Aims. The aim of this study was to investigate the impact of the level of upper instrumented vertebra (UIV) in frail patients undergoing surgery for adult spine deformity (ASD). Methods. Patients with adult spinal deformity who had undergone T9-to-pelvis fusion were stratified using the ASD-Modified Frailty Index into not frail, frail, and severely frail categories. ASD was defined as at least one of: scoliosis ≥ 20°, sagittal vertical axis (SVA) ≥ 5 cm, or pelvic tilt ≥ 25°. Means comparisons tests were used to assess differences between both groups. Logistic regression analyses were used to analyze associations between frailty categories, UIV, and outcomes. Results. A total of 477 patients were included (mean age 60.3 years (SD 14.9), mean BMI 27.5 kg/m. 2. (SD 5.8), mean Charlson Comorbidity Index (CCI) 1.67 (SD 1.66)). Overall, 74% of patients were female (n = 353), and 49.6% of patients were not frail (237), 35.4% frail (n = 169), and 15% severely frail (n = 71). At baseline, differences in age, BMI, CCI, and deformity were significant (all p = 0.001). Overall, 15.5% of patients (n = 74) had experienced mechanical complications by two years (8.1% not frail (n = 36), 15.1% frail (n = 26), and 16.3% severely frail (n = 12); p = 0.013). Reoperations also differed between groups (20.2% (n = 48) vs 23.3% (n = 39) vs 32.6% (n = 23); p = 0.011). Controlling for osteoporosis, baseline deformity, and degree of correction (by sagittal age-adjusted score (SAAS) matching), frail and severely frail patients were more likely to experience mechanical complications if they had heart failure (odds ratio (OR) 6.6 (95% CI 1.6 to 26.7); p = 0.008), depression (OR 5.1 (95% CI 1.1 to 25.7); p = 0.048), or cancer (OR 1.5 (95% CI 1.1 to 1.4); p = 0.004). Frail and severely frail patients experienced higher rates of mechanical complication than ‘not frail’ patients at two years (19% (n = 45) vs 11.9% (n = 29); p = 0.003). When controlling for baseline deformity and degree of correction in severely frail and frail patients, severely frail patients were less likely to experience clinically relevant proximal junctional kyphosis or failure or mechanical complications by two years, if they had a more proximal UIV. Conclusion. Frail patients are at risk of a poor outcome after surgery for adult spinal deformity due to their comorbidities. Although a definitively prescriptive upper instrumented vertebra remains elusive, these patients appear to be at greater risk for a poor outcome if the upper instrumented vertebra is sited more distally. Cite this article: Bone Joint J 2024;106-B(11):1342–1347

Background. Surgical treatment of AIS includes several purposes such as arrest deformity progression through a solid fusion, obtain a permanent correction of the deformity and others. Objectives. To evaluate the improvement of sagittal spinopelvic parameters and clinical outcomes in patients with adolescent idiopathic scoliosis 2 years after corrective surgery. Methods. Radiological and clinical data of 134 consecutive scoliosis patients including 11 boys and 124 girls with the average age of 15.37 years, with AIS Lenke 1, 2, 3, 4, 5 or 6 were included in this retrospective study with 2-year follow-up. Whole spine anterior/posterior and lateral Xray, CT scan and MRI were taken preoperatively, immediately after surgery, at 3 months and 2 years after corrective surgery. Radiological parameters were evaluated and compared pre and post operatively. Result. In coronal plan, significant reduction was observed in main curve, proximal curve and distal curve P<0.001, 2 years after corrective surgery. Meanwhile, the translation of apex vertebra decreased p<0.001. But sagittal profile of the patients did not show obvious changes such as LL, TK. The pelvic parameters indicated that PI was 50.6 degrees, PT was 13.8, SS was 37.0 and TPA was 47.5 degrees preoperatively. Vertebral body height increased dramatically just after surgery and showed further in the last follow up. Conclusion. The changes in coronal plan was significant 2 years after correction surgery for AIS patients and were not correlated with restoration of sagittal profile. Conflict of interest. None. Sources of funding. None

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Historically, patients undergoing surgery for adolescent idiopathic scoliosis (AIS) have been nursed postoperatively in a critical care (CC) setting because of the challenges posed by prone positioning, extensive exposures, prolonged operating times, significant blood loss, major intraoperative fluid shifts, cardiopulmonary complications, and difficulty in postoperative pain management. The primary aim of this paper was to determine whether a scoring system, which uses Cobb angle, forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and number of levels to be fused, is a valid method of predicting the need for postoperative critical care in AIS patients who are to undergo scoliosis correction with posterior spinal fusion (PSF).

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This systematic review aims to identify 3D predictors derived from biplanar reconstruction, and to describe current methods for improving curve prediction in patients with mild adolescent idiopathic