Posterior Spinal Fusion Research Articles

Minimally Invasive Posterior Spinal Nonfusion Surgery in Patients With Adolescent Idiopathic Scoliosis Using a Bipolar One-Way Self-Expanding Rod System: Protocol for a Single-Center Clinical Cohort Study.

The current surgical treatment for patients diagnosed with progressive and severe adolescent idiopathic scoliosis (AIS) consists of the correction of the spinal curvature, followed by posterior spinal fusion (PSF). However, research has uncovered short- and long-term complications of posterior spinal fusion in patients with AIS. Minimally invasive growing rod techniques have successfully been used to treat patients with early-onset scoliosis and neuromuscular scoliosis. It may be questioned if minimally invasive posterior spinal nonfusion (PSnF) surgery with bipolar instrumentation can be used for the treatment of AIS. This study will be performed to monitor the efficacy and safety of PSnF surgery by using a commercially available Conformité Européenne-certified spinal implant consisting of bilateral bipolar one-way self-expanding rods (OWSER) for the treatment of patients diagnosed with AIS. In 14 selected patients with AIS with Lenke 1-6 curves, minimally invasive PSnF surgery with the OWSER system is performed after the failure of conservative treatment (curve progression of >5° within 1 year). The patients are over 7 years of age, with a major Cobb angle of ≥30°, sufficient flexibility, and a Risser stage of ≤2. Patients will be followed over time, according to the standard medical care. Efficacy will be measured using radiological and patient satisfaction assessments and safety will be determined by the amount of perioperative complications. Patient inclusion started on November 17, 2021 and we hope to finalize patient inclusion by the beginning of 2025. The first results will be expected by the beginning of 2024. Minimally invasive PSnF in patients with AIS is presented as a less invasive surgical technique that prevents the progression of the scoliotic curve and that allows minor posture correction of coronal imbalance. This will be the first study to examine whether the PSnF bipolar OWSER instrumentation will be the next generation of surgical instrumentation in AIS. ClinicalTrials.gov NCT04441411; https://clinicaltrials.gov/study/NCT04441411. DERR1-10.2196/47222.

Results of posterior spinal fusion after failed anterior vertebral body tethering.

In patients with adolescent idiopathic scoliosis (AIS) undergoing anterior vertebral tethering (AVBT), some will subsequently require posterior spinal fusion (PSF). Limited data exist on clinical and radiographic outcomes of fusion after tether failure. 490 patients who underwent AVBT were retrospectively analyzed. Twenty patients (4.1%) subsequently underwent conversion to PSF. A control group of patients with primary PSF (no previous AVBT) was matched for comparison. Data were compared using paired t-tests and Fisher Exact Tests. There was a significant increase in estimated blood loss (EBL) (p = 0.002), percent estimated blood volume (%EBV) (p = 0.013), operative time (p = 0.002), andincreased amount of fluoroscopy (mGy) (p = 0.04) as well as number of levels fused (p = 0.02) in the AVBT conversion group compared to primary fusion. However, no difference was found in implant density (p = 0.37), blood transfusions (p = 0.11), or intraoperative neuromonitoring events (p > 0.99). Both groups attained similar thoracic and lumbar percent correction (major coronal curve angle) from pre-op to the latest follow-up (thoracic p = 0.507, lumbar p = 0.952). A subset of patients with AVBT will require conversion to PSF. Although technically more challenging, revision surgery can be safely performed with similar clinical and radiographic outcomes to primary PSF.

Flexibility-tilt agreement best predicts shoulder balance following posterior spine fusion for adolescent idiopathic scoliosis.

We propose a novel concept, called flexibility-tilt agreement (FTA), which could be applied intra-operatively to improve shoulder balance following posterior spine fusion for Adolescent Idiopathic Scoliosis (AIS). We retrospectively applied this concept to a cohort with thoracic-only curves, seeking to: (1) evaluate the impact of FTA and other peri-operative variables on post-operative shoulder balance, and (2) evaluate deformity characteristics associated with achieving FTA. A single-institution registry was queried for patients undergoing PSF from 2000 to 2017 with main thoracic and double thoracic curves with at least 2-year follow-up. Flexibility was defined as the Cobb angle of the unfused proximal thoracic curve (cephalad to chosen UIV) on pre-operative bender. Tilt refers to post-operative UIV tilt angle. FTA means these values cancel (Flexibility + Tilt = 0 ± 5°). Logistic regression was performed to determine the association between peri-operative variables and shoulder balance. One hundred and sixty-one patients were included, mean age 13.6years old, and 47-month mean follow-up. FTA was achieved in 74 (46%) patients and was associated with post-operative (OR = 4.59) and final (OR = 6.98) medial shoulder balance with a threshold of 6° (AUC = 0.77, p = 0.038). FTA was the best predictor of shoulder balance of all tested variables. Patients that showed flexibility-tilt agreement, or FTA, had vastly increased odds of medial and lateral shoulder balance at a minimum of 2-year follow-up for all thoracic curves. Future studies can evaluate whether applying FTA to determine intra-operative corrective maneuvers prospectively leads to improvements in shoulder balance. Level III-retrospective comparative study.

