Spinal Deformity Research Articles

Does aberrant electrocortical dynamics pattern imply atypical balance control in adolescents with idiopathic scoliosis?

Adolescent idiopathic scoliosis (AIS) is a developmental disorder described as a three-dimensional spine deformity with multifactorial etiology. The multifactorial model of AIS suggests that the patient population is diverse. Identifying individuals with sensorimotor control impairments could enable personalized treatments, potentially leading to improved outcomes for those with AIS. We hypothesize that abnormal electrocortical dynamics within the sensorimotor cortex will be related to less efficient balance control in standing during ankle proprioception alteration in the absence or presence of vision. To test this hypothesis, the balance control performance of adolescents with AIS will be assessed on a force platform by computing the root mean square value of the scalar distance between the center of pressure and the center of gravity. Electroencephalography will be recorded while challenging balance control by altering ankle proprioception in the presence and absence of visual cues. Time-frequency analyses will be calculated to determine alpha, and beta band power in both conditions. Pilot data from 13 participants with AIS were analyzed to support our hypothesis. Three participants with less efficient balance control showed electrocortical dynamics changes, such as an increase in beta band power in the presence and absence of vision and a decrease in alpha band power in the presence of vision compared to the AIS group with efficient balance control. These findings support our hypothesis of suboptimal sensorimotor information processing in the subgroup of adolescents with AIS with less efficient balance control, which could have significant implications for developing personalized treatments for AIS.

Dynamic Alignment Changes of the Spine, Pelvis, and Lower Limbs during Gait Analyzed Using Inertial Motion Capture in Patients with Adult Spinal Deformity

Dynamic Alignment Changes of the Spine, Pelvis, and Lower Limbs during Gait Analyzed Using Inertial Motion Capture in Patients with Adult Spinal Deformity

Surgical Management of Adult Spinal Deformity Patients with Osteoporosis

Adult spinal deformity (ASD) commonly affects older adults, with up to 68% prevalence in those over 60, and is often complicated by osteoporosis, which reduces bone mineral density (BMD) and increases surgical risks. Osteoporotic patients undergoing ASD surgery face higher risks of complications like hardware failure, pseudoarthrosis, and proximal junctional kyphosis (PJK). Medical management with antiresorptive medications (e.g., bisphosphonates, SERMs, and denosumab) and anabolic agents (e.g., teriparatide, abaloparatide, and romosozumab) can improve BMD and reduce complications. While bisphosphonates reduce fracture risk, teriparatide and newer agents like romosozumab show promise in increasing bone density and improving fusion rates. Surgical adaptations such as consideration of age-adjusted alignment, fusion level selection, cement augmentation, and the use of expandable screws or tethers enhance surgical outcomes in osteoporotic patients. Specifically, expandable screws and cement augmentation have been shown to improve fixation stability. However, further research is needed to evaluate the effectiveness of these treatments, specifically in osteoporotic ASD patients.

Electrical stimulation methods for scoliosis in children: a literature review

Introduction. Scoliosis is one of the most common orthopedic diseases of childhood and adolescence, leading to disability and reducing the child’s quality of life. The prevalence of scoliosis in the structure of pediatric orthopedic pathology reaches 30 %. In 50 % of cases, the disease is characterized by a severe progressive course, especially during puberty. Aim. Studying the effectiveness of electrical stimulation methods for scoliosis in children to develop recommendations for their practical use based on the analysis of systematic reviews and randomized controlled trials. Materials and methods. The search was carried out using the database of evidence-based physiotherapy PubMed, Cyberleninka and eLIBRARY using the keywords: «electrical stimulation», «pulse currents», «scoliosis», «children» for the period from 2008–2024.Exclusion criteria: articles published on this topic before 2008. Main content. The main methods of physiotherapy used in the treatment of scoliosis in children are electrotherapy methods, among which electrical stimulation plays a leading role. The advantage of electrical stimulation for scoliosis in children is to provide training in the strength and tone of the back muscles on the side of the deformity. Electrical stimulation is indicated for scoliosis of I and II degrees. The greatest effect in the correction of scoliotic spinal deformity in children is observed with the combined use of electrical stimulation and exercise therapy. This review provides data on the relevance of medical rehabilitation of scoliosis in children, the mechanism of action of electrical stimulation, data on the effectiveness of using electrical stimulation methods for scoliosis in children: sinusoidal modulated currents, diadynamic therapy, transcutaneous electrical neurostimulation, interference therapy, fluctuarization and functional programmable electrical stimulation. Conclusion. Currently, a wide range of electrical stimulation technologies has been developed for the medical rehabilitation of children with scoliosis, among which sinusoidally modulated currents and diadynamic currents are most often used. Transcutaneous electrical neurostimulation, having a predominantly antinociceptive effect, also has an effect on muscle contractions. Functional programmable electrical stimulation of muscles is a promising technology for medical rehabilitation of children with scoliosis, requiring further study and scientific justification.

