Spinal Reconstructive Surgery Research Articles

Vascularized Iliac Crest Bone Graft for the Reconstruction of Anterior Vertebral Corpus Defects: A Literature Review and Cadaveric Feasibility Study.

Vertebral body defects pose a significant challenge in spinal reconstructive surgery. Compression fractures of the vertebral corpus are typically treated with vertebral augmentation procedures. There are significant risks associated with the introduction of foreign material in the spine, including infection and pseudarthrosis. Vascularized bone grafts (VBGs) have become a popular alternative for spinal reconstruction in the last decade thanks to their robust blood supply and autologous nature. VBGs have been described predominantly for the reconstruction of posterior vertebral defects. The objective of this study is to describe a novel procedure for the reconstruction of vertebral corpus defects in the lumbar and distal thoracic spine. This is a cadaveric anatomy study. The authors performed the novel surgical technique on an anonymized cadaveric donor in the prone position and recorded the procedure through clinical photography. Consent for the procedure and photography was obtained from the Center for Procedural Innovation. A 5-cm-long posterior iliac crest VBG (IC-VBG) was successfully harvested on a pedicle of the quadratus lumborum muscle. The VBG was rotated and mobilized anteromedially to the vertebral corpus. In this donor, the IC-VBG could be inset with minimal tension anywhere along the vertebral bodies of the spine from the L5 to the T9 level. A rotated, anteromedially mobilized IC-VBG represents a novel technique for reconstruction of the anterior vertebral corpus of the lumbar and distal thoracic spine with a lower risk of infection and pseudarthrosis than reconstruction with foreign materials.

Two-stage spinal osteotomy combined with lateral lumbar interbody fusion for lumbar kyphosis: illustrative case

BACKGROUND Adult spinal reconstructive surgery that requires multilevel spinal fusion is highly invasive and requires two-stage surgery using lateral lumbar interbody fusion (LLIF) and/or percutaneous pedicle screw (PPS) fixation to make it less invasive. However, it is still difficult to make spinal osteotomy less invasive, and the high complication rate is an issue. OBSERVATIONS The authors present the surgical techniques of a two-stage Schwab grade 4 spinal osteotomy using LLIF, which could reduce surgical invasiveness and enable good correction and anterior spinal column reconstruction for lumbar kyphosis, and also report a case treated with this procedure. The first surgery consisted of L2–5 LLIF and L6–S1 posterior lumbar interbody fusion with temporary PPS fixation. The second surgery, 2 weeks after the first surgery, was a grade 4 osteotomy performed in the L4 vertebral body at a 30° angle toward the center of the LLIF cage between L3 and L4, followed by PPS fixation from T10 to the pelvis and additional fixation with two collateral rods. LESSONS Two-stage grade 4 osteotomy using LLIF could reduce invasiveness and blood loss while providing good anterior support. This surgical method is expected to make spinal reconstruction surgeries requiring osteotomy less invasive. https://thejns.org/doi/10.3171/CASE24515

The association between locomotive function and incidence of proximal junctional kyphosis following adult spine deformity surgery

Background and objectivesThis retrospective review study aimed to determine whether functional mobility test (FMT) results are related to the incidence of proximal junctional kyphosis (PJK) after surgical correction of adult spinal deformity (ASD).MethodsA total of 157 patients who underwent reconstructive spinal surgery for ASD between July 2019 and December 2021 were included in this study. Three types of FMTs were performed preoperatively: timed-up-and-go (TUG) test, five times sit-to-stand (STS) test, and alternate step (AS) test. The primary outcome measure was the occurrence of PJK at 1 year after surgery. Oswestry disability index (ODI) and EuroQOL-5-dimension (EQ-5D) scores were surveyed as patient-reported outcome measures of the surgery.ResultsThe occurrence of PJK was observed in 41 of the 157 patients (26.1%) at 1 year after surgery. Among the three functional mobility tests, STS test results were significantly higher in the patients who developed PJK. The receiver operating characteristics curve drawn with the STS test had an area under the curve of 0.69 and the optimal cutoff value was suggested as 22 seconds. Multivariate logistic regression analysis identified the STS test along with age and preoperative ODI score as the significant predictors of PJK (p = 0.026, 0.005 and 0.001, respectively).ConclusionsA longer test time on the STS test result was associated with a higher occurrence of postoperative PJK. A cutoff value of 22 s can be suggested. Preoperative surveillance of these patients and providing additional efforts and surgical procedures for the prevention of PJK are anticipated to improve the surgical outcome of ASD correction.

