Posterior Correction Research Articles

Fusionless All-Pedicle Screws for Posterior Deformity Correction in AIS Immature Patients Permit the Restoration of Normal Vertebral Morphology and Removal of the Instrumentation Once Bone Maturity Is Reached.

The aim of this study was to report the restoration of normal vertebral morphology and the absence of curve progression after the removal of instrumentation in AIS patients that underwent posterior correction of the deformity by a common all-screws construct without fusion. A series of 36 AIS immature patients (Risser 3 or less) were included in the study. Instrumentation was removed once the maturity stage was complete (Risser 5). The curve correction was assessed pre- and postoperatively, before instrumentation removal, directly post-removal, and more than two years after instrumentation was removed. Epiphyseal vertebral growth modulation was assessed by the coronal wedging ratio (WR) at the apical level of the main curve (MC). The mean preoperative coronal Cobb was corrected from 53.7° ± 7.5 to 5.5° ± 7.5° (89.7%) at the immediate postop. After implant removal (31.0 ± 5.8 months), the MC was 13.1°. T5-T12 kyphosis showed significant improvement from 19.0° before curve correction to 27.1° after implant removal (p < 0.05). Before surgery, the WR was 0.71 ± 0.06, and after removal, 0.98 ± 0.08 (p < 0.001). At the end of the follow-up, the mean sagittal range of motion (ROM) of the T12-S1 segment was 51.2 ± 21.0°. The SRS-22 scores improved from 3.31 ± 0.25 preoperatively to 3.68 ± 0.25 at the final assessment (p < 0.001). In conclusion, a fusionless posterior approach using common all-pedicle screws correctly constructed satisfactory scoliotic main curves and permitted the removal of instrumentation once bone maturity was reached. The final correction was highly satisfactory, and an acceptable ROM of the previously lower instrumented segments was observed.

Additional growth of the spine and changes in spinal alignment after posterior spinal fusion in adolescent idiopathic scoliosis.

Previous studies have evaluated growth in spinal height immediately following surgical posterior correction of idiopathic scoliosis, yet have not reported on further spinal growth following surgery. The aims of this study were to investigate the characteristics of spinal growth after scoliosis surgery and determine whether they affect spinal alignment. The study included 91 patients (mean age 13.93 years) who underwent spinal fusion using pedicle screws for the treatment of adolescent idiopathic scoliosis (AIS). The study population included 70 female and 21 male patients. The height of the spine (HOS), length of the spine (LOS), and spinal alignment parameters were measured on anteroposterior and lateral radiographs. A stepwise multiple linear regression analysis was used to examine the variables that affected HOS gain from growth. The patients were divided into two groups, the growth group and the nongrowth group, according to whether the HOS gain from growth exceeded 1 cm, to analyze the effect of spinal growth on its alignment. The mean (± SD) HOS gain from growth was 0.88 ± 0.66 (range -0.46 to 3.21) cm, with 40.66% of patients exhibiting growth ≥ 1 cm. This increase was significantly related to young age, male sex, and a small Risser stage (sex: b = -0.532, p < 0.001, male = 1, female = 2; Risser stage: b = -0.185, p < 0.001; age: b = -0.125, p = 0.011; adjusted R2 = 0.442). The variation in LOS was similar to that of HOS. Thoracic kyphosis and upper instrumented vertebra-lowest instrumented vertebra Cobb angle were reduced in both groups, with a greater reduction observed in the growth group. Patients with an increase in HOS < 1 cm showed a larger lumbar lordosis and a greater tendency for the sagittal vertical axis (SVA) to shift backward and the pelvic tilt to decrease (anteverted pelvis) than in the growth group. The spine still has growth potential after corrective fusion surgery for AIS, and 40.66% of the patients in this study continued to vertically grow by 1 cm or more. Unfortunately, the height changes cannot be accurately predicted by currently measured parameters. Changes in the sagittal alignment of the spine may affect the vertical growth increment.

“Scoliosis 3D”—A Virtual-Reality-Based Methodology Aiming to Examine AIS Females’ Body Image

Modern techniques such as virtual-reality (VR) tasks might offer a unique method for eliciting state-variable fluctuations in body satisfaction and associated behaviors. The study aim was to develop the application of biometric avatars in VR as a useful tool to investigate changes within body representation in adolescent idiopathic scoliosis (AIS). All the avatars were created on the basis of 3D scans of bodies of real female patients with thoracic scoliosis, of 12–18 years of age, consecutively selected for brace treatment or posterior correction and fusion. A 3D, white-light LED scanner was used. The models were rigged using 3DS Max software, to enable the possibility of human-type interaction and animation. The “Avatar Scoliosis 3D” is an innovative 3D, interactive-XR application, loosely based on the virtual-mirror concept, and contains a number of predefined avatars, each with a different Cobb angle. It is possible to change a selected avatar to one with a different Cobb angle (lower or higher), should the patient decide the visualization of the original is incompatible with their own perception. In conclusion, the possible application of biometric avatars in VR as a useful tool to investigate changes within body image in AIS was proposed.