The problem of double thoracic idiopathic scoliosis: a non-systematic literature review

Objective. To analyze the current situation in the community of spine surgeons regarding the determination of the zone of posterior spinal fusion for double thoracic idiopathic scoliosis.Material and Methods. The content of 16 publications containing the results of surgical correction of double thoracic scoliotic deformities was analyzed. The number of studied clinical cohorts was 25, of which in 13 groups only the right-sided main thoracic (MT) curve (MT group) was blocked, and in 12 – both MT and left-sided proximal upper thoracic (PT) curve (MT + PT group). Four parameters were analyzed in both groups: preoperative Cobb angle, preoperative curve mobility, deformity correction, and postoperative deformity progression.Results. Significant differences were found in the MT and MT + PT groups only in two cases: for the initial Cobb angle of the PT curve and the magnitude of its correction (Cobb angle before surgery minus Cobb angle immediately after the intervention). When choosing the extent of the instrumental fusion zone, the authors of the publications included in the review were guided, first of all, by the initial magnitude of the Cobb angle of the proximal thoracic curve. In the MT + PT group, it averaged 37–40° and was 11–13° more than in the MT group. At the same time, PT curve mobility in both groups is not statistically different. The achieved correction was statistically significantly greater in the МT + РT group, despite a more severe proximal curvature as compared to the MT group. Postoperative dynamics of kyphosis (both T2–T5 and T5–T12) is insignificant. The length of the instrumental spinal fusion zone has virtually no effect on the parameters of the sagittal contour of the thoracic spine. A fairly high frequency of the adding-on phenomenon development (20.6 %) indicates the presence of a connection between this complication and the dynamics of PT curve, but the available data are not enough to formulate a final conclusion. Literature data regarding patients’ self-assessment of quality of life after surgical treatment of Lenke types 1 and 2 scoliosis are scarce, although the majority of those operated on assess the result of treatment as positive.Conclusion. The problem of determining the extent of the instrumental fusion zone for double thoracic scoliosis remains unresolved. Most surgeons focus not so much on the mobility of the proximal curve, but on its magnitude. There is no consensus in predicting the development of the adding-on phenomenon; there is little information about changes in the quality of life of patients after surgery. New research is needed.

Selection of Fusion Levels in Adolescent Idiopathic Scoliosis.

PURPOSEOF REVIEW: Posterior spinal fusion (PSF) is the preferred treatment for adolescent idiopathic scoliosis (AIS) patients with surgical range curves. Selection of the proper upper and lower instrumented vertebrae (UIV and LIV) is essential in curve correction and achieving a successful outcome, while preventing short and long-term complications. RECENT FINDINGS: The literature lacks high-level evidence, especially on outcomes of modern surgical techniques. However, evidence seems to show that a great majority of AIS patients have excellent clinical and functional long-term outcomes after PSF. We have reviewed the evidence and provided our level selection recommendations, which should be weighed against the body of evidence on the topic when selecting fusion levels in AIS.

Combined Anterior Thoracic Vertebral Body Tethering and Posterior Lumbar Tethering Results in Quicker Return to Sport and Activity Compared to Posterior Spinal Instrumented Fusion in Patients with Adolescent Idiopathic Scoliosis.