When is staging complex adult spinal deformity advantageous? Identifying subsets of patients who benefit from staged interventions.

The objective of this study was to identify baseline patient and surgical factors predictive of optimal outcomes in staged versus same-day combined-approach surgery. Adult spinal deformity (ASD) patients with baseline and perioperative (by 6 weeks) data were stratified based on single-stage (same-day) or multistage (staged) surgery, excluding planned multiple hospitalizations. Means comparison analyses were used to assess baseline demographic, radiographic, and surgical differences between cohorts. Backstep logistic regression and conditional inference tree analysis were used to identify variable thresholds associated with study-specific definitions of an optimal outcome in each cohort, defined as no intraoperative or surgery-related in-hospital adverse event. There were 439 patients with complex ASD in the dataset (mean age 64.0 ± 9.3 years, 68% female, mean BMI 28.7 ± 5.5 kg/m2). Overall, 58.8% of patients were in the same-day group, while 41.2% were in the staged group. Demographically, cohorts were not significantly different (p > 0.05), but staged patients were more frail per total Edmonton Frail Scale score (p = 0.043). Staged patients also reported greater numeric rating scale scores for back pain than same-day patients (p = 0.002). Cohorts were comparable in magnitude of planned correction of C7-S1 sagittal vertical axis, pelvic incidence-lumbar lordosis (PI-LL) mismatch, and T4-12 kyphosis (all p > 0.05). Controlling for baseline age, frailty, and number of levels fused, staged patients reported significantly higher PROMIS Discretionary Social Activities scores by 6 weeks (p = 0.029). Radiographic outcomes by 6 weeks were comparable between cohorts, in terms of both magnitude of change from baseline and overall result (all p > 0.05). Same-day patients were significantly more likely to experience in-hospital complications (p = 0.013). When considering frailty thresholds for staging, only a Charlson Comorbidity Index ≤ 1.0 was associated with optimal outcome in same-day patients, while Edmonton Frail Scale score ≥ 7 (p = 0.036), ≥ 9 levels fused (p = 0.016), and baseline PI-LL mismatch ≥ 15.3° (p = 0.028) were associated with optimal outcome for staged patients. Yet, staging alone was not significantly associated with an optimal outcome perioperatively (p = 0.056). While staged and same-day combined-approach surgeries yield comparable radiographic and patient-reported outcomes, certain subsets of complex ASD patients may benefit from staged surgery despite the invariably increased hospital length of stay. Individuals with increased frailty, moderate to severe PI-LL mismatch, and increased anticipated number of levels fused may experience a lower risk of perioperative adverse events if they undergo a staged procedure. Clinical trial registration no.: NCT04194138 (ClinicalTrials.gov).

Making wrong site surgery a "never event" in spinal deformity surgery by use of a "landmark vertebra" to eliminate variability in identifying a target vertebral level.