Increased risk of thoracic hypokyphosis after posterior spinal correction and fusion in adolescent idiopathic scoliosis with thoracic double curve

Adolescent idiopathic scoliosis (AIS) is often associated with thoracic hypokyphosis or even lordosis. To analyze the influence of posterior correction and fusion in thoracic, structurally double-curved AIS. Out of 127 thoracic AIS (Lenke types1 and2) recorded prospectively, idiopathic double thoracic curve AIS were analyzed retrospectively. Surgery 2010-2019 with pedicle screw double rod systems in ascoliosis center. Follow-up (FU) at least 2years. Frontal and sagittal angles (whole-spine radiographs, 2planes): thoracic curve (MK), proximal-thoracic curve (PK) and lumbar curve (LK), thoracic kyphosis (TK), lumbar lordosis (LL). values as MW ± SD, students t‑test (significance a = 0.05), Pearson's correlation, sub-analysis with sagittal modifiers (-, N, +). Atotal of 47AIS-double thoracic curve were identified, mean FU 29.3 ± 12.2months, mean age 14 ± 1.5years. The mean correction (FU-preop) of MK was 67%, PK 53%, LK 73%, each significant, (p < 0.05). On average, TK (FU-preop) decreased by -6.5 ± 11.6° (p < 0.05), no significant change from FU (p = 0.6). TK (FU-preop) increased by 8.6 ± 5.0° (p < 0.05) in hypokyphotic cases, significantly decreased by -4.8 ± 9.6° in normokyphotic AIS and -25.3 ± 11.1° in hyperkyphotic cases, respectively (p < 0.05). In hypokyphosis: moderately strong correlation between correction PK (r = -0.5) and spontaneous correction LK (r = 0.8) (frontal plane) and change from pre- to postop TK (sagittal plane) (p < 0.05). Moderate correlation for hyperkyphosis: correction PK (r = -0.5) and postop TK (p < 0.05). No relevant correlations for normokyphosis. 17% had postop hypokyphosis, of which 0% had preop hypokyphosis. Rod diameter (5.5 mm vs. 6 mm) had no significant effect on TC. Posterior instrumented correction and fusion (pedicle screw dual rod systems) can significantly correct both lateral curves in idiopathic double thoracic curves, although it is associated with an increased risk of postop thoracic hypokyphosis, especially in preoperatively normokyphotic patients.

Long-term results of surgical correction of Scheuermann’s kyphosis

Objective. To analyze long-term results of surgical correction of kyphosis due to Scheuermann’s disease.Material and Methods. Design: retrospective cohort study. The study group included 43 patients (m/f ratio, 34/9). The mean age was 19.1 (14–32) years; the mean postoperative follow-up was 6 ± 10 (5–20) years. Two-stage surgery including discectomy and interbody fusion followed by posterior correction and fusion was conducted in 35 cases (Group A). Eight patients (Group B) underwent only posterior correction and spinal fusion. The following parameters were determined for each patient: thoracic kyphosis (TK), lumbar lordosis (LL) (scoliotic deformity of the thoracic/thoracolumbar spine, if the curve magnitude was &gt; 5°), sagittal vertical axis (SVA), sagittal stable vertebra (SSV), first lordotic vertebra (FLV), proximal junctional angle (PJA) and distal junctional angle (DJA). All measurements were performed immediately before surgery, one week after surgery, and at the end of the follow-up period. All patients answered the SRS-24 questionnaire after surgery and at end of the follow-up period.Results. Groups were comparable in terms of age and gender of patients, body mass index and initial Cobb angle (p &lt; 0.05). The curve decreased from 77.8° to 40.7° in Group A and from 81.7° to 41.6° in Group B. The loss of correction was 9.1° and 6.0° in groups A and B, respectively. The parameters of lumbar lordosis remained normal during the follow-up period. At implant density less than 1.2, deformity correction and correction loss were 44.5° (54.7 %) and 3.9°, respectively (p &lt; 0.05). Proximal junctional kyphosis (PJK) was detected in 21 out of 43 patients (48.8 %). The frequency of PJK was 45.4 % among patients whose upper end vertebra was included in the fusion and 60 % among those whose upper end vertebra was not included. PJK developed in eight (47.8 %) out of 17 patients with kyphosis correction ≥ 50 % and in 13 (50.0 %) of those with correction &lt; 50 %. The rate of DJK development was 39.5 %. The lower instrumented vertebra (LIV) was located proximal to the sagittal stable vertebra in 16 cases, with 12 (75 %) of them being diagnosed with DJK. In 27 patients, LIV was located either at the SSV level or distal to it, the number of DJK cases was 5 (18.5 %); p &lt; 0.05. Only two patients with complications required unplanned interventions. According to the patient questionnaires, the surgical outcome score increases between the immediate and long-term postoperative periods for all domains and from 88.4 to 91.4 in total. The same applies to answer to the question about consent to surgical treatment on the same conditions: positive answers increased from 82 to 86 %.Conclusions. Two-stage surgery, as a more difficult and prolonged one, has no advantages over one-stage operation in terms of correction magnitude and stability of the achieved effect. Surgical treatment improves the quality of life of patients with Scheuermann’s disease, and the improvement continues in the long-term postoperative period.

