structural support for complex spine reconstruction. VBGs are associated with a lower risk of adverse events and shorter times to fusion than allografts, and bypass the need for lengthy microsurgical anastomosis. Five types of VBGs for spine reconstruction are described in this article, including iliac crest, rib, occiput, scapula, and spinous process VBG. Virtually any vertebral level can be reached for arthrodesis using one or more of these VBGs.

The impact of intraoperative intravenous lidocaine infusion on early postoperative pain after complex spine surgeries

BackgroundThis study aimed to assess the effect of intravenous lidocaine infusion affected on early postoperative pain control after complex spin surgeries.Ninety patients who were scheduled for complex spine surgery were included in this prospective double-blinded controlled trial. They were randomly assigned to one of two groups: L and P. Patients in group L received a loading dose of lidocaine 1 mg/kg then followed by 1.5 mg/kg/h infusion till the end of the surgery, while in group P, lidocaine was replaced with normal saline.ResultsThe pain score assessed by VAS at rest showed statistically significant lower values in group L at 30 min, 8, 12, and 24 h postoperatively. VAS during movement was significantly higher in group P only after 24 h postoperatively. The entire dose of intraoperative fentanyl consumed was significantly lower in group L. The time elapsed to ask for the first dose of rescue analgesia was significantly longer in group L. The first rescue dose of nalbuphine was significantly lower in group L. In group P, the overall dose of narcotics consumed in the first postsurgical day was significantly higher.ConclusionsWhen compared to placebo, lidocaine infusion significantly reduced the postoperative pain scores, as well as the entire dose of intraoperative and postoperative narcotics used.

The Surgical Outcomes of Pedicle Subtraction Osteotomy per Different First Assistant: Retrospective Analysis of 312 Cases.

Pedicle subtraction osteotomies (PSOs) are complex spinal deformity surgeries that are associated with high complication rates. They are typically done by an experienced spine surgeon with another attending, resident, or physician assistant serving as the first assistant. The purpose of this study was to determine whether selecting a surgical team for single-level PSO based on case difficulty and fusion length could equalize intraoperative and perioperative outcomes among three groups: dual-attending (DA), attending and orthopaedic resident (RS), and attending and physician assistant (PA). This study was a retrospective cohort analysis of 312 patients undergoing single-level thoracic or lumbar PSO from January 2007 to December 2020 by a fellowship-trained orthopaedic spine surgeon. Demographic, intraoperative, and perioperative data within 30 days and 2 years of the index procedure were analyzed. Patient demographics did not markedly differ between surgical groups. The mean cohort age was 64.5 years with BMI 31.9 kg/m 2 . Patients with the DA approach had a significantly longer surgical time (DA = 412 min vs. resident = 372 min vs. physician assistant = 323 min; P < 0.001). Patients within the DA group experienced a significantly lower rate of infection (DA = 2.1% [3/140] vs. RS = 7.9% [9/114] vs. PA = 1.7% [1/58], P = 0.043), surgical complication rate (DA = 26% [37/140] vs. RS = 41% [47/114] vs. PA = 33% [19/58], P < 0 .001), and readmission rate (DA = 6.4% [9/140] vs. RS = 12.3% [14/114] vs. PA = 19% [11/58] P = 0.030) within 30 days of surgery. No notable differences were observed among groups in 2-year complication, infection, readmission, or revision surgery rates. These study results support the DA surgeon approach. Resident involvement, even in less complex cases, can still negatively affect perioperative outcomes. Additional selection criteria development is needed.

Orthopaedic surgeons and the legal tightrope: safeguarding patient welfare amidst rising litigation

Medicolegal litigation is a critical aspect of orthopaedic practice. These disputes can arise due to a variety of reasons, including medical negligence, malpractice, and breach of duty. Orthopaedic surgeons are at risk of being involved in medicolegal cases due to the nature of their work, which involves complex surgical procedures and postoperative care. They are required to manage a wide range of cases, from minor fractures to complex spinal and joint surgeries. As with any medical field, orthopaedic surgery being a complex and dynamic medical specialty; carries with it a certain amount of legal responsibility, with litigation rates on the rise globally. This article aims to provide an overview of the areas in orthopaedics where medicolegal litigation is highest and highlight some of the strategies that can be employed to reduce the risk of litigation.