Short-Term Risk Factors for Distal Junctional Kyphosis after Spinal Reconstruction Surgery in Patients with Osteoporotic Vertebrae.

Level 3 retrospective cohort case-control study. This study aimed to investigate the risk factors for distal junctional kyphosis (DJK) caused by osteoporotic vertebral fractures following spinal reconstruction surgery, with a focus on the sagittal stable vertebra. Despite the rarity of reports on DJK in this setting, DJK was reported to reduce when the lower instrumented vertebra (LIV) was extended to the sagittal stable vertebra in the posterior corrective fixation for Scheuermann's disease. This study included 46 patients who underwent spinal reconstruction surgery for thoracolumbar osteoporotic vertebral fractures and kyphosis and were followed up for 1 year postoperatively. DJK was defined as an advanced kyphosis angle >10° between the LIV and one lower vertebra. The patients were divided into groups with and without DJK. The risk factors of the two groups, such as patient background, surgery-related factors, radiographic parameters, and clinical outcomes, were analyzed. The DJK and non-DJK groups included 14 and 32 patients, respectively, without significant differences in patient background. Those with instability in the distal adjacent LIV disc had a significantly higher risk of DJK occurrence (28.6% vs. 3.2%, p=0.027). DJK occurrence significantly increased in those with the sagittal stable vertebra not included in the fixation range (57.1% vs. 18.8%, p=0.020). Other preoperative radiographic parameters were not significantly different. Instability in the distal adjacent LIV disc (adjusted odds ratio, 14.50; p=0.029) and the exclusion of the sagittal stable vertebra from the fixation range (adjusted odds ratio, 5.29; p=0.020) were significant risk factors for DJK occurrence. Regarding spinal reconstruction surgery in patients with osteoporotic vertebral fractures, instability in the distal adjacent LIV disc and the exclusion of the sagittal stable vertebra from the fixation range were risk factors for DJK occurrence in the short term.

Transcriptomic and Proteomic Characterization of the Immune Response to Elective Spinal Reconstructive Surgery: Impact of Aging and Comparison with Traumatic Injury Response.

Major surgery triggers trauma-like stress responses linked to age, surgery duration, and blood loss, resembling polytrauma. This similarity suggests elective surgery as a surrogate model for studying polytrauma immune responses. We investigated stress responses across age groups and compared them with those of polytrauma patients. Patients undergoing major spinal reconstruction surgery were divided into older (age >65 years, n = 5) and young (age 18 to 39 years, n = 6) groups. A comparison group consisted of matched trauma patients (n = 8). Blood samples were collected before, during, and after surgery. Bone marrow mononuclear cells and peripheral blood mononuclear cells were analyzed using cellular indexing of transcriptomes and epitopes sequencing or single-cell RNA sequencing. Plasma was subjected to dual-platform proteomic analysis (SomaLogic and O-link). Response to polytrauma was highest within 4 hours. By comparison, the response to surgery was highest at 24 hours. Both insults triggered significant changes in cluster of differentiation 14 monocytes, with increased inflammation and lower major histocompatibility complex-class 2 expression. Older patient's cluster of differentiation 14 monocytes displayed higher inflammation and less major histocompatibility complex-class 2 suppression; a trend was also seen in bone marrow mononuclear cells. Although natural killer cells were markedly activated after polytrauma, they were suppressed after surgery, especially in older patients. In plasma, innate immunity proteins dominated at 24 hours, shifting to adaptive immunity proteins by 6 weeks with heightened inflammation in older patients. Senescence-associated secretory phenotype proteins were higher in older patients at baseline and further elevated during and after surgery. Although both major surgery and polytrauma initiate immune and stress responses, substantial differences exist in timing and cellular profiles, suggesting major elective surgery is not a suitable surrogate for the polytrauma response. Nonetheless, distinct responses in young vs older patients highlight the utility of elective spinal in studying patient-specific factors affecting outcomes after major elective surgery.