Retrospective comparative study. To compare patient-reported physical activity between anterior thoracic vertebral body tethering and posterior lumbar spine tethering (ATVBT/PLST) and posterior spinal instrumentation and fusion (PSIF) with minimum 2year follow-up. Consecutive skeletally immature patients with idiopathic scoliosis and a thoracic and lumbar curve magnitude ≥40° who underwent either ATVBT/PLST or PSIF from 2015-2019 were included. The primary outcome was rate of returning to sport. Secondary outcomes included ability to bend and satisfaction with sport performance as well as weeks until return to sport, school, physical education (PE) classes, and running. Ten patients underwent ATVBT/PLST and 12 underwent PSIF. ATVBT/PLST patients reported significantly faster return to sport (13.5weeks vs 27.9weeks, P = .04), running (13.3weeks vs 28.8weeks, P = .02), and PE class (12.6weeks vs 26.2weeks, P = .04) compared to PSIF patients. ATVBT/PLST patients reported that they had to give up activities due to their ability to bend at lower rates than PSIF patients while reporting "no changes" in their ability to bend after surgery at higher rates than PSIF patients (0% vs 4% giving up activities and 70% vs 0% reporting no changes in bending ability for ATVBT/PLST and PSIF, respectively, P = .01). Compared to PSIF patients, ATVBT/PLST patients experienced less main thoracic and thoracolumbar/lumbar curve correction at most recent follow-up (thoracic: 41 ± 19% vs 69 ± 18%, P = .001; thoracolumbar/lumbar: 59 ± 25% vs 78 ± 15%, P = .02). No significant differences in the number of revision surgeries were observed between ATVBT/PLST and PSIF patients (4 (40%) and 1 (8%) for ATVBT/PLST and PSIF, respectively, P = .221). ATVBT/PLST patients reported significantly faster rates of returning to sport, running, and PE. In addition, ATVBT/PLST patients were less likely to have to give up activities due to bending ability after surgery and reported no changes in their ability to bend after surgery more frequently than PSIF patients. However, the overall rate of return to the same or higher level of sport participation was high amongst both groups, with no significant difference observed between ATVBT/PLST and PSIF patients.

Contusion Spinе Injury in the Thoracolumbar Junction Region

Summary – Contusion spine injuries resulting from direct traumatic mechanisms that lead to spinal cord lesion are relatively rare during peacetime. The specific characteristics of such injuries are not extensively covered in contemporary literature. The need to optimize treatment methods for military personnel engaged in active combat operations on the territory of Ukraine necessitates an examination of this specific type of injury.
 Objective: To describe the clinical presentation and explore possible therapeutic approaches for closed contusion spinal cord injuries in the thoracolumbar junction.
 Materials and Methods: We conducted an analysis of patient data from those admitted for inpatient treatment at the Romodanov Neurosurgery Neurosurgery of National Academy of Medical Sciences of Ukraine, as well as patients referred to other healthcare institutions in Kyiv, from February 2022 to May 2023.
 Results: We analyzed the treatment outcomes of 5 patients, aged 27 to 53 years (mean age: 37.6 years), presenting with initial neurological deficits classified as ASIA A. Surgery was performed in 3 patients. All cases underwent wide laminectomy with facetectomy at the level of injury. Large arachnoid cysts were drained, and in one case, a subdural hematoma was removed. Posterior spinal fusion using an 8-screw transpedicular system was performed in all patients, utilizing a minimally invasive percutaneous approach. At the 2-month follow- up positive dynamics were observed in all patients. Neurological status improved to ASIA B in 2 cases and ASIA C in 1. Recovery of proprioceptive sensitivity was noted, as well as an increase in the intensity of neuropathic pain (up to 5-7 points at 2 months). In 2 patients undergoing conservative therapy, the neurological impairment level remained ASIA A, with pain intensity not exceeding 2 points.
 Conclusions: The findings emphasize the need for more comprehensive instrumental assessment in patients with suspected contusion spinal cord injuries. Active use of surgical treatment methods in this type of injury contributes to achieving better clinical outcomes.

Minimally Invasive Surgery for Posterior Spinal Instrumentation and Fusion in Adolescent Idiopathic Scoliosis: Current Status and Future Application.

The posterior minimally invasive spine surgery (MISS) approach-or the paraspinal muscle approach-for posterior spinal fusion and segmental instrumentation in adolescent idiopathic scoliosis (AIS) was first reported in 2011. It is less invasive than the traditionally used open posterior midline approach, which is associated with significant morbidity, including denervation of the paraspinal muscles, significant blood loss, and a large midline skin incision. The literature suggests that the MISS approach, though technically challenging and with a longer operative time, provides similar levels of deformity correction, lower intraoperative blood loss, shorter hospital stays, better pain outcomes, and a faster return to sports than the open posterior midline approach. Correction maintenance and fusion rates also seem to be equivalent for both approaches. This narrative review presents the results of relevant publications reporting on spinal segmental instrumentation using pedicle screws and posterior spinal fusion as part of an MISS approach. It then compares them with the results of the traditional open posterior midline approach for treating AIS. It specifically examines perioperative morbidity and radiological and clinical outcomes with a minimal follow-up length of 2 years (range 2-9 years).

Alterations in Magnitude and Shape of Thoracic Kyphosis Following Surgical Correction for Adult Spinal Deformity.