Despite the introduction of "standardized counting" methods, errors in counting spinal levels and subsequent wrong-level surgery (WLS)remain critically important patient safety concerns. Previous work by our group has documented inconsistency in the identification of T12 despite the use of these systems including the Spinal Deformity Study Group (SDSG)conventions. To assist with consistent and repeatable identification of proposed preoperative surgical levels, the current study investigates a new strategy: utilization of a "landmark vertebra". It was hypothesized that individuals using a "landmark vertebra" strategy will achieve high concordance with target level identification between distinct time points as compared to conventional methods defining T12. Survey participants analyzed 99 pre-op radiographs, identifying and naming a "landmark vertebra" with concise descriptions like "last bilaterally ribbed vertebra." They then noted the proposed lowest instrumented vertebra's (LIV) distance relative to landmark (i.e., one below landmark). After a waiting period, participants used their written descriptions of the landmark and distance to LIV to reidentify these vertebrae. Cohen's Kappa (k) was used to measure intra-rater agreeability. The landmark strategy was compared to our previous work evaluating consistency in defining T12 based on the SDSG system. All raters showed perfect to near-perfect agreement when re-identifying the landmark and target vertebrae (k = 0.819-1.00; Table1A). Raters at all training levels had higher agreeability in naming the landmark vertebra and target when compared to raters at similar training levels defining T12 (k = 0.34-0.91; Table1B). This high agreement across training demonstrates the strategy's versatility and generalizability. Utilization of a landmark strategy proved to be highly effective in reducing intra-rater variability, with perfect to near-perfect agreement among all raters and consistently higher agreeability when compared to defining T12. Level II-prospective survey.

A Novel Preoperative Scoring System to Accurately Predict Cord-Level Intraoperative Neuromonitoring Data Loss During Spinal Deformity Surgery

Background: An accurate knowledge of a patient’s risk of cord-level intraoperative neuromonitoring (IONM) data loss is important for an informed decision-making process prior to deformity correction, but no prediction tool currently exists. Methods: A total of 1,106 patients with spinal deformity and 205 perioperative variables were included. A stepwise machine-learning (ML) approach using random forest (RF) analysis and multivariable logistic regression was performed. Patients were randomly allocated to training (75% of patients) and testing (25% of patients) groups. Feature score weights were derived by rounding up the regression coefficients from the multivariable logistic regression model. Variables in the final scoring calculator were automatically selected through the ML process to optimize predictive performance. Results: Eight features were included in the scoring system: sagittal deformity angular ratio (sDAR) of ≥15 (score = 2), type-3 spinal cord shape (score = 2), conus level below L2 (score = 2), cervical upper instrumented vertebra (score = 2), preoperative upright largest thoracic Cobb angle of ≥75° (score = 2), preoperative lower-extremity motor deficit (score = 2), preoperative upright largest thoracic kyphosis of ≥80° (score = 1), and total deformity angular ratio (tDAR) of ≥25 (score = 1). Higher cumulative scores were associated with increased rates of cord-level IONM data loss: patients with a cumulative score of ≤2 had a cord-level IONM data loss rate of 0.9%, whereas those with a score of ≥7 had a loss rate of 86%. When evaluated in the testing group, the scoring system achieved an accuracy of 93%, a sensitivity of 75%, a specificity of 94%, and an AUC (area under the receiver operating characteristic curve) of 0.898. Conclusions: This is the first study to provide an ML-derived preoperative scoring system that predicts cord-level IONM data loss during pediatric and adult spinal deformity surgery with >90% accuracy. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Assessment of Maximum Extension Reservoir of Lumbar Spine using Fulcrum Hyperextension Radiographs in Severe Sagittal Spinal Malalignment

Study design. Retrospective study Objectives. To report on the usefulness of fulcrum hyperextension radiograph to assess the maximum extension reservoir (MER) of lumbar spines in adult spinal deformity (ASD) surgery. Summary of background data. The maximum degree of lumbar lordosis (LL) by lateral lumbar interbody fusion (LLIF) will be affected by the MER, which is determined by combination of severity and flexibility of kyphotic deformities of lumbar spine. Although LLIF and anterior column realignment (ACR) are used to treat severe sagittal spinal malalignments, no clear guidelines exist regarding LLIF alone versus ACR. Methods. We included patients with severe sagittal malalignment undergoing ≥5-level fusion including the sacrum for ASD. The patients were divided into two groups according to performance of ACR: LLIF group (LLIF alone) and ACR group. Preoperative LL was compared according to patient’s positions; standing, active extension, supine, and fulcrum hyperextension. The offsets between postoperative and preoperative fulcrum hyperextension LL were calculated and compared between the groups. Results. Altogether, 161 patients were included in the study (mean age, 70.2 y; total levels fused, 7.3). Preoperative LL was significantly greatest in fulcrum hyperextension, followed by supine, active extension, and standing positions (37.2°, 26.5°, 23.8°, and 11.7°, respectively, P<0.001). The offsets between postoperative and preoperative fulcrum LL were significantly different between the LLIF and ACR groups (-0.7° vs. 17.8°, P<0.001). Subgroup analysis using patients with an LL offset>0° revealed that the mean LL offsets were 7.6° and 19.4° in the LLIF and ACR groups, respectively. Conclusions. Fulcrum hyperextension radiographs best represented the MER. Therefore, it can be used to predict the maximum LL by LLIF alone, which can be estimated as fulcrum hyperextension LL + 7.6°. This threshold can guide the selection between LLIF alone and ACR in deformity correction using the lateral approach.