Improving outcomes in adult spinal deformity surgery

Proximal junctional kyphosis and failure are important complications in reconstructive spine surgery. The impact of proximal junctional pathology on health status is variable, and junctional failure may involve compromise of neural and physical function, and may require revision surgery. The risk factors for proximal junctional kyphosis include multilevel fusion to the sacrum, malalignment of the spine, choice of UIV, magnitude of realignment, bone and muscle quality, tension band integrity and characteristics of the unfused spine. The pathophysiology of proximal junctional pathology involve fracture and bony failure, ligamentous and soft tissue failure, and combined bone and soft tissue failure. Prevention of proximal junctional pathology is an important goal, and has a significant impact on improving the outcomes and durability of spinal reconstructive surgery. Prevention strategies are derived from an understanding of the underlying causes of junctional pathology. Preoperative planning to determine optimal post-operative alignment, and intraoperative strategies to achieve that alignment are important for prevention of junctional pathology. Preoperative preparation of the patient with optimization of bone quality, extensor muscle strength and body mass index may prevent junctional pathology. Surgical strategies including anterior column load sharing and posterior augmentation of fixation are useful for prevention of junctional pathology. Cement augmentation at the upper instrumented vertebra, with possible inclusion of the next cephalad vertebra may be protective of bone failure. Ligamentoplasty and preservation of the tension band may be protective of soft tissue failure. Proximal junctional pathology remains an important complication in spinal reconstructive surgery. Understanding the factors associated with proximal junctional pathology including the mechanisms underlying junctional kyphosis, and awareness of the strategies for avoidance of junctional pathology will empower the surgeon to reduce the risk of post-operative junctional kyphosis and lead to improved outcomes in adult spinal deformity surgery.

Clinical effect of limited posterior decompression and 13-mm titanium mesh implantation onsevere thoracolumbar burst fractures: A case series.

Posterior incision with 270° spinal canal decompression and reconstruction surgery is a treatment option for thoracolumbar burst fractures (TLBF), but the large diameter titanium mesh placement is difficult. This study evaluated the characteristics and clinical effects of limited posterior decompression and 13-mm titanium mesh implantation to treat TLBF. 13-mm titanium meshes could be used to fix thoracolumbar burst fractures. This case series included patients who underwent limited posterior decompression and 13-mm titanium mesh implantation at China Medical University Shaoxing Hospital (01/2015-12/2019). The Cobb angle, injury vertebral anterior edge height loss percentage, and spinal canal occupancy rate were analyzed. The degree of spinal cord injury was evaluated according to the ASIA grade. Fifteen patients were included (eight males and seven females). The patients were 32.2 ± 4.6 years of age. The American Association of Spinal Injury improved after surgery (A/B/C/D/E: from 2/6/5/2/0 to 0/0/2/8/5, P < 0.001). The Cobb angle decreased after surgery (from 20.1 ± 4.8° to 7.1 ± 1.4°, P < 0.001) but increased to 8.2 ± 0.9° at 1 year (P = 0.003). The percentage of loss of the anterior edge height of the injured vertebrae decreased after surgery (from 40.9% ± 6.1% to 7.5% ± 1.8%, P < 0.001) and decreased at 1 year (7.0% ± 1.5%, P = 0.044). The spinal canal occupancy rate decreased after surgery (from 64.8% ± 7.8% to 20.1% ± 4.2%, P < 0.001) but did not decrease further at 1 year (19.4% ± 3.4%, P = 0.166). Spinal canal limited posterior decompression, and 13-mm titanium mesh implantation in the treatment of TLBF can achieve one-stage spinal canal decompression and three-column reconstruction. The curative effect was satisfying. Level IV; case series.