Getting it right first time: national survey of surgical site infection 2019.

Surgical site infections (SSIs) are associated with increased morbidity and mortality. Deep SSI, or prosthetic joint infection (PJI), is associated with revision surgery involving longer operative times with higher infection rates, longer length of stay (LoS) and high costs in addition to the catastrophic effect on the patient. The surveillance of SSI is important for patient decision making, identification of outliers for support and maximising focussed improvement. This paper reports the findings of the second Getting it Right First Time (GIRFT) national SSI survey for orthopaedic and spinal surgery. Data were submitted prospectively by 67 orthopaedic units and 22 spinal units between 1 May 2019 and 31 October 2019. For a patient to be included, they had to present with SSI within the study period and within 1 year of the index procedure. A total of 309 SSIs were reported from primary and revision, total hip, knee, shoulder, elbow and ankle replacements, and 58 SSIs were reported from lumbar spine single level discectomy or decompression, lumbar spine single-level instrumented posterior fusion, posterior cervical spine decompression and instrumented fusion and posterior correction of adolescent idiopathic scoliosis. SSIs rates have remained low compared with the 2017 survey. There were variations in SSI rates by procedure, with primary shoulder replacement reporting the lowest (0.4%) and revision shoulder replacement the highest (2.5%) rates. The authors recommend that the elective surgical restart following the COVID-19 pandemic provides a unique opportunity for all units to implement a full SSI prevention bundle to minimise the risk of infection and improve patient outcomes.

New Technique Seeking Prophylaxis in the Displacement of Distal Ventriculoperitoneal Shunt Catheter – Case Report

AbstractIdiopathic intracranial hypertension is a comorbidity treated in neurosurgical practice today with the ventriculoperitoneal derivation technique. However, despite its great safety and efficacy, this technique is susceptible to infrequent failures, such as displacement of the catheter leading to the need for reoperation. In the present article, we report a case involving a peritoneal catheter tip retropulsion for subcutaneous tissue in an obese patient with posterior correction using an extending connector to the distal catheter, without harming the drainage flow. In our case report, the patient went on without complications and without the occurrence of new displacement after 8 months of surgery. The results obtained by this technique supported the idea that this alternative construction minimizes the risk of displacement of the peritoneal tip catheter in obese patients and with high intra-abdominal pressure, helping to reduce the need for reoperations. In addition, the present case report supports the need for further studies and clinical trials on the subject.

Strategy and Efficacy of Surgery for Congenital Cervicothoracic Scoliosis with or without Hemivertebra Osteotomy.

ObjectiveCervicothoracic scoliosis will cause severe deformities in the early stage, and its structure is complex and the surgical methods are varied. The purpose of this research is to explore the indication and analyze the corrective effect of the two different posterior approach surgical strategies, including correction with fusion and hemivertebra osteotomy, for congenital cervicothoracic scoliosis deformities in children and adolescents.MethodsThis was a retrospective study of 21 patients with cervicothoracic scoliosis who received surgical treatment from January 2010 to June 2020, including nine cases of posterior hemivertebra osteotomy and fusion surgery and 12 cases of posterior correction and fusion alone. The Cobb angle, T1 tilt angle, clavicular angle, neck tilt angle, radiographic shoulder height, sagittal vertical axis, coronal balance distance, and local kyphosis angle were measured preoperatively, postoperatively, and at the last follow‐up. Posterior approach hemivertebra resection or correction with fusion surgery was adopted based on the different individual characteristics of deformity such as main curve Cobb angle, growth potential, and flexibility. Patients were divided into two groups (osteotomy group and nonosteotomy group) according to whether a hemivertebra osteotomy was performed, and the corrective results in the two groups were compared. Paired‐sample t tests or independent‐sample t tests were used.ResultsThe median follow‐up after surgery of the 21 patients was 36 months (range, 18–72 months). The Cobb angle was corrected from 45.81° ± 14.23° preoperatively to 10.48° ± 5.56° postoperatively (correction rate, 77.78% ± 8.93%). The T1 tilt angle decreased from 15.26° ± 7.08° preoperatively to 3.33° ± 2.14° postoperatively (correction rate,73.42% ± 21.86%). The radiographic shoulder height was corrected from 1.13 ± 0.74 cm preoperatively to 0.52 ± 0.42 cm postoperatively (correction rate, 39.51% ± 35.65%). The clavicular angle improved from 2.52° ± 1.55° preoperatively to 1.16° ± 0.96° postoperatively (correction rate, 47.18% ± 35.84%). No significant differences were found at the last follow‐up (p > 0.05). The Cobb angle of the main curve, T1 tilt angle, clavicular angle, cervical tilt angle, and shoulder height difference were similar in the two groups (p > 0.05).ConclusionsPosterior approach hemivertebra resection or correction with fusion surgery can be used in the treatment of congenital cervicothoracic scoliosis with satisfactory results, and the surgeon can make an individualized surgical plan according to individual characteristics of deformity.