Accuracy of 3D printed spine models for pre-surgical planning of complex adolescent idiopathic scoliosis (AIS) in spinal surgeries: a case series

Adolescent idiopathic scoliosis (AIS) is a noticeable spinal deformity in both adult and adolescent population. In majority of the cases, the gold standard of treatment is surgical intervention. Technological advancements in medical imaging and 3D printing have revolutionised the surgical planning and intraoperative decision making for surgeons in spinal surgery. However, its applicability for planning complex spinal surgeries is poorly documented with human subjects. The objective of this study is to evaluate the accuracy of 3D printed models for complex spinal deformities based on Cobb angles between 40° to 95°.This is a retrospective cohort study where, five CT scans of the patients with AIS were segmented and 3D printed for evaluating the accuracy. Consideration was given to the Inter-patient and acquisition apparatus variability of the CT-scan dataset to understand the effect on trueness and accuracy of the developed CAD models. The developed anatomical models were re-scanned for analysing quantitative surface deviation to assess the accuracy of 3D printed spinal models. Results show that the average of the root mean square error (RMSE) between the 3DP models and virtual models developed using CT scan of mean surface deviations for the five 3d printed models was found to be 0.5±0.07 mm. Based on the RMSE, it can be concluded that 3D printing based workflow is accurate enough to be used for presurgical planning for complex adolescent spinal deformities. Image acquisition and post processing parameters, type of 3D printing technology plays key role in acquiring required accuracy for surgical applications.

Differences in Perioperative Management of Patients Undergoing Complex Spine Surgery: A Global Perspective.

The aim of this survey was to understand institutional spine surgery practices and their concordance with published best practices/recommendations. Using a global internet-based survey examining perioperative spine surgery practice, reported institutional spine pathway elements (n=139) were compared with the level of evidence published in guideline recommendations. The concordance of clinical practice with guidelines was categorized as poor (≤20%), fair (21%-40%), moderate (41%-60%), good (61%-80%), or very good (81%-100%). Seventy-two of 409 (17.6%) institutional contacts started the survey, of which 31 (7.6%) completed the survey. Six (19.4%) of the completed surveys were from respondents in low/middle-income countries, and 25 (80.6%) were from respondents in high-income countries. Forty-one incomplete surveys were not included in the final analysis, as most were less than 40% complete. Five of 139 (3.6%) reported elements had very good concordance for the entire cohort; hospitals with spine surgery pathways reported 18 elements with very good concordance, whereas institutions without spine surgery pathways reported only 1 element with very good concordance. Reported spine pathways included between 7 and 47 separate pathway elements. There were 87 unique elements in the reviewed pathways. Only 3 of 87 (3.4%) elements with high-quality evidence demonstrated very good practice concordance. This global survey-based study identified practice variation and low adoption rates of high-quality evidence in the care of patients undergoing complex spine surgery.

P12 Patient-specific automated cerebrospinal fluid pressure control to augment spinal wound closure: a case series using LiquoGuard®

Abstract Introduction Post-operative spinal cerebrospinal fluid (CSF) leaks are a common and potentially serious surgical complication. The management of intra- and post-operative leaks is heterogeneous. Numerous studies advocate for dural repair and CSF diversion. The LiquoGuard7 allows automated and precise CSF pressure and volume control, with the calculation of patient-specific biometrics. We sought to summarize our experience with patient-specific CSF automated drainage with layered spinal wound closure. Methods This single-centre case series included patients undergoing complex spinal surgery where: 1) a high-flow intra- and/or postoperative CSF leak was expected and 2) concurrent CSF diversion was performed via lumbar drain attached to a LiquoGuard7®. CSF diversion was tailored to calculated CSF production rates and other case factors to maintain a neutral pressure across the operative site. Results Three patients were included, with a variety of pathologies (T7/T8 disc prolapse; T8-T9; T4-T5 metastatic spinal cord compression). The first two patients underwent CSF diversion to prevent post-op CSF leak, whilst case 3 required this in response to post-op CSF leak. CSF hyperproduction (140-150ml/hr) was evident in all cases. With patient-specific CSF diversion regimes, no cases required further intervention for CSF fistulae repair (including for pleural CSF effusion), wound breakdown or infection. Conclusion Automated patient-specific cerebrospinal fluid drainage may have a role in the closure of complex spinal wounds with high-flow CSF leaks, with a smaller risk profile than traditional manual drainage. Further larger studies are needed to explore the comparative benefits and cost-effectiveness of these devices.

Plastic Surgery Closure of Complex Spinal Wounds.

Wound breakdown and infection are common complications after complex spine surgery and may occur in up to 40% of high-risk patients. These are challenging scenarios which can result in a prolonged hospital stay, revision surgery, and elevated costs. Reconstructive specialists can do prophylactic closures for high-risk groups to potentially reduce the risk of developing a wound complication. These plastic surgery techniques often involve multilayered closure, with the addition of local muscle and/or fasciocutaneous flaps. The goal of this study was to review the literature for risks associated with wound complications, identification of high-risk patients, and the advantages of using plastic surgery techniques. In addition, we elaborate on the multilayered and flap closure technique for complex spine surgery which is done at our institution.