Retrospective review of prospective multicenter data. This study aimed to investigate the shape of TK before and after fusion in ASD patients treated with long fusion. ASD patients undergoing posterior spinal fusions including at least T5 to L1 without prior fusion extending to the thoracic spine were included. Patients were categorized based on the preoperative T1-T12 kyphosis into: Hypo-TK (if < 30°), Normal-TK, and Hyper-TK (if > 70°). Regional kyphosis at T10-L1 (Distal), T5-T10 (Middle), and T1-T5 (Proximal) and their relative contributions to total kyphosis were compared between groups, and the pre-to postoperative changes were investigated using paired t test. In total, 329 patients were included in this analysis (mean age: 57 ± 16years, 79.6% female). Preoperative T1-T12TK for the entire cohort was 40.9 ± 2° (32% Hypo-TK, 11% Hyper-TK, 57% Normal-TK). The Hypo-TK group had the smallest distal TK (5.9 vs 17.1 & 26.0), and middle TK (8.0 vs 25.3 & 45.4), but the percentage of contribution to total kyphosis was not significantly different (Distal: 24.1% vs 34.1% vs 32.8%; Middle: 46.6% vs 53.9% vs 56.8%, all P > .1). Postoperatively, T1-12TK increased significantly (40.9 ± 2.0° vs 57.8 ± 17.6°). Each group had a decrease in distal kyphosis (Hypo-TK 2.6 ± 10.4°; Normal-TK 8.9 ± 11.5°; Hyper-TK 14.9 ± 12°, all P < .05). The middle kyphosis significantly decreased for Hyper-TK (11.8 ± 12.4) and increased for both Normal-TK and Hypo-TK (3.8 ± 11° and 14.2 ± 11°). Proximal TK increased significantly for all groups by 14-18°. Deterioration from Normal-TK to Hyper-TK postoperatively was associated with lower rate of patient satisfaction (59.6% vs 77.3%, P = .032). Posterior spinal fusion for ASD alters the magnitude and shape of thoracic kyphosis. While 60% of patients had a normal TK at baseline, 30% of those patients developed iatrogenic hyperkyphosis postoperatively. Patients with baseline hypokyphosis were more likely to be corrected to normal TK than hyperkyphotic patients. Future research should investigate TK restoration in ASD and its impact on clinical outcomes and complications.

Unilateral interlaminar fenestration on the convex side provides a reliable access for intrathecal administration of nusinersen in spinal muscular atrophy: a retrospective study

BackgroundAs the first gene therapy for spinal muscular atrophy (SMA), nusinersen is supposed to be administrated via intrathecal injection regularly for a lifetime. However, for SMA patients with severe spinal deformities, bony fusion following posterior spinal instrumentation sets great obstacles for the application of nusinersen. Therefore, efforts have been devoted to the exploration of appropriate approach for nusinersen administration. This study aims to evaluate the safety and reliability of unilateral interlaminar fenestration on the convex side during spinal fusion surgery for intrathecal nusinersen injection in SMA.ResultsSMA patients receiving posterior spinal fusion and interlaminar fenestration in Peking Union Medical College Hospital from January 2020 to October 2021 were retrospectively analyzed. 13 patients were included. Of the 13 patients, 10 were classified into SMA type II and 3 into SMA type III. Distal fusion to pelvis was undertaken in 11 patients; while L5 was selected as the lowest instrumented vertebra in the other 2 patients. All patients received interlaminar fenestration on the convex side only with an area of about 15 mm × 20 mm. Fenestration at L2–L3 level was performed in 6 patients; while L3–L4 level was selected for windowing in the remaining 7 patients. 9 of the 13 patients received lumbar puncture and intrathecal nusinersen administration during the 1-year follow-up, with an accumulative total of 50 times. All injections were performed successfully under ultrasound guidance, with no one transferred to radiographic assistance. No severe complications occurred after injection.ConclusionsIn SMA with severe scoliosis planning to receive posterior spinal fusion, unilateral lumbar interlaminar fenestration on the convex side provides a feasible and reliable access for intrathecal nusinersen administration after surgery.

Posterior spinal fusion for adolescent idiopathic scoliosis and the impact of postoperative intravenous dexamethasone supplementation.