Anterior Column Support With Anterior Lumbar Interbody Fusion Cage Through Posterior Approach Maneuver: A Technical Note and Preliminary Radiologic Report.

Retrospective cohort study. To evaluate the feasibility of anterior column support through a posterior approach using an anterior lumbar interbody fusion (ALIF) cage. Anterior fusion is an effective way to maintain spinal lordosis; however, it may be technically difficult in some cases. Conventional lumbar fusion and spinal deformity correction surgeries were performed using a conventional ALIF cage with a modified extratransforaminal lumbar interbody fusion (ExTLIF). Patients with 1 or 2 fusion levels were classified into group 1, and those with spinal deformity correction were classified into group 2. Radiologic parameters were evaluated during the follow-up periods. A total of 51 patients underwent this procedure. Thirty-five patients (19 male and 16 female, 69.4±9.6y old) with 37 fusion sites were in group 1, and 16 patients (3 male and 13 female, 71.4±5.7y old) were in group 2. The mean follow-up periods of groups 1 and 2 were 12.3±3.4 and 10.7±4.7 months, respectively. In group 1, the mean lumbar lordosis and segmental lumbar lordosis increased significantly during the last follow-up (39.9±13.0 and 20.6±6.0 degrees, respectively, both P<0.001), and the mean disc space also increased at the last follow-up (P<0.001). The same was observed in group 2 with significant increases in the mean lumbar lordosis and segmental lumbar lordosis at the last of the follow-up period (46.8±9.3 and 16.9±8.9 degrees, respectively, both P<0.001). The disc space also increased significantly (P<0.001). Fusion rates were 94.2% and 87.5% in groups 1 and 2, respectively, and the corresponding subsidence rates were 85.4% and 68.8%. In group 1, there was a significant correlation between subsidence and cage height (P=0.046). This procedure (ExTLIF) can be applied in cases where an anterior approach is contraindicated as well as for deformity correction. Level III.

Outcomes and Complications After Elective Thoracic and Lumbar Spinal Fusion in Elderly Patients: A Comparison of Methods to Predict Adverse Events.

Retrospective study. The current study compares the ability of the modified Frailty Index (mFI), the American Society of Anesthesiologists (ASA) classification, the modified Charleston Comorbidity Index (mCCI), the American College of Surgeons Surgical Risk Calculator (SRC), and the Fusion Risk Score (FRS) to predict perioperative outcomes. Comorbidity indices were calculated for patients undergoing elective thoracic and lumbar spinal fusion at a single institution and assessed for their discriminative ability in predicting the desired outcomes using an area under the curve (AUC) analysis. 393 patients met the inclusion and exclusion criteria. Patients being treated for adult spinal deformity (ASD) had the highest rate of complications (44.4%). The FRS had acceptable discrimination (AUC >0.7) and the highest ability among the methods studied to predict any adverse effects, new neurological deficit, return to OR within 90 days, and surgical site infection. It had good discrimination ability (AUC >0.8) predicting durotomy, respiratory failure (RF) requiring intubation, hemodynamic instability, and sepsis. The SRC had acceptable discrimination and highest ability to predict deep venous thrombosis (DVT). The mCCI had excellent and the highest ability to predict acute renal failure (ARF). For the other outcomes, the indices had either poor predictive ability (AUC 0.6-0.7) or no discriminative ability (AUC <0.6). The FRS had a better ability than the ASA, mCCI, mFI, and SRC to predict the most perioperative adverse events and reoperation. Further study is needed to develop preoperative indices with better predictive ability of postoperative outcomes.

Assessment of spinopelvic relationship among Turkish orthopedic surgeons in total joint replacement: a survey.