Safety and Efficacy of High-Dose Tranexamic Acid in Spine Surgery: A Retrospective Single-Institution Series

Currently, tranexamic acid (TXA) is the most widely used antifibrinolytic agent in spine surgery and has been proven to reduce perioperative blood loss. However, the safety of high-dose regimens remains in established. A retrospective chart review was performed to identify all adult patients who underwent spine surgery with high-dose TXA (50 mg/kg loading dose, mg/kg/h maintenance dose) between September 2019 and March2020. Thirty-six patients were treated with intraoperative high-dose TXA during the study period. The mean age was 56.6 (range: 22-82). Average body mass index was 27.2 (5.1) kg/m2. Average preoperative Charlson Comorbidity Index was 3.0 (2.7). The mean number of spinal levels operated on was 6.9 (4.3). Seven cases (19.4%) were revision surgeries. The mean intraoperative blood loss was 587.1 (900.0) mL, and total blood loss was 623.8 (991.9) mL. Postoperatively, time to ambulation was on average 1.7 (1.7) days. The mean total length of stay was 9.8 days (7.9, range 2-41). The most common indication for surgery was tumor (n= 9, 25%), followed by fracture (n= 8, 22.2%), deformity (n= 7, 19.4%), pseudarthrosis (n= 6, 16.7%), and symptomatic lumbar disc herniation (n= 2, 5.6%). There were no thromboembolic or other significant complications among the 36 patients. This retrospective case series demonstrates that the use of high-dose TXA provides is potentially safe and efficacious in adult patients undergoing complex spine surgeries. However, further investigations are required before the true safety and optimal dosing can be determined for high-dose TXA.

D45. Early Outcomes of Muscle Flap Closures in Complex Spine Surgeries: A Propensity-matched Cohort Analysis

PURPOSE: Plastic surgery closure with muscle flaps after complex spinal reconstruction has become popular. Existing evidence for this practice consists of small, uncontrolled, single-center cohort studies. We aimed to compare 30-day postoperative wound-related complications between flap closure and traditional closure after posterior thoracolumbar fusions (PTLFs) for non-infectious pathologies using a national database. METHOD: We performed a propensity-matched analysis using the 2010-2020 NSQIP dataset. RESULTS: Of 117,756 PTLFs meeting inclusion criteria, a higher proportion of flap closures had ASA Class III/IV than traditional closures (65.4% vs. 54.1%; p<0.001). 1,520 PTLFs (760 in each group) were included in the propensity-matched cohort. Unadjusted 30-day wound complication rates were 3.0% for flap and 1.6% for traditional closure (p=0.09). Surgeries were longer with flap closure (p<0.001). After adjusting for operative time, flap closure was associated with lower wound complication odds (AOR, 0.98; p=0.041) and prolonged LOS (AOR, 1.05; p=0.001). Readmission, reoperation, home discharge, mortality, and non-wound complication were not associated with flap use. CONCLUSION: Plastic surgery closure was performed in patients with higher ASA classifications, suggesting consultation in sicker patients. Our propensity-matched cohort analysis of flap closure in PTLFs resulted in lower odds of wound complications than traditional closure. Sequelae of longer procedure time in flap closure may contribute to longer LOS. Further study is needed to assess long-term complications in prophylactic flap closure in complex spine surgeries.

Intraoperative Computed Tomography Scanner-Guided Junctional Zone Spinal Surgery in Fluoroscopic Limitation Zone-An Early Experience

Objective: Confirmation of the level for surgery at the junctional zones of the spine is associated with unique difficulties. C-Arm has its limitations in these areas. The use of intraoperative CT scan with navigation greatly helps in the surgery at junctional zones. These junctional zones include the craniocervical junction, cervico-dorsal junction, and sacroiliac junction. In 2019, we installed an Airo Brain Lab 32-slice MDCT in our facility and researched to evaluate its advantages in junctional zone fluoroscopy-restricted spine operations. Material and Methods: We performed 20 complex surgeries in all these 3 junctional zones with the use of an intraoperative computed tomography scanner. 3 patients had craniovertebral junction fixation under intra-op CT while 6 had lateral mass fixation. 3 patients had cervicodorsal junction fixation and 4 patients had lumbosacral fixation. Results: 2 out of 3patients with cervicodorsal fixation had correction of screws trajectory after usage of intra-op CT and 1 patient with lumbosacral fixation. All patients were discharged home with neurology better or the same as compared to pre-op. status while 13 patients had a favorable outcome. Conclusion: Intraoperative computed tomography scanner is opening new horizons for complex spinal surgeries. Keywords: , ,, .