Predicting Bone Health Using Machine Learning in Patients undergoing Spinal Reconstruction Surgery.

Retrospective study of data collected prospectively. The goal of this study is to create a predictive model of preoperative bone health status in adult patients undergoing adult spinal reconstructive (ASR) surgery using machine learning (ML). Despite understanding that bone health impacts spine surgery outcomes, spine surgeons lack the tools to risk stratify patients preoperatively to determine who should undergo bone health screening. An ML approach mines patterns in data to determine the risk for poor bone health in ASR patients. Two hundred and eleven subjects over the age of 30 with dual energy X-ray absorptiometry scans, who underwent spinal reconstructive surgery were reviewed. Data was collected by manual and automated collection from the electronic health records. The Weka software was used to develop predictive models for multiclass classification of healthy, osteopenia, and osteoporosis (OPO) bone status. Bone status was labeled according to the World Health Organization (WHO) criteria using dual energy X-ray absorptiometry T scores. The accuracy, sensitivity, specificity, and area under the receiver operating curve (AUC) were calculated. The model was evaluated on a test set of unseen data for generalizability. The prevalence of OPO was 23.22% and osteopenia was 52.61%. The random forest model achieved optimal performance with an average sensitivity of 0.81, specificity of 0.95, and AUC of 0.96 on the training set. The model yielded an averaged sensitivity of 0.64, specificity of 0.78, and AUC of 0.69 on the test set. The model was best at predicting OPO in patients. Numerous patient features exhibited predictive value, such as body mass index, insurance type, serum sodium level, serum creatinine level, history of bariatric surgery, and the use of medications such as selective serotonin reuptake inhibitors. Predicting bone health status in ASR patients is possible with an ML approach. Additionally, data mining using ML can find unrecognized risk factors for bone health in ASR surgery patients.

A Complement Type to SRS-Schwab Adult Spinal Deformity Classification: The Failure of Pelvic Compensation

Retrospective review. To determine characteristics of patients with adult spinal deformity (ASD) who showed failed pelvic compensation even with significant sagittal imbalance. Patients who show failed pelvic compensation despite significant sagittal imbalance reportedly present distinct clinical outcomes. However, to our knowledge, no study has clearly defined or characterized this subgroup of patients with ASD. We examined 126 patients who underwent reconstructive spinal surgery for ASD between September 2016 and September 2020. Radiographic spinopelvic parameters were assessed. The patients were divided into four quadrant groups based on the two axes of pelvic tilt/pelvic incidence (PT/PI) and the sagittal vertical axis (SVA) with reference to the population median values (0.68 and 147.5mm, respectively). Patients with low PT/PI and high SVA were considered to have failed pelvic compensation, and they were compared with other patient groups. Patients with failed pelvic compensation (low PT/PI and high SVA) had worse clinical outcomes than those with successful pelvic compensation (high PT/PI and high SVA) at one year after surgery. Regarding radiographic outcomes, patients with failed pelvic compensation showed a significantly larger postoperative SVA even after correcting the PI-lumbar lordosis mismatch was corrected to a comparable range with the group of successful pelvic compensation. Notably, patients with failed pelvic compensation showed larger cross-sectional areas of the psoas and back extensor muscles than those with successful pelvic compensation. This suggests that failure of pelvic compensation did not occur because of back muscle weakness, which implies another underlying pathophysiology, including neurological origin. Compared with patients with successful pelvic compensation, those with failed pelvic compensation showed lower postoperative improvements in clinical and radiographic outcomes. Therefore, it is important to consider pelvic compensation when planning surgical correction of deformities. Distinct surgical approaches, including overcorrection of the PI-lumbar lordosis mismatch or global sagittal alignment, should be attempted to ensure postoperative symptom improvement.