This study aims to investigate the preferences of orthopedics and traumatology specialists in evaluating the spinopelvic relationship in primary total hip arthroplasty (THA) in Türkiye. Members of the Turkish Orthopedics and Traumatology Association (n=2485) were invited to fill out the questionnaire. The survey was created using Google Forms and distributed to participants via WhatsApp and Gmail by sharing the link. A total of 205 orthopedic surgeons responded and completed the questionnaire. The survey included 13 questions about the duration of their experience, the number of THA and spinal instrumentation procedures they performed, the dislocation rates they encountered after surgery, and the radiological assessments they performed for the spinopelvic relationship. Sixty-three percent of the participants evaluated spinopelvic parameters in patients undergoing THA. Forty-seven percent of surgeons state that in their daily practice, they determine the angle of the acetabular component according to whether the spinal deformity is rigid, flexible, balanced, or unstable. While 88% of the participants stated the rate of encountering dislocation after primary THA as less than 2%, 12% of the participants stated it as more than 2%. It was observed that 40% of the surgeons with a prosthetic dislocation rate of more than 2% evaluated the spinopelvic relationship, while 67% of the surgeons with a dislocation rate of less than 2% evaluated the spinopelvic relationship. Approximately half of the orthopedic surgeons in Türkiye plan component placement in primary THA cases by considering the spinopelvic relationship. In order to increase awareness about the spinopelvic relationship, it would be beneficial to give more space to this subject in training programs and conferences. N/A.

T-Bar Angular Offset: A Novel Angle for Predicting Postoperative Coronal Balance Using Intraoperative Stitched Radiographs

BACKGROUND AND OBJECTIVES: Accurate intraoperative assessment of coronal alignment is critical to achieving favorable clinical outcomes in adult spinal deformity surgery. However, surgical positioning creates challenges in predicting standing coronal alignment. Gravity-based plumblines require an upright posture and are not possible intraoperatively. Intraoperative stitched radiography (ISR) is increasingly being used to evaluate coronal balance as an alternative to 36-inch films, which can be cumbersome. However, ISR does not allow for the measurement of absolute distances, which limits the intraoperative assessment of the coronal plane. We propose a novel angle to assess coronal balance on ISR: the T-bar angular offset (TAO). We evaluate TAO as a measure of coronal balance and assess the degree to which TAO measured on ISR can predict postoperative coronal balance. METHODS: Patients undergoing spinal fusion surgery with ISR were identified retrospectively. A virtual T-bar was created by drawing a line bisecting the S1 endplate perpendicular to a line connecting the acetabula. A second line was drawn from the origin of the first to the midpoint of the superior endplate of the upper instrumented vertebra (UIV) or C7. The angles subtended by these lines were defined as the UIV TAO and C7 TAO, respectively. RESULTS: Sixty-eight patients were identified, with a median (range) of 8 (3-21) levels fused. Intraoperative UIV TAO correlated with both postoperative UIV TAO (R = 0.695, P &lt; .001) and postoperative UIV central sacral vertical line (R = 0.435, P = .002). Intraoperative C7 TAO did not correlate with either postoperative C7 TAO (R = 0.213, P = .22) or C7 central sacral vertical line (R = 0.063, P = .72). CONCLUSION: TAO is a useful angular measure that can be used on noncalibrated ISR to predict the positioning of the UIV relative to the sacrum during spinal fusion surgery. However, it does not appear to be predictive of the coronal alignment of C7.

Using Artificial Intelligence to Identify Three Presenting Phenotypes of Chiari Type-1 Malformation and Syringomyelia