Postoperative care pathways for adolescent idiopathic scoliosis patients undergoing posterior spinal fusion have demonstrated decreases in postoperative opioid consumption, improved pain control, and lead to decreased lengths of stay. Our objective was to implement postoperative steroids to reduce acute postoperative opioid consumption, pain scores, and length of stay. Dosing consisted of intravenous dexamethasone 0.1 mg/kg up to 4 mg per dose for a total of three doses at 8, 16, and 24 h postoperatively. As part of a quality initiative, we compared three cohorts of patients. The initial retrospective epidural cohort (EPI) (n = 59) had surgeon placed epidural catheters with infusion of ropivacaine 0.1% postoperatively for 18-24 h. Following an institutional change in postoperative care, epidural use was discontinued. A second cohort (n = 149), with prospectively collected data, received a surgeon placed erector spinae plane block and wound infiltration with a combination of liposomal and plain bupivacaine (LB). A third cohort (n = 168) was evaluated prospectively. This cohort received a surgeon placed erector spinae plane block and wound infiltration with liposomal and plain bupivacaine and additionally received postoperative dexamethasone for three doses (LB + D). Compared to the LB cohort, the LB + D cohort demonstrated statistically significant decreases in oral milligram morphine equivalents per kilogram at 0-24, 24-48, and 48-72 h. There was a statistically significant difference in median pain scores at 24-48 and 48-72 h in LB + D versus LB. The LB + D cohort's median length of stay in hours was significantly less compared to the LB cohort (52 h vs. 70 h, p < 0.0001). Postoperative intravenous dexamethasone was added to an established postoperative care pathway for patients undergoing posterior spinal fusion for idiopathic scoliosis resulting in decreased VAS pain scores, opioid consumption, and shorter length of stay.

A Novel Multiple Screw Distraction Reducer System in the Treatment of Scoliosis with a Severe Rib Hump.

The treatment of scoliosis with a severe rib hump remains a major challenge. Traditional vertebral rotation techniques are not satisfactory, and thoracoplasty has many pulmonary complications that limit its application. A novel surgical device, the multiple screw distraction reducer (MSDR) system, provides longitudinal distraction during the corrective operation while at the same time providing lateral translation and axial derotation, which may facilitate the correction of a rib hump. This study was performed to investigate the effectiveness of the MSDR system for adolescent idiopathic scoliosis (AIS) with a severe rib hump. This was a case-matched study of patients with retrospectively collected data from our hospital between January 2017 and December 2021. Sixty-eight patients who underwent one-stage posterior pedicle screw-instrumented spinal fusion were matched by the Cobb angle of the main curve and rib hump. All patients underwent a minimum of 2 years of follow-up. The patients were divided into two groups: the MSDR group (using the MSDR system, n = 34) and the DVR group (using direct vertebral derotation, n = 34). The patients were evaluated for the height of the rib hump, deformity correction, complications, and SRS-30 scores. The unpaired Student's t-test and Pearson's χ2 -test were used to compare the outcome measures between the two groups. Multiple linear regression analysis was used to examine the variables that affected the correction of a rib hump. The rib hump was 30.21 ± 6.21 mm versus 29.35 ± 6.52 mm (p = 0.583) preoperatively and 9.18 ± 4.06 mm versus 13.82 ± 5.54 mm (p < 0.001) at the last follow-up in the MSDR and DVR groups, respectively. The correction rates were 70.83% and 53.56%, respectively (p < 0.001). Preoperatively, the main thoracic curve was 58.43° ± 7.97° and 57.84° ± 6.32° (p = 0.736) and was corrected to 10.92° ± 5.47° and 19.14° ± 5.32° (p < 0.001) at last follow-up in the MSDR and DVR group, respectively. Thoracic kyphosis was restored from 18.24° ± 5.19° and 17.98° ± 5.28° (p = 0.836) in the MSDR and DVR group to 24.59° ± 4.41° and 19.32° ± 4.96° (p < 0.001), respectively. Correction of apical vertebra rotation and translation in the main thoracic curve were significantly better in the MSDR group than in the DVR group (p < 0.05). There was no significant difference in the Lenke type, implant density, estimated blood loss, or follow-up duration between the two groups, whereas the operation time in the DVR group was significantly less than that in the MSDR group. There were only two minor pulmonary complications in the MSDR group. At the last follow-up, the MSDR group scored higher in terms of appearance and satisfaction (p < 0.05). The MSDR system, enabling better coronal alignment, thoracic kyphosis, and axial derotation, could be a safe and effective technique for severe rib hump correction in AIS.

The global impact of the COVID-19 pandemic on pediatric spinal care: A multi-centric study.