Axial Neck-Shoulder Pain After Posterior Correction and Fusion for Adolescent Idiopathic Scoliosis With Structural Thoracic Curve: Does Cranial Fusion Level Affect Neck Symptoms?

A retrospective cohort study using prospectively collected data. To investigate the incidence and impact of fusion to the upper thoracic spine on neck-shoulder symptoms after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Axial neck-shoulder pain is established as a sequela of posterior cervical spine surgery and is mainly caused by the dissection of extensor muscles in the cervical and upper thoracic spine. Sixty-three female patients with AIS who underwent PSF using segmental pedicle screw constructs for structural main thoracic curve with a minimum 2-year follow-up were included. Axial neck-shoulder pain was assessed using the visual analog scale and cervical spine function domain score of the Japanese Orthopedic Association Cervical Myelopathy Evaluation Questionnaire. The patients were divided into 2 groups, a higher group (underwent fusion up to T3 or above, n=27) and a lower group (underwent fusion up to T4 or below, n=36), and radiologic and clinical outcomes were compared. The incidence of axial neck-shoulder pain (visual analog scale ≥30) preoperatively and at the 2-year follow-up was 29 and 40%, respectively. The pain and mental health domains of the Scoliosis Research Society-22 and cervical spine function domain of the Japanese Orthopedic Association Cervical Myelopathy Evaluation Questionnaire were correlated with the severity of axial neck pain. In the comparison of clinical outcomes between the 2 groups, the pain domain score of the Scoliosis Research Society-22 in the lower group was significantly better than that in the higher group at the 2-year follow-up ( P <0.05). Other parameters showed no significant differences preoperatively or at the 2-year follow-up. Female patients with AIS had a relatively high incidence of axial neck-shoulder pain after PSF, which affected their health-related quality of life. Both groups showed similar clinical outcomes, and the cranial fusion level did not affect axial neck-shoulder pain and cervical spine function. Level 3.

Posterior Surgery in the Treatment of Craniovertebral Junction Deformity with Torticollis.

ObjectiveTo investigate the clinical effect of posterior surgery in the treatment of craniovertebral junction (CVJ) deformities with torticollis and methods for preventing and treating complications in order to obtain a reasonable treatment strategy.MethodsFrom January 2007 to December 2017, 78 patients who suffered from CVJ deformities with torticollis treated by posterior surgery were analyzed. The surgical techniques were all posterior correction and fusion to restore the anatomical alignment of the craniovertebral junction. The visual analog score (VAS) and Short Form‐36 (SF‐36) health survey questionnaire were utilized to evaluate preoperative and postoperative neck pain, and changes in the torticollis angle and atlas‐dens interval (ADI) were evaluated through anteroposterior X‐ray and computed tomography. Intra‐ and postoperative complications were all recorded. One‐way ANOVA, LSD‐t test, and χ2 test were performed to evaluate the difference between the preoperative and postoperative data.ResultsThe mean follow‐up time was 37.4 ± 15.7 months, the average operation time was 115.6 ± 12.8 min, and the average blood loss was 170.8 ± 26.3 mL. According to the deformity site, the range of posterior correction and fusion was as follows: 38 cases of C1–C2, 33 cases of C0–C2, and seven cases of C0–C3. The preoperative SF‐36, VAS, torticollis angle, and ADI were 42.6 ± 8.8, 4.8 ± 1.1, 37.2 ± 11.2°, and 4.9 ± 2.3 mm, respectively. The difference was significant at 3 months post operation (p < 0.05), and there was no significant difference at the final follow‐up compared with 3 months post operation (p > 0.05).ConclusionIt can objectively achieve favorable correction and satisfactory clinical effects under posterior correction and fixation for CVJ deformities with torticollis. Intra‐ and postoperative complications can be settled by proper management.