BACKGROUND AND OBJECTIVES: Chiari type-1 malformation (CM1) and syringomyelia (SM) are common related pediatric neurosurgical conditions with heterogeneous clinical and radiological presentations that offer challenges related to diagnosis and management. Artificial intelligence (AI) techniques have been used in other fields of medicine to identify different phenotypic clusters that guide clinical care. In this study, we use a novel, combined data-driven and clinician input feature selection process and AI clustering to differentiate presenting phenotypes of CM1 + SM. METHODS: A total of 1340 patients with CM1 + SM in the Park Reeves Syringomyelia Research Consortium registry were split a priori into internal and external cohorts by site of enrollment. The internal cohort was used for feature selection and clustering. Features with high Laplacian scores were identified from preselected groups of clinically relevant variables. An expert clinician survey further identified features for inclusion that were not selected by the data-driven process. RESULTS: The feature selection process identified 33 features (28 from the data-driven process and 5 from the clinician survey) from an initial pool of 582 variables that were incorporated into the final model. A K-modes clustering algorithm was used to identify an optimum of 3 clusters in the internal cohort. An identical process was performed independently in the external cohort with similar results. Cluster 1 was defined by older CM1 diagnosis age, small syringes, lower tonsil position, more headaches, and fewer other comorbidities. Cluster 2 was defined by younger CM1 diagnosis age, more bulbar symptoms and hydrocephalus, small syringes, more congenital medical issues, and more previous neurosurgical procedures. Cluster 3 was defined by largest syringes, highest prevalence of spine deformity, fewer headaches, less tonsillar ectopia, and more motor deficits. CONCLUSION: This is the first study that uses an AI clustering algorithm combining a data-driven feature selection process with clinical expertise to identify different presenting phenotypes of CM1 + SM.

Epidural Anesthesia in a Patient with Severe Thoracic Kyphosis Undergoing Primary Cesarean Delivery: A Case Report

The administration of neuraxial anesthesia among parturient patients with concomitant spine deformity poses challenges to anesthesiologists. The apprehension stems from the increased possibility of a failed block and complications arising from potential neurologic injury due to anatomic variance. This is a case report of a 30-year old female gravida 1 para 0 at 36 4/7 weeks age of gestation with severe thoracic kyphosis who underwent emergency primary low segment cesarean section under epidural anesthesia. Ultrasonography of the spine was done pre-induction to visualize spinal anatomy and verify anatomic landmarks. Epidural anesthesia was attempted twice before achieving adequate block to dermatomal level T4 within approximately seven minutes. The patient was able to tolerate the procedure well without significant intraoperative events. Fetal outcomes were also favorable with APGAR scores of 9,9. This case report emphasizes that with extensive preoperative evaluation and preparation, an individualized anesthetic plan may be devised. Ultrasound-guided epidural catheter insertion can be a safe option for obstetric patients with thoracic kyphosis.

Comparing outcomes for single-segment vertebral column decancellation performed at different vertebras in ankylosing spondylitis-an observational study

BackgroundThe surgical procedure of vertebral column decancellation (VCD) has been increasingly performed in orthopaedic surgery for those with spinal deformity. To investigate the results of single-segment VCD performed at different vertebra for correcting thoracolumbar kyphosis in ankylosing spondylitis (AS) and to guide the osteotomy strategy.MethodsEighty-six AS patients (77 males, 9 females) having thoracolumbar kyphosis underwent single-segment VCD (ranging from T12 to L3) between January 2016 and September 2019 were enrolled and divided into four groups according to the osteotomy vertebra: T12 in 9 cases (Group A), L1 in 15 cases (Group B), L2 in 47 cases (Group C), and L3 in 15 cases (Group D). Demographics, operational data, radiological and clinical data were compared among the four groups.ResultsAll patients had significant improvements in spinopelvic alignments and health-related quality of life after correction surgeries. Having the similar demographics, patients in the group C obtained the maximum local kyphosis and global kyphosis correction of 45.05° ± 9.07° (P < 0.001) and 43.42° ± 11.24° (P < 0.001) respectively. However, those in the group A had the largest correction in thoracic kyphosis (41.88° ± 9.57°) and chin-brow vertical angle (24.74° ± 6.38°) respectively (P < 0.001). Moreover, the VCD of L2 or L3 would result in much larger correction in lumbar lordosis and sagittal vertical axis than those in the group A and B respectively (P < 0.001), patients in the group A and B suffered from much higher incidence of complications perioperatively although (P = 0.043).ConclusionSingle-segment VCD performed among thoracolumbar segments can effectively restore spinopelvic alignments and improve the health related quality of life for AS patients with thoracolumbar kyphosis deformity. Moreover, L2 may be the optimal osteotomy vertebra for those patients.Trial registrationClinical trial number: not applicable.Level of evidenceIII, therapeutic study.