The COVID-19 pandemic has affected healthcare worldwide since December 2019. We aimed to identify the effect of the COVID-19 pandemic on outpatient clinic and surgical volumes and peri-operative complications for pediatric spinal deformities patients. In this multi-center retrospective study, outpatient visits (in-person and virtual care) and pediatric spine surgeries volumes in four high-volume pediatric spine centers were compared between March and December 2019 and the same period in 2020. Peri-operative complications were collected and compared in the same periods. Descriptive statistics were calculated, and comparative analyses were performed. During the 2020 study period, the outpatient visit (in-person and virtual care) volume decreased during local lockdown periods by 71% for new patients (p < 0.001) and 53% for returning patients (p = 0.03). Overall, for 2020, there was a 20% reduction in new patients (p = 0.001) and 21% decrease in returning patients (p < 0.001). During the pandemic, there was also 20% less overall surgical volume of adolescent idiopathic scoliosis (AIS) patients undergoing primary posterior spinal fusion, with a 70% reduction during lockdown times (p < 0.001). Complication rate and profile were similar between periods. There was a significant decrease in outpatient pediatric spine outpatient visits, particularly new patients, which may increase the proportion of pediatric patients with spinal deformities that present late, meeting surgical indication. This, in combination with the reduction in surgical volume of AIS over the first year of the pandemic, could result in an extended waitlist for surgeries during years to come. Complication rate was similar for both periods, suggesting it is safe to continue elective pediatric spine surgery even in a time of a pandemic. level IV.

Factors Associated with Postoperative Opioid Use in Adolescents

BackgroundWe aimed to identify factors associated with postoperative prescription opioid use in adolescents. MethodsAdolescents aged 13–20 years undergoing surgery were prospectively recruited from a children's hospital. Adolescent-parent dyads completed a preoperative survey, measuring clinical and sociodemographic factors, and two postoperative surveys evaluating self-reported opioid use at 30- and 90-days. Poisson regression analysis identified factors associated with the number of pills used within 90-days, adjusting for age, gender, race/ethnicity, surgery type, and pain at discharge. ResultsWe enrolled 119 adolescents who reported postoperative opioid use following posterior spinal fusion (PSF) (50 %), arthroscopy (23 %), pectus excavatum repair (11 %), tonsillectomy (8 %), and hip reconstruction (7 %). Overall, 81 % of adolescents reported unused opioids. The median pain score at discharge was 7 (IQR:5–8). Adolescents reported using a median of 7 (IQR:2–15) opioid pills, with 20 (IQR:7–30) pills left unused. Compared to all other surgeries, adolescents undergoing PSF reported the highest median pill use (10, IQR:5–29; p = 0.004). Adolescents undergoing tonsillectomy reported the lowest median pill use (1, IQR:0–7; p = 0.03). On regression analysis, older patient age was associated with a 12 % increase in pill use (95 % CI:3%–23 %). Undergoing PSF was associated with a 63 % increase in pill use (95 % CI:15%–31 %). Each additional pain scale point reported at discharge was associated with a 13 % increase in pill use (95 % CI:5%–22 %). ConclusionsOlder age, surgery type, and patient-reported pain at discharge are associated with postoperative prescription opioid use in adolescents. Understanding patient and surgery-specific factors associated with opioid use may guide surgeons to minimize excess opioid prescribing. Level of evidenceII.

Evaluating the Necessity of Screw Replacement in Sacral Bone Loosening: A Minimally Invasive Approach for Treatment with Local Anesthesia

Abstract Background This study aimed to investigate a minimally invasive approach to address the issue of bone loosening in patients who have undergone posterior spinal fusion surgery. If left untreated, sacral bone loosening can result in nerve damage, reduced mobility, and chronic pain. The standard surgical treatment involves replacing the loosened screw with a larger one, requiring significant surgical intervention and complete instrument disassembly. The use of polymethylmethacrylate (PMMA) to increase the strength of the vertebral body was also described, but the results were contradictory. We aim to evaluate the efficacy of filling just only the gap between bone and screw instead of the vertebral body. Methods This study included patients who had undergone posterior transpedicular stabilization but showed signs of sacral bone loosening in follow-up. The gap between the screw and the bone was targeted instead of the vertebral body and filled using PMMA. The procedure was performed under local anesthesia and fluoroscopy, and the preoperative and postoperative visual analog scale (VAS) scores were compared at 1, 3, and 12 months after the procedure. Results The study included 17 patients who underwent 28 procedures, with 11 patients receiving bilateral and 6 receiving unilateral approaches. The results showed a significant decrease in postoperative VAS scores compared to the preoperative scores, indicating reduced pain and discomfort. PMMA, as a bone filler, has been reported to provide good stability and support to the bone-implant interface, thereby reducing the risk of screw loosening and improving the outcome of spinal fusion surgery. Conclusion In conclusion, the study demonstrates the efficacy of a minimally invasive approach using PMMA to treat sacral bone loosening in patients who have undergone posterior spinal fusion surgery. The procedure is safe, minimally invasive, and provides significant pain relief, making it a viable alternative to traditional surgical methods.

Comparison of Radiographic and Patient-Reported Outcomes After Surgery in Adolescent Idiopathic Scoliosis Between Robotics and Navigation: An Analysis Using Propensity Score Matching.