Postoperative shoulder balance in Lenke type 1 adolescent idiopathic scoliosis patients with large thoracic curve (Cobb angle ≥ 70 degrees): a radiographic study

BackgroundLarge amounts of thoracic curve correction had been considered as a risk factor for postoperative shoulder imbalance (PSI) in adolescent idiopathic scoliosis (AIS) patients. This study aims to evaluate postoperative shoulder balance in Lenke type 1 AIS patients with large thoracic curve (Cobb angle ≥ 70 degrees) and compared it with those with moderate thoracic curve (Cobb angle < 70 degrees).MethodsA total of 47 Lenke type 1 AIS patients underwent posterior correction surgery between Sept. 2016 to Nov. 2018 in our institution were included. All these patient were divided into 2 groups based on the severity of main thoracic (MT) curve. Group A consisted of 25 cases with MT curve equal to or more than 70 degree while Group B consisted of 22 cases with MT curve less than 70 degree. Proximal thoracic (PT) Cobb angle, MT Cobb angle, MT apical vertebral translation (AVT), T2-T5 kyphosis, T5-T12 kyphosis, and radiographic shoulder height (RSH) were compared between these 2 groups preoperatively, immediately after surgery, and at a minimum of two-year follow-up.ResultsAlthough all the correction of PT Cobb angle (15.8° ± 6.0° vs 12.5° ± 3.6°, P = 0.028), that of MT Cobb angle 47.3° ± 9.1° vs 30.9° ± 6.7°, P < 0.001) and that of MT AVT (35.1 mm ± 16.0 mm vs 24.1 mm ± 8.9 mm, P = 0.007) were significantly larger in Group A when compared with Group B, RSH was comparable between these 2 groups at last follow up (7.5 mm ± 7.4 mm vs 9.2 mm ± 4.2 mm P = 0.363). Most of the patients gained satisfactory shoulder balance with only 7 cases with minimal PSI in group A (28%) and only 6 cases with minimal PSI in group B (27.3%) at last follow-up (P > 0.05).ConclusionsAlthough Lenke type 1 AIS patients with large thoracic curve had more amounts of MT curve correction when compared with those with moderate thoracic curve, it did not lead to higher incidence of PSI if the correction rate is proper.

Surgical outcomes of posterior correction surgery for scoliosis associated with syringomyelia

ObjectiveAlthough syringomyelia is considered a risk factor for neurological complications of correction surgery for scoliosis, only a few reports on the surgical results of the correction surgery complicated with associated syringomyelia are available. The purpose of this study is to verify the potential risk of neurological complications due to the presence of syringomyelia and explore the factors affecting the surgical outcomes of posterior correction surgery for scoliosis associated with syringomyelia. MethodsThis is a retrospective observational study in a single university hospital setting. Among 754 consecutive patients who underwent posterior correction and fusion surgery for scoliosis from 2009 through 2018 in our institution, we identified 28 patients presenting with spinal syringomyelia on preoperative whole spine MRI. The identified cases comprised 14 males and 14 females aged 11 years to 23 years (14.0 ± 2.9 years), and those with wide-type syrinx within fused spinal levels had undergone surgery for syringomyelia beforehand. First, we investigated the occurrence rate of peri- and postoperative neurological complications. Then we explored the factors affecting the correction rate of the Cobb angle and the incidence of coronal decompensation. ResultsNeurological complication (transient sensory deficits in bilateral legs) occurred in one case with thoracic single curve and narrow-type syrinx, disappearing spontaneously within several weeks postoperatively. The cases with an L4 long curve (n = 3, including L4 in thoracolumbar long C-shaped curve) showed a significantly poor correction rate (38.7%, p = 0.003) and developed postoperative coronal decompensation. ConclusionsPrior treatment for wide-type syrinx located within the spinal fusion level effectively prevented severe neurological complications, and when treating cases with long-curve L4 scoliosis associated with syringomyelia, the surgeons should note the occurrence of postoperative coronal decompensation.

Sequential correction technique in degenerative scoliosis with type C coronal imbalance: a comparison with traditional 2-rod technique.

The aim of this study was to compare the radiographic and clinical outcomes in patients with degenerative scoliosis (DS) with type C coronal imbalance who underwent either a sequential correction technique or a traditional 2-rod technique with a minimum of 2 years of follow-up. DS patients with type C coronal imbalance undergoing posterior correction surgery from February 2014 to January 2018 were divided into groups by technique: the sequential correction technique (SC group) and the traditional 2-rod technique (TT group). Radiographic parameters, including Cobb angle, coronal balance distance (CBD), global kyphosis (GK), thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic incidence (PI), pelvic tilt (PT), and sacral slope, were assessed pre- and postoperatively. The SF-36 questionnaire was used to assess quality of life. A total of 34 patients were included. Significant postoperative improvement in the Cobb angle of the main curve, CBD, GK, TK, LL, SVA, and PT was found in both groups (p < 0.05). Postoperatively, the coronal balance was type A in 13 patients (92.9%) in the SC group and in 16 patients (80.0%) in the TT group (p = 0.298). In the TT group, 1 patient had deteriorative coronal imbalance immediately postoperatively, and coronal imbalance deteriorated from type A to type C in 2 patients during follow-up. The scores of Physical Functioning, Role-Physical, Bodily Pain, Vitality, Social Functioning, Role-Emotional, and Mental Health were statistically improved postoperatively (p < 0.05) in both groups. Type C coronal imbalance at the last follow-up was associated with a relatively worse quality of life. There were no implant failures during follow-up in the SC group, whereas rod fracture was observed in 3 patients in the TT group. Compared with the traditional 2-rod technique, the sequential correction technique can simplify rod installation procedure, enhance internal instrumentation, and reduce risk of implant failures. The sequential correction technique could be routinely recommended for DS patients with type C coronal imbalance.

The Efficacy of Single-Stage Correction by Posterior Approach for Neglected Congenital Scoliosis: Comparative Analysis According to the Age of Surgical Intervention.

Background: A single-stage correction for congenital scoliosis through a posterior-only approach is a commonly used surgical technique. However, there are few studies on the surgical treatment effect of posterior single-stage correction in patients with neglected congenital scoliosis. Methods: Patients who underwent a single-stage posterior correction for congenital scoliosis with a minimum follow-up of 2 years were divided into three groups based on age: Group A (7–11 years), B (12–18 years) and C (>18 years). A comparison of surgical, radiological, and clinical outcomes was performed for three groups. Results: The Cobb angle changed form 75 ± 18° to 37 ± 18° with a correction rate of 53%. Group A showed a significantly higher correction rate than Group B and C (all p < 0.001). The amount of blood loss in Groups B and C was significantly larger than that of Group A (p = 0.015). Pulmonary complications were significantly higher in Group C (p = 0.007). Conclusions: A single-stage correction with pedicle screws through a posterior-only approach achieved a significant correction with improved outcomes, even in neglected cases. However, the early correction for younger patients was still more beneficial in terms of bleeding loss, complications, and flexible curve correction.

Restoring Theoretically Optimal Lumbar Lordosis Deduced from Pelvic Incidence and Thoracic Kyphosis has Advantages to Decrease the Risk of Postoperative Mechanical Complications in Adult Spinal Deformity.

ObjectiveTo establish a regression formula for LL based on individual PI and TK in asymptomatic population aged over 50 years and evaluate its predictive power for the occurrence of postoperative mechanical complications in patients with adult spinal deformity (ASD).MethodsA total of 178 asymptomatic adults were recruited for the study. The association between LL and PI, LL and TK, was investigated to establish a predictive formula for ideal LL based on PI and TK. Additionally, 93 ASD patients undergoing posterior correction surgery were retrospectively analyzed. The absolute value of the gap between postoperative actual LL and theoretical LL was defined as ΔLL. Patients were classified into two groups depending on the presence or absence of mechanical complications. The demographic and radiological data of patients were compared between the two groups.ResultsA significant association was found between LL and PI (r = 0.599, P < 0.001), LL and TK (r = 0.523, P < 0.001). A novel formula was developed as follows: LL = 0.7*PI + 0.4*TK + 1 (R2 = 0.524). In the validation cohort, 29 patients developed mechanical complications. Postoperative ΔLL (12.5 ± 7.6° vs. 7.0 ± 5.4°, P = 0.001) significantly increased the incidence of mechanical complications. The most appropriate threshold of ΔLL for predicting mechanical complications was 9.8°. For patients whose ΔLL were <9.8° and >9.8°, the incidence of mechanical complications was 19.4% and 54.8%, respectively.ConclusionIdeal lumbar lordosis should be matched for PI and TK. The developed prediction formula for LL based on PI and TK in asymptomatic adults may help surgeons to understand the mechanisms of lumbar alignment generation and predict occurrence of mechanical complications after ASD surgery.

The impact of blood conservation techniques on transfusion requirements for posterior adolescent idiopathic scoliosis corrections: do we need a routine cross-match for the operation?

Various strategies are utilised to reduce blood loss and allogenic blood transfusion for posterior instrumented correction of Adolescent Idiopathic Scoliosis (AIS). The aim of this study was to evaluate post-operative blood transfusion requirements to determine whether routine cross matching of blood is essential. This is a prospective case series of 84 patients who underwent posterior correction of AIS between September 2016 and March 2018. We reviewed demographic, operative, radiological data and transfusion requirements. Results of transfusion requirements in 44 patients who underwent Ponte osteotomies (F:M = 36:8; mean age 14.8years) were compared with 40 patients (F:M = 9:31; mean age 14.4years) who did not and provided the control group. A transfusion trigger of 80mg/dl with clinical caveats was utilised. Cross matching and procurement costs of allogenic blood/unit were ascertained. Five patients required postoperative blood transfusion on days 2 or 3. Anaesthetic time (p = 0.0003) and preoperative Cobb angle (p = 0.0166) were significant variables between both groups and post-operative Hb (p = 0.0084) and number of levels fused (p = 0.0312) being significant in patients requiring transfusion. Unutilised units on the day of the operation incurred £30,030 (£380/patient or £154/unit) in operational costs. Our audit demonstrates that transfusion on the day of the operation was not required. We recommend that routine crossmatching is not essential for primary posterior correction for AIS with blood conservation techniques. Blood grouping with availability of urgent blood is sufficient at the onset of operation. This has financial implications and cost savings. III.

Role of crenel lateral lumbar interbody fusion in the precise selection of fusion level in posterior correction for adult degenerative scoliosis

Objective: To investigate the role of minimally invasive crenel lateral lumbar interbody fusion (CLIF) in the decision of fusion level in posterior correction for severe adult degenerative scoliosis. Methods: This is a prospective study.Patients with level Ⅴ and Ⅵ of Lenke-Silva classification who were treated at Department of Orthopedics,the Second Affiliated Hospital, School of Medicine, Zhejiang University from June 2016 to March 2019 were included.First,the enrolled patients completed the preoperative clinical and imaging examination,the Lenke-Silva classification was evaluated,the surgical segments in first-stage CLIF was determined and the fusion segments required for single-stage posterior correction was predicted.After the first-stage CLIF,patients received reassessment of Lenke-Silva classification and global coronal and sagittal balance.Patients were divided into two groups:the effective group (level of Lenke-Silva classification decreased) and the ineffective group (level of Lenke-Silva classification unchanged).Second-stage posterior surgery was performed based on the results of reassessments.The fusion segment,Cobb angle,parameters of global coronal and sagittal plane,visual analogue pain score (VAS) and Oswestry disability index (ODI) were compared between the two groups preoperatively,after first-stage CLIF,second-stage posterior fixation and at the final follow-up.The potential factors associated with the decrease of the level of Lenke-Silva classification were recorded and compared between the two groups.Independent sample t test,repeated measure analysis of variance,rank sum test,χ2 test or Fisher exact method were used to compare the difference among groups. Results: Fifty-four patients were enrolled,including 8 males and 46 females,aged (68.8±5.8) years (range:56 to 77 years).Preoperatively,26 patients were classified as level Ⅴ by Lenke-Silva classification,28 cases were grade Ⅵ.CLIF was performed in 194 segments,with 114 segments(58.8%) receiving anterior column realignment (ACR) and 15 segments(7.7%) using hyperlordotic cages.After first-stage CLIF,22 patients with level Ⅴ and 10 patients with Ⅵ of Lenke-Silva classification decreased and were classified into effective group.The level of the remaining 4 patients with level Ⅴ and 18 patients with grade Ⅵ unchanged and were classified into ineffective group.Preoperatively,the apical vertebrae was below L1 in all 32 patients of effective group and 18 (81.8%,18/22) patients of ineffective group.The difference was statistically significant (P=0.023).There were 7 (31.8%,7/22) patients had continuous osteophyte in front of the intervertebral space in ineffective group,while none patient had continuous osteophyte in front of the intervertebral space in effective group,and the difference was statistically significant (P=0.001).In first-stage CLIF,more intraoperative ACR(71.2% vs.39.5%,χ²=20.660,P<0.01)and hyperlordotic cage (12.7% vs.0,P=0.001) were used in the effective group,while there was less severe cage subsidence after the operation (5.9% vs.15.8%,χ²=4.793,P=0.029) in effective group.After first-stage CLIF,there was no difference in the Cobb angle between the two groups.While,lumbar lordosis (LL) in effective group (34.0±8.3)° was greater than that of the ineffective group (25.5±9.7)° (t=3.478,P=0.001),and the difference between the pelvic incidence (PI) and LL in effective group (15.7±4.6)°was significantly smaller than ineffective group(20.0±10.8)° (t=-2.129,P=0.038).The posterior fusion levels was less,the rate of fusion to thoracic spine region and the actual fusion segment was less than that of single-stage posterior correction in effective group (all P<0.01).All patients were follow-up for 24 to 45 months.There was no significant difference in radiological and clinical results between the two groups after first-,second-stage surgery and at the final follow-up (all P>0.05). Conclusions: First-stage CLIF decreased the Lenke-Silva classification of some patients with severe degenerative scoliosis.Combined with the reassessment of Lenke-Silva classification and global coronal and sagittal plane,it helps to accurately determine the fusion segment.Decrease of Lenke-Silva classification is associated with the preoperative level of apical vertebrae,continuous osteophytes in front of the intervertebral space,intraoperative use of ACR and hyperlordotic cage and the degree of cage subsidence postoperatively.

OV05 CONCOMITANT MIRS (MINI INVASIVE RIVES STOPPA) AND DREAM (DIASTASIS REPAIR ENDOSCOPICALLY ASSISTED MINI-INVASIVE) FOR THE CORRECTION OF COMBINED VENTRAL HERNIA AND DIASTASIS RECTI

Abstract Aim Concomitant MIRS (Minimally Invasive Rives-Stoppa) and DREAM (Diastasis Repair Endoscopically Assisted Minimally-invasive) for the correction of combined ventral hernias and diastasis recti. Material and Methods The video shows the combined repair of umbilical hernia and diastasis correction by concomitant minimally invasive hernia repair without division of the posterior sheath and diastasis correction by parietoscopy. Results A short periumbilical incision is performed, the Alexis retractor is put in place, preaponeurotic dissection is carried out by direct access and two axial incisions of both anterior sheaths are performed parallel to and 1cm next to the midline. The umbilical hernia and one unexpected epigastric hernia are reduced and repaired by suture. Additional suture approximating the medial borders of anterior sheath incisions over the previous suture is performed to strengthen the repair. The patch is deployed in the retromuscular space superficial to the suture line, without any incision of the posterior sheath and without any fixation. Then the top of the Alexis retractor and the camera are put in place, insufflation at 10mm Hg is started and the parietoscopic step is carried out. Two 5mm trocars are placed and preaponeurotic dissection is extended up to the xiphoid process. The diastasis correction is carried out by a continuous suture approximating both rectus muscles from the xiphoid process to the umbilical hernia suture. Conclusions The MIRS technique consists of retromuscular patch repair without division of the posterior sheath, and concomitant DREAM technique reinforces the hernia repair and provides diastasis correction.

Post-marketing surveillance on safety and efficacy of posterior spinal correction and fusion with the CD Horizon Solera instrumentation for adolescent idiopathic scoliosis. A retrospective cohort study

BackgroundPost-Market Clinical Follow-Up has been integrated into the new Medical Device Regulations since 2020. The CD Horizon Solera 4.75 mm instrumentation (CD-Solera) was introduced worldwide in 2009, and specifically intended for surgical treatment of pediatric and adolescent scoliosis patients. The objective of this study was to evaluate the safety and efficacy of the CD-solera 4.75 instrumentation in surgical treatment of adolescent idiopathic scoliosis (AIS). Methods94 consecutive AIS patients, 82 female, 12 male, who underwent posterior correction with CD-Solera instrumentation between 2010 and 2016 at age 14.8 ± 1.6 years, were retrospectively included. The minimum follow-up was two years. On pre- and postoperative biplanar full spine radiographs Cobb angles of the primary and secondary curves and sagittal profile were measured before surgery, immediately postoperative, and at two-year follow-up. Medical records were reviewed for complications. Clinical outcome was analyzed using theSRS-22r questionnaire. ResultsIn this study 77% of the patients had a structural thoracic curve (type Lenke 1 or 2), and 23% had a structural (thoraco-)lumbar curve (Lenke 3-6). A correction of 55.1% and 51.7% was achieved respectively immediately post-operative, and at last-year follow up for the primary curve. The mean loss of correction was 2°. Health related quality of life was 4.0 (good) on the SRS-22r-questionnaire. In total six revision operations were executed, of which one was related to the material (rod breakage). Other reasons for revision operation were not due to the material. No neurological problems were encountered. ConclusionIn patients with AIS the initial correction and maintenance of correction as achieved by posterior spinal fusion using the CD-Solera instrumentation, is comparable to other reported devices. Complication rates are low and health related quality of life comparable to literature. The CD-Solera can be regarded as a safe and effective instrumentation in surgical treatment of AIS.

Surgical Outcome Prediction Using a Four-Dimensional Planning Simulation System With Finite Element Analysis Incorporating Pre-bent Rods in Adolescent Idiopathic Scoliosis: Simulation for Spatiotemporal Anatomical Correction Technique.

An optimal surgical strategy for adolescent idiopathic scoliosis (AIS) is to provide maximal deformity correction while preserving spinal mobile segments as much as possible and obtaining a balanced posture. From a spatiotemporal deformity correction standpoint, we recently showed that anatomical four-dimensional (4D) spinal correction could be accomplished by curving the rod. In the surgical procedure, two rods are bent identically to confirm spinal anatomical alignment without referring to the intraoperative alignment of the deformity. Therefore, anatomically designed rods have been developed as notch-free, pre-bent rods for easier anatomical reconstruction. In addition to providing the best spinal instrumentation configurations as pre-bent rods, prediction of surgical outcome along with its biomechanical impact can be obtained by simulation of the surgical procedures with computer modeling. However, an objective model that can simulate the surgical outcome in patients with AIS has not been completely elucidated. The present study aimed to compare simulated deformity corrections based on our newly developed spatiotemporal morphological 4D planning simulation system incorporating pre-bent rods and actual deformity corrections in patients with AIS. A consecutive series of 47 patients who underwent anatomical posterior correction for AIS curves were prospectively evaluated. After multilevel facetectomy, except for the lowest instrumented segment, 11 types of pre-bent rods were used. Patient demographic data, radiographic measurements, and sagittal rod angles were analyzed within 1 week of surgery. Our simulation system incorporating pre-bent rods showed a significant correlation with the actual postoperative spinal alignment. The present study demonstrated the feasibility of our simulation system and the ability to simulate the surgical procedure using the pre-bent rods. The simulation system can be used to minimize the differences between the optimal and possible outcomes related to the instrumentation levels and rod shapes. Preoperative assumption of rod shape and length can contribute to a reduction in operative time which decreases blood loss and risk of infection. The results of the finite element analysis in the simulation system measured for each individual patient would also provide a more realistic representation of the surgical procedures.