BN SO46 - PANDORA's BOX- When anatomy trumps the pathology

Abstract Background Obturator hernias are usually attributed to elderly females presenting with small bowel obstruction. We present a case of an elderly gentleman with severe Kyphoscoliosis presenting with small bowel obstruction. His past medical history included Ischaemic Heart Disease with stents in the coronary arteries and on dual antiplatelets. His Kyphoscoliosis precluded him from being able to lie flat on his back. The spinal deformity as revealed in the CT scans proved challenging to position him dsafely for surgery. The lack of access between costal margins and the pelvis meant that surgical access with Laparoscopy was going to be impossible. Method After initial resuscitation, he underwent CT scan of his Chest, abdomen and pelvis which revealed an obstructed Obturator Hernia on the left side with small bowel obstruction. The CT was also concerning for the Anaesthetists due to the challenge posed by the severe Kyphoscoliosis. After fibreoptic intubation, abdomen was accessed through a transverse muscle cutting incision, at the level of the umbilicus. The Obturator membrane was approached from above and the hernia was reduced. The obstructed small bowel was viable and the defect in the obturator membrane was closed with No1 Ethibond sutures. The abdomen was closed with mass closure. Results Patient had a smooth post operative period and was discharged home after 2 weeks. Obturator hernias are notorious for their occult presentation. Unless the patient is scanned with CT imaging, it is impossible to make the diagnosis although clinical signs like Howship- Romberg sign may be present with pain on internal rotation of the hip, as a result of irritation of the Obturator nerve. Obturator Neuralgia may be elicited with positive Hannington- Kiff sign, which is an absence of absent adductor reflux in the thigh. Conclusion Obturator hernias are typically seen in skinny old females. When presenting with small bowel obstruction, Obturator herniae are challenging both in terms of diagnosis as well as in management. In our case, the challenging anatomy posed greater risk to safe airway control. From surgical view, laparoscopy as a less invasive option was ruled out because of the restricted access. When anatomy is challenging, the Surgeon will be forced to think outside the box and consider access to the abdomen through incisions which are not routinely used. The preoperative imaging shows the challenge posed by the extreme spinal deformity.

Life-threatening postoperative hemorrhage caused by lumbar artery injury in asymmetrical pedicle subtraction osteotomy for severe spinal deformity: two case reports.

To present two cases of life-threatening hemorrhage related to lumbar artery injury in adult spinal deformity (ASD) patients following S2‑alar‑iliac (S2AI) fixation and asymmetrical pedicle subtraction osteotomy (PSO), and discuss the possible reasons for postoperative hemorrhage in these patients. Patient A was a 52-year-old female with degenerative lumbar scoliosis who underwent posterior spinal fusion from T8-S2 and one-level PSO at L2. Patient B was a 24-year-old male with severe kyphoscoliosis due to non-ambulatory cerebral palsy, who underwent posterior spinal fusion from T3-S2 and one-level PSO at L1. Both patients underwent asymmetric PSO, where a larger wedge was resected from the convex side of the vertebral body rather than the concave side. Both patients occurred a sudden increase in drainage within 3h postoperatively, who were under anesthesia in AICU. Digital subtraction angiography (DSA) was emergently performed and revealed that the bleeding sites were from the lumbar artery, which was adherent to the convex side of the osteotomized vertebra in both cases. Then successful bleeding control was achieved through vascular embolization. Postoperative CT revealed spike formation at the anterior edges of the open wedge at the PSO level due to sagittal translation (ST), with noticeable derotation of the osteotomized vertebra. For patients with severe kyphoscoliosis, asymmetrical PSO increases the risk of lumbar artery injury on the convex side, and postoperative ST may further contribute to this risk. In cases where a sudden increase in drainage is observed postoperatively, it is crucial to consider the possibility of lumbar artery injury, particularly on the convex side of the osteotomized vertebra.