Purpose This study aimed to compare the radiographic and patient-reported outcomes after surgery in adolescent idiopathic scoliosis (AIS) between robotics and navigation using propensity score matching. Methods This retrospective study involved 50 patients undergoing posterior spinal fusion for AIS between October 2016 and August 2022, utilizing navigation or robotic systems, analyzing them using propensity score matching. The evaluations included assessments using X-ray, Scoliosis Research Society 22-Item (SRS-22) Questionnaire, and CT, considering variables such as age, gender, BMI, and Lenke type. Results Post matching, 13 cases each from robotics and navigation groups were compared. No significant differences were found in the demographic variables, preoperative X-ray parameters, and preoperative SRS-22 scores between the two groups. The robotics group demonstrated a higher perfect accuracy rate (94.0% vs. 84.7%, p=0.005) and a lower deviation rate in pedicle screw placements (1.6% vs. 4.1%, p=0.223). At one year postoperatively, there were no significant differences in the X-ray parameters between both groups. Likewise, no significant differences were found in each domain of SRS-22, but function, self-image, mental health, and satisfaction scores were numerically higher in the robotics group. Conclusion The application of a spinal robotic system in AIS surgery presented enhanced screw accuracy and lower deviation rates, compared to navigation, with no significant differences observed in the X-ray parameters and each domain of SRS-22 at one year postoperatively. This suggests that, to improve patientquality of life (QOL), it is essential for robotic-assisted spine surgery to focus not only on screw accuracy but also on the development of novel robotic-assisted techniques.

Impact of Teriparatide on Complications and Patient-Reported Outcomes of Patients Undergoing Long Spinal Fusion According to Bone Density.

Surgery for adult spinal deformity (ASD) poses substantial risks, including the development of symptomatic pseudarthrosis, which is twice as prevalent among patients with osteoporosis compared with those with normal bone mineral density (BMD). Limited data exist on the impact of teriparatide, an osteoanabolic compound, in limiting the rates of reoperation and pseudarthrosis after treatment of spinal deformity in patients with osteoporosis. Osteoporotic patients on teriparatide (OP-T group) were compared with patients with osteopenia (OPE group) and those with normal BMD. OP-T patients were matched with OPE patients and patients with normal BMD at a 1:2:2 ratio. All patients had a minimum 2-year follow-up and underwent posterior spinal fusion (PSF) involving >7 instrumented levels. The primary outcome was the 2-year reoperation rate. Secondary outcomes included pseudarthrosis with or without implant failure, proximal junctional kyphosis (PJK), and changes in patient-reported outcomes (PROs). Clinical outcomes were analyzed using conditional logistic regression. Changes in PROs were analyzed using a mixed-effects model. Five hundred and forty patients (52.6% normal BMD, 32.9% OPE, 14.4% OP-T) were included. In the unmatched cohort, 2-year reoperation rates (odds ratio [OR] = 0.45 [95% confidence interval (CI): 0.20 to 0.91]) and pseudarthrosis rates (OR = 0.25 [95% CI: 0.08 to 0.61]) were significantly lower in the OP-T group than the OPE group. Seventy-eight patients in the OP-T group were matched to 156 patients in the OPE group. Among these matched patients, at 2 years, 23.1% (36) in the OPE group versus 11.5% (9) in the OP-T group had a reoperation (OR = 0.45, p = 0.0188), 21.8% (34) versus 6.4% (5) had pseudarthrosis with or without implant failure (OR = 0.25, p = 0.0048), and 6.4% (10) versus 7.7% (6) had PJK (OR = 1.18, p = 0.7547), respectively. At 2 years postoperatively, PROs were better among OP-T patients than OPE patients. Subsequently, 78 patients in the OP-T group were matched to 156 patients in the normal BMD group. Among these matched patients, there was no significant difference in 2-year reoperation (OR = 0.85 [95% CI: 0.37 to 1.98]), pseudarthrosis (OR = 0.51 [95% CI: 0.181 to 1.44]), and PJK rates (OR = 0.77 [95% CI: 0.28 to 2.06). Osteoporotic patients on teriparatide demonstrated lower reoperation and symptomatic pseudarthrosis rates 2 years postoperatively compared with osteopenic patients. Moreover, patient-reported and clinical outcomes for osteoporotic patients on teriparatide were not different from those for patients with normal BMD. Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Effects of Preoperative Use of Povidone-Iodine–Impregnated Dressing on Postoperative Rate of Surgical Site Infection in Patients Undergoing Posterolateral Lumbar Spinal Fusion Surgery: A Randomized, Nonblinded, Active-Controlled Trial