Lidocaine Infusion for the Management of Postoperative Pain and Delirium (LIMPP): protocol for a randomised control trial

IntroductionPostoperative delirium is a frequent adverse event following elective non-cardiac surgery. The occurrence of delirium increases the risk of functional impairment, placement to facilities other than home after discharge, cognitive...

Determining a Cutoff Value for Hand Grip Strength to Predict Favorable Outcomes of Adult Spinal Deformity Surgery.

Retrospective review. To establish a cutoff value for hand grip strength and predict the favorable outcomes of adult spinal deformity surgery. Hand grip strength (HGS) has been suggested to predict surgical outcomes in various fields, including adult spinal deformity (ASD). However, to the best of our knowledge, no study has established a cutoff value for HGS in patients with ASD. This study included 115 female patients who underwent reconstructive spinal surgery for ASD between September 2016 and September 2020. HGS was measured preoperatively. The Oswestry Disability Index (ODI), EuroQOL-5-dimension (EQ-5D), and visual analog scale (VAS) scores for back pain were all recorded both before and after surgery. Patients were dichotomized either into favorable or unfavorable outcome groups using an ODI cutoff score of 22 at 1year after surgery. Multivariate logistic regression analysis was done to identify significant factors leading to favorable outcomes. A receiver operating characteristic (ROC) curve was drawn to define the cutoff value of HGS for favorable outcomes. Multivariate logistic regression analysis showed that HGS is significantly associated with favorable surgical outcomes in ASD (P = .031). The ROC curve suggested a cutoff value of 14.20kg for HGS (area under the curve (AUC) = .678, P = .013) to predict favorable surgical outcomes in ASD. The surgical complications were not significantly affected by HGS. The HGS of patients with ASD can be interpreted with a cutoff value of 14.20kg. Patients with HGS above this cutoff value showed superior surgical outcomes at 1year after surgery compared to those below this cutoff value.

Two cases of spinal reconstruction surgery for Parkinson’s disease patients with worsening postural abnormalities after lumbar vertebral fracture

Two cases of spinal reconstruction surgery for Parkinson’s disease patients with worsening postural abnormalities after lumbar vertebral fracture

Perioperative Management of a Patient with Chin-On-Chest Deformity Presenting for Reconstructive Spine Surgery

Chin-on- chest deformity is not uncommon sequelae of ankylosing spondylitis. Apart from difficult airway, several other considerations might include co-existing cardio-respiratory embarrassment, osteoporotic bones, and neurological perturbations. We describe the successful anesthetic management of a case of chin-on-chest deformity with no access to midline neck structures and extremely difficult airway posted for corrective spine surgery.

Best Practice Guidelines for Assessment and Management of Osteoporosis in Adult Patients Undergoing Elective Spinal Reconstruction.

Expert consensus study. This expert panel was created to establish best practice guidelines to identify and treat patients with poor bone health prior to elective spinal reconstruction. Currently, no guidelines exist for the management of osteoporosis and osteopenia in patients undergoing spinal reconstructive surgery. Untreated osteoporosis in spine reconstruction surgery is associated with higher complications and worse outcomes. A multidisciplinary panel with 18 experts was assembled including orthopedic and neurological surgeons, endocrinologists, and rheumatologists. Surveys and discussions regarding the current literature were held according to Delphi method until a final set of guidelines was created with over 70% consensus. Panelists agreed that bone health should be considered in every patient prior to elective spinal reconstruction. All patients above 65 and those under 65 with particular risk factors (chronic glucocorticoid use, high fracture risk or previous fracture, limited mobility, and eight other key factors) should have a formal bone health evaluation prior to undergoing surgery. DXA scans of the hip are preferable due to their wide availability. Opportunistic CT Hounsfield Units of the vertebrae can be useful in identifying poor bone health. In the absence of contraindications, anabolic agents are considered first line therapy due to their bone building properties as compared with antiresorptive medications. Medications should be administered preoperatively for at least 2 months and postoperatively for minimum 8 months. Based on the consensus of a multidisciplinary panel of experts, we propose best practice guidelines for assessment and treatment of poor bone health prior to elective spinal reconstructive surgery. Patients above age 65 and those with particular risk factors under 65 should undergo formal bone health evaluation. We also established guidelines on perioperative optimization, utility of various diagnostic modalities, and the optimal medical management of bone health in this population.Level of Evidence: 5.

The role of less invasive surgery in the treatment of adolescent idiopathic scoliosis and adult spinal deformity

<h2>Abstract</h2> The overall impact of spinal deformity reconstructive surgery on short- and long-term quality of life and patients' perioperative experience has been widely studied in recent literature. With the advancement of modern less invasive (anterior/lateral/posterior percutaneous) spinal deformity techniques the ‘gold standard' role of open traditional approaches has been questioned. Minimally invasive surgical (MIS) techniques are rapidly evolving and further research is required to determine whether a particular surgical treatment may be suitable for all patients or a patient-tailored individual treatment and surgical technique should be selected and could offer better results. Focus of the present article is to report the most recent research in ‘pure' less invasive spinal deformity surgery (LIS) as applied both for adolescent idiopathic scoliosis (AIS) and adult spinal deformity (ASD) and describe a single centre's experience on such ‘treatment philosophy' as adopted in the last 7 years.

Systematic Review of Reciprocal Changes after Spinal Reconstruction Surgery : Do Not Miss the Forest for the Trees.

The purpose of this review was to synthesize the research on global spinal alignment and reciprocal changes following cervical or thoracolumbar reconstruction surgery. We carried out a search of PubMed, EMBASE, and Cochrane Library for studies through May 2020, and ultimately included 11 articles. The optimal goal of a truly balanced spine is to maintain the head over the femoral heads. When spinal imbalance occurs, the human body reacts through various compensatory mechanisms to maintain the head over the pelvis and to retain a horizontal gaze. Historically, deformity correction has focused on correcting scoliosis and preventing scoliotic curve progression. Following substantial correction of a spinal deformity, reciprocal changes take place in the flexible segments proximal and distal to the area of correction. Restoration of lumbar lordosis following surgery to correct a thoracolumbar deformity induces reciprocal changes in T1 slope, cervical lordosis, pelvic shift, and lower extremity parameters. Patients with cervical kyphosis exhibit different patterns of reciprocal changes depending on whether they have head-balanced or trunk-balanced kyphosis. These reciprocal changes should be considered to in order to prevent secondary spine disorders. We emphasize the importance of evaluating the global spinal alignment to assess postoperative changes.

Patient-Reported Long-Term Outcomes After Free Vascularized Fibula Graft in Spinal Reconstruction: a 24-year Cohort

The use of free vascularized fibula grafts (FVFG) in complex spinal deformity surgery intends to allow for life-long stability of the spine with good long-term clinical outcome. However, these long-term outcomes of this technique are still lacking. The objective of this study is to report the long-term postoperative outcomes and establish the long-term viability of this method for spinal reconstruction. A retrospective cohort study was conducted in all patients who underwent spinal reconstructive surgery utilizing a FVFG at a tertiary medical centre. Questionnaires taken from the participants were the Numeric Pain Rating Scale (NPRS), Oswestry Low Back Pain Disability (also known as Oswestry Disability Index (ODI)), Scoliosis Research Society 22r (SRS-22), the EQ-5D-5L and a self-assembled questionnaire regarding donor site comorbidities and patient satisfaction. Over a period of 24 years (1995-2019), we used FVFG for spinal reconstruction in 31 patients. A total of 25 patients were included in this study, 8 patients were deceased at the time of this study, and sixteen patients responded to the questionnaires. Patient satisfaction was rated 6.8 out of 10, the average SRS-22r score was 3.6, EQ-5D-5L score was 0.725, and the ODI score showed a minimal disability (0-20%) postoperatively. Overall complication-free survival was 8.9 years. Nine patients underwent a re-operation in the spinal area; five for the removal of the spinal instrumentation. Patients reported satisfied and good long-term outcomes following FVFG surgical procedure for complex spinal deformities. Therefore, considering the alternatives, this procedure provides a good long-term solution for complex spinal deformity surgery.

Myelopathic Patients Undergoing Severe Pediatric Spinal Deformity Surgery Can Improve Neurologic Function to That of Non-Myelopathic Patients by 1-Year Postoperative.

Multi-center, prospective, observational cohort. To compare myelopathic vs. non-myelopathic ambulatory patients in short- and long-term neurologic function, operative treatment, and patient-reported outcomes. Pediatric deformity patients from 16 centers were enrolled with the following inclusion criteria: aged 10-21 years-old, a Cobb angle ≥100° in either the coronal or sagittal plane or any sized deformity with a planned 3-column osteotomy, and community ambulators. Patients were dichotomized into 2 groups: myelopathic (abnormal preoperative neurologic exam with signs/symptoms of myelopathy) and non-myelopathic (no clinical signs/symptoms of myelopathy). Of 311 patients with an average age of 14.7 ± 2.8 years, 29 (9.3%) were myelopathic and 282 (90.7%) were non-myelopathic. There was no difference in age (P = 0.18), gender (P = 0.09), and Risser Stage (P = 0.06), while more patients in the non-myelopathic group had previous surgery (16.1% vs. 3.9%; P = 0.03). Mean lower extremity motor score (LEMS) in myelopathic patients increased significantly compared to baseline at every postoperative visit: Baseline: 40.7 ± 9.9; Immediate postop: 46.0 ± 7.1, P = 0.02; 1-year: 48.2 ± 3.7, P < 0.001; 2-year: 48.2 ± 7.7, P < 0.001). The non-myelopathic group had significantly higher LEMS immediately postoperative (P = 0.0007), but by 1-year postoperative, there was no difference in LEMS between groups (non-myelopathic: 49.3 ± 3.6, myelopathic: 48.2 ± 3.7, P = 0.10) and was maintained at 2-years postoperative (non-myelopathic: 49.2 ± 3.3, myelopathic: 48.2 ± 5.7, P = 0.09). Both groups improved significantly in all SRS domains compared to preoperative, with no difference in scores in the domains for pain (P = 0.12), self-image (P = 0.08), and satisfaction (P = 0.83) at latest follow-up. In severe spinal deformity pediatric patients presenting with preoperative myelopathy undergoing spinal reconstructive surgery, myelopathic patients can expect significant improvement in neurologic function postoperatively. At 1-year and 2-year postoperative, neurologic function was no different between groups. While non-myelopathic patients had significantly higher postoperative outcomes in SRS mental-health, function, and total-score, both groups had significantly improved outcomes in every SRS domain compared to preoperative.

196. Best practice guideline on the assessment and management of osteoporosis in adult patients undergoing elective spinal reconstruction

<h3>BACKGROUND CONTEXT</h3> Poor bone health in patients undergoing reconstructive spine surgery can lead to complications such as vertebral fractures, pseudarthrosis, proximal junctional kyphosis, and instrumentation failure. No guidelines currently exist for the management of osteoporosis and osteopenia in patients undergoing spinal reconstructive surgery. This expert panel was created to establish best practice guidelines to identify and treat patients with poor bone health prior to undergoing elective spinal reconstruction. <h3>PURPOSE</h3> An expert panel to define best practice guidelines for the assessment and management of osteoporosis in patients undergoing elective spinal reconstruction. <h3>STUDY DESIGN/SETTING</h3> Expert panel, consensus study. <h3>OUTCOME MEASURES</h3> Consensus above 70% on final statements. <h3>METHODS</h3> A multidisciplinary panel with 20 experts was assembled including orthopedic and neurological surgeons, endocrinologists, and rheumatologists. Three rounds of surveys and discussions regarding the current literature were held until a final set of guidelines was created with over 70% consensus. <h3>RESULTS</h3> A total of 21 statements were included in the final survey. Bone health should be considered in every patient prior to elective spinal reconstruction. All patients above 65 and those under 65 with particular risk factors (chronic steroid use, high fracture risk or previous fracture, limited mobility, and eight other key factors) should have a formal bone health evaluation prior to undergoing surgery. DEXA scans of the hip are preferable due to their wide availability. Opportunistic CT Hounsfield Units can be useful in identifying poor bone health. Patients with osteoporosis and osteopenia should be appropriately optimized prior to elective surgery. In the absence of contraindications, teriparatide and abaloparatide are considered first-line agents due to their bone building properties as compared to antiresorptive medications such as bisphosphonates. These treatments should be administered preoperatively for at least 2 months and postoperatively for at least 8 months. <h3>CONCLUSIONS</h3> Based on the consensus of a multidisciplinary panel of experts, we propose best practice guidelines for assessment and treatment of poor bone health prior to elective spinal reconstructive surgery. Patients above age 65 and those with particular risk factors under 65 should undergo formal bone health evaluation. We also reached consensus on perioperative optimization, utility of various diagnostic modalities, and the optimal medical management of bone health in this population. We believe that these guidelines will help reduce adverse postoperative outcomes related to bone health <h3>FDA DEVICE/DRUG STATUS</h3> Teriparatide, abaloparatide, bisphosphonates: Approved.

Factors affecting disc angle restoration in oblique lateral interbody fusion at L5–S1

Optimal restoration of the L5-S1 disc angle (DA) is an important surgical goal in spinal reconstructive surgery. Anterior approach is beneficial for L5-S1 DA reconstruction and fusion. However, factors associated with a greater DA restoration in oblique lateral interbody fusion (OLIF) at L5-S1 have not been studied. This study aimed to identify factors that aid in achieving a greater DA in OLIF at L5-S1. A retrospective analysis. This study involved 61 consecutive patients who underwent OLIF at L5-S1 for lumbar degenerative disease and were followed for more than 1 year. Patients with incomplete data or posterior column osteotomy at L5-S1 were excluded. The L5-S1 DA was measured preoperatively, postoperatively, and at the last follow-up on standing lateral lumbar radiographs. The associations between demographics and/or surgical and/or radiological factors and the L5-S1 DA at the last follow-up were analyzed using multiple regression analysis. Demographics and surgical factors were reviewed from the medical records with respect to age, sex, body mass index, bone mineral density, diagnosis, surgery level, cage parameters (cage lordotic angle and height), laminectomy performed and/or not performed, estimated blood loss, operative time, configuration of the left common iliac vein. Radiological factors were measured with respect to sagittal parameters, the L5-S1 disc parameters, and the postoperative cage parameters. The mean preoperative DA at L5-S1 was 5.4±5.0°, which increased to 18.9±5.6° postoperatively (p<.001) and was maintained as 16.5±5.9° at the last follow-up (p<.001). The preoperative DA, end plate lesions, anterior spur, facet joint osteoarthritis, or cage position at L5-S1 did not affect the DA at the last follow-up (all p>.05). Multiple regression analysis showed four independent variables, including increased age, increased cage lordotic angle, laminectomy performed, and absence of cage subsidence as the factors associated with the greater DA at L5-S1. OLIF at L5-S1 showed favorable DA restoration regardless of the preoperative conditions. To achieve a greater DA, surgeons should try to distract the anterior disc space for insertion of a larger lordotic cage. Laminectomy during posterior fixation is recommended for achieving additional DA restoration.