Efficacy of intervertebral release combined with asymmetric osteotomy in rigid degenerative scoliosis

PurposeThe aim of this study is to evaluate the clinical efficacy and safety of treating patients with rigid degenerative scoliosis by restoring intervertebral balance through a combination of interbody release and asymmetric grade 1 and 2 osteotomy.MethodThe medical collected clinical and radiographic data of patients with rigid degenerative scoliosis from our department between 2015 and 2022. A total of 60 patients were included in the study, comprising 20 males and 40 females, with an average follow-up period of 30.7 months. Data recorded included surgery duration, blood loss, number of fixed segments, hospital stay, complications, clinical scores, and radiographic parameters.ResultsThe sagittal vertical axis improved from 4.28 ± 1.48 cm preoperatively to 2.90 ± 1.18 cm postoperatively, while the coronal vertical axis improved from 3.29 ± 1.72 cm preoperatively to 1.12 ± 0.62 cm postoperatively. The preoperative coronal Cobb angle was 30.85 ± 7.33°, which improved to 4.14 ± 3.06°postoperatively. Additionally, lumbar lordosis increased from 24.50 ± 17.24°preoperatively to 30.35 ± 6.11°postoperatively. VAS scores for back pain and leg pain, ODI scores, and JOA scores showed varying degrees of improvement.ConclusionInterbody release combined with asymmetric Grade 1 and 2 osteotomy to restore intervertebral balance significantly improves spinal deformity and postoperative functional scores in patients with rigid degenerative scoliosis.

TIA-UNet: transformer-enhanced deep learning for adolescent idiopathic scoliosis spinal x-ray image segmentation

Abstract Adolescent Idiopathic Scoliosis (AIS) is a common spinal deformity where precise diagnosis is crucial for developing effective treatment strategies. Traditional manual x-ray image analysis is time-consuming and highly dependent on the operator’s expertise, thus constraining diagnostic efficiency and accuracy. This study aimed to develop an automated thoracolumbar spine segmentation method utilizing deep learning to enhance the efficiency and accuracy of AIS diagnosis. We introduced TIA-UNet, an innovative network architecture that combines Convolutional Neural Networks (CNN) with Transformer models. By integrating the IR Block and DA Block, TIA-UNet was optimized for feature extraction and multi-scale information fusion. The model underwent training and validation using our established Adolescent Scoliosis Medical Dataset (ASMD). TIA-UNet attained a Dice similarity coefficient of 90. 02%, a Mean Intersection over Union (MIoU) of 81. 96%, and a Hausdorff Distance (HD) of 4. 09, significantly surpassing current state-of-the-art methods such as UNet and TransUNet. Moreover, TIA-UNet exhibited superior computational efficiency regarding parameter count, inference time, and floating-point operations (FLOPs). As an automated medical image segmentation algorithm, TIA-UNet enhanced segmentation accuracy while maintaining high computational efficiency, demonstrating significant potential for clinical diagnostic applications. This study provides compelling evidence supporting the utilization of deep learning techniques in medical image analysis.

Changes in Physical Function After Long Corrective Fusion to the Ilium for Adult Spinal Deformity

Study Design. Prospective cohort study. Objective. To investigate longitudinal changes in physical functional status after long corrective fusion in patients with adult spinal deformity (ASD) during 2 years of follow-up. Summary of Background Data. In ASD surgery, reports assessing physical functional status in long-term observations for more than a year are lacking. Assessing whether patients maintain significant improvements in their physical status with a longer follow-up duration is crucial. Methods. A total of 70 female patients with ASD who underwent long corrective fusion of ≥ 7 segments between June 2016 and June 2022 were included in this study. Preoperative and postoperative assessments (at 6 months, 1 year, and 2 years) included radiographic spinopelvic parameters, health-related quality of life (HRQOL) using the Scoliosis Research Society Outcome Instrument-22 (SRS-22) questionnaire, and physical function tests conducted by a physical therapist. Results. All domains of the SRS-22 improved the most in the first 6 months after surgery (P &lt;0.0001); however, the Pain and Function domains continued to improve gradually until 2 years postoperatively. Regarding trunk dynamic balance, the timed up-and-go test score improved gradually until 2 years postoperatively (P &lt;0.0001). Regarding gait performance, gait speed and the 6-minute walking test improved the most in the first 6 months after surgery (P &lt;0.01) and almost reached a plateau 1 year postoperatively. Conclusions. Long corrective fusion for ASD significantly enhanced physical function and HRQOL within 2 years, with the greatest improvement in the first 6 months after surgery. These findings underscore the importance of increasing activities of daily living through early exercise instruction, as well as preventive measures to avoid early surgery-related complications. Level of Evidence. 3