BACKGROUND AND OBJECTIVES: No study has evaluated the efficacy of using preoperative antiseptic dressings in reducing the rate of surgical site infection (SSI) in spine surgery thus far. To investigate the efficacy of the use of preoperative povidone-iodine–impregnated antiseptic dressings in patients undergoing instrumented posterolateral lumbar spinal fusion. METHODS: This was a randomized, nonblinded, active-controlled, parallel-group clinical trial. Patients were randomly assigned to the 2 study groups, including treatment and control. Patients in the treatment group received povidone-iodine–impregnated antiseptic dressing applied to the anticipated incision site 12 hours before the operation. The control group merely received the standard perioperative care with no additional intervention or placebo. Patients were followed up for 90 days, and SSIs were recorded. RESULTS: A total of 200 patients were included in this study (100 in each arm). Three cases of SSI were observed in the treatment group compared with 12 in the control one. A significant reduction in the postoperative rate of SSI was observed in the treatment group compared with the control one (P = .029). In addition to study intervention (P = .029), body mass index (P = .005), smoking status (P = .005), duration of the procedure (P = .003), American Society of Anesthesiologists class (P = .002), and diabetes mellitus (P &lt; .001) were significantly associated with the postoperative rate of SSI. CONCLUSION: To the best of our knowledge, this study for the first time showed that preoperative use of antiseptic dressings is significantly effective in reducing the rate of SSI in instrumented posterior lumbar spinal fusion surgery. Future studies are warranted to evaluate the efficacy of different preparations or the effectiveness of the present one in patients undergoing spine procedures with other surgical characteristics.

Gender-Related Factors Influence the Subjective Perception of Deformity in Patients Undergoing Surgery for Idiopathic Scoliosis.

The present study aims to depict the importance of gender-related factors in the subjective perception of spine deformity in adolescents undergoing posterior instrumented fusion for scoliosis. Patients undergoing posterior spinal instrumentation and fusion (PSF) for idiopathic adolescent scoliosis (AIS) were recruited. The following data were recorded: gender, age, parents' civil status, Tegner Activity Scale (TAS), body mass index (BMI), concomitant diseases, and history of neuropsychological disorders. Each patient underwent clinical and radiological evaluations according to the protocol used at our institution. All the patients were assessed before surgery using the following Patient-Reported Outcome Measures (PROMs): the Italian version of the revised Scoliosis Research Society-22 patient questionnaire (SRS-22R), the Quality-of-Life Profile for Spinal Deformities (QLPSDs) questionnaire, and the Spinal Appearance Questionnaire (SAQ). The present study recruited 80 patients (male: 19, female: 61). A significant correlation was observed between BMI, TAS, and subjective perception scores. A worse deformity perception was observed in female patients and patients with divorced parents. Gender-related factors impact the subjective perception of spine deformity in patients undergoing PSF for AIS. Specific assessment and correction are needed to improve postoperative outcomes in these patients.

The effect of spinal range of motion on functional balance, quality of life, and perception of appearance in adolescent idiopathic scoliosis after posterior spinal fusion surgery.

Spinal fusion, which is widely used in the surgical treatment of adolescent idiopathic scoliosis (AIS), limits the movements of the vertebral column. In this study, it was aimed to investigate the relationship between spinal mobility in the postoperative period with functional balance, quality of life, and perception of appearance in individuals with AIS. Thirty patients with AIS who underwent posterior spinal fusion surgery 1 to 3years ago were included in the study. A universal goniometer was used to measure a spinal range of motion (ROM), functional reach test for functional balance, Scoliosis Research Society-30 (SRS-30) for quality of life, and Spinal Appearance Questionnaire (SAQ) for perception of appearance. Surgical fusion length was significantly correlated with movements in the sagittal and transverse planes (r = - 0.383-[- 0.608]; p = < 0.001-0.037). Except for spinal left rotation, there was a significant positive correlation between functional balance level and ROM results (r = 0.374-0.523; p = 0.003-0.42). The SRS-30 total score correlated significantly with all other ROM measures except for rotations (r = 0.434-0.574; p = 0.00-0.016). SAQ total data correlated significantly with all ROM measurements (r = - 0.553-[- 0.395]; p = 0.002-0.031). In AIS, limitation of movement in the coronal, sagittal, and transverse planes is observed after fusion surgery. Spinal ROM is affected by the level of fusion performed at surgery. Postoperative spinal limitation of motion adversely affected functional balance, quality of life, and perception of appearance. We believe that comprehensive rehabilitation approaches that improve postoperative range of motion and increase functionality are important for optimal postoperative recovery.