357 Image-Guided Farlateral Lumbar Foraminotomy and Microdiscectomy: Operative Technique and Outcomes

INTRODUCTION: Three dimensional image-guidance is frequently used to improve the safety of complex spine surgeries. Its adoption remains mostly limited as and aid with instrumentation placement. METHODS: We performed a retrospective chart review of image-guided farlateral foraminotomies and microdiscectomies performed by a single surgeon from January 2018 to July 2021. Demographics, operative times and outcomes were collected. The stealth reference arc is fixated on the patient's skin using the Ioband. The O-arm is used to perform an intraoperative CT-scan automatically registered to the image-guided system. The location of the paraspinal incision is ascertained using the image-guided dilator to allow adequate trajectory to the neural foramen that minimizes the amount of facet joint that needs to be removed. The foraminotomy and/or discectomy is accomplished using microsurgical technique. Image guidance can be used to help guide the foraminotomy. RESULTS: 20 patients were included in our study; 14 (70%) underwent image-guided farlateral microdiscectomy and 6 (30%) foraminotomy. The most common microdiscectomy level was L5-S1 (50%). Mean age was 66 ± 10.2 (SD) years; 16(80%) were male; BMI 27.5 ± 3 kg/m2;. Total procedure time was 117.4 ± 24.6 minutes; OR time 172.5 ± 22.5 minutes; EBL 21.5 ± 16.6 ml. Average length of stay 0.85 ± 0.6 days, with 5 (25%) discharge on the same day; all patients were discharged home. We did not observe intraoperative complications; all patients reported significant improvement of their presenting symptoms. Mean follow-up was 19.4 ± 28.7 months. CONCLUSIONS: FDA-approved use of spinal image-guidance requires a reference arc to be attached to the bony spine. Our technique of attaching the reference arc to the skin is an off-label use, we do not recommend it for instrumentation placement as there is mild navigation inaccuracy (2-3 mm). This technique allows for general accuracy to ascertain the location of the incision and trajectory and can help guide the foraminotomy.

Medical complications and health-related quality of life in complex pediatric spine deformities exceeding 100 degrees or treated by 3CO.

Retrospective review of prospectively collected data. To determine the incidence of medical complications in the pediatric population aged 10-20years with baseline deformities exceeding 100 degrees or who had 3CO at surgery. Severe pediatric spine deformity poses a great challenge to the treating physician and carries a high complication rate. Pulmonary complications are among the most life threatening. The onus is on the treating surgeon to identify patients who are high risk and institute measures to mitigate the risk for successful outcomes. Data of 251/311pts from FOX pediatric database from 17 international sites was queried for incidence of major medical complications. Comparative analysis was done to determine the impact of such complications on HRQoL using paired t-test. Risk factors associated with medical complications were assessed using Firth logistic regression. 251/311pts had min 2year f/u. 142F/109M, average age 14.61years (10-20). Etiologies included 96 Cong,94 Idiopathic, 14-Post TB, 12-NM,12-NF,10-syndromic,8 others. Curve types included Scoliosis-121, Kyphoscoliosis 72, Kyphosis 58. Coronal and sag cobb avg 88° ± 41.47 and 91.92° ± 39.17, respectively. Deformity apices were in the thoracic region in 88% of patients. Pre-op co-morbidities included 54 (21.5%) cardiopulmonary; 7(2.79%) Genitounrinary;13 (5.18%) GI;13 (5.18%) Anxiety/depression; neurological 24 (9.56%). HGT was utilized in 103pts (41%) at an average duration of 68days. Mean OR time was 459min, blood loss averaged 1465ml. VCR was performed in 120(47.81%), PSO in 16 pts (6.37%), SPO in 145pts (57.77%), Thoracoplasty in 132 pts (52.8%). 96% had blood and other blood products transfusion (FFP and platelets). There were 35 post-op medical complications occurring in 29pts (11.6%). Event-specific cumulative incidence was 24 (9.6%) pulmonary, 5(2.0%) gastrointestinal, 3(1.2%) cardiovascular, 1(0.4%) genitourinary and 1(0.4%) other complication. There was no mortality. Osteotomy grade was found to be anindependent predictor of pulmonary complication. Despite significant improvement in baseline SRS total and Domain scores at 2year FU irrespective of medical complication, the improvement in SRS scores were blunted in the complication group. Medical complications are common among pediatric patients undergoing complex spine surgery for severe deformity. However, medical complications can be managed successfully. Although baseline HRQoL improved irrespective of medical complication status, clinical differences in the magnitude of the changes in HRQoL were observed in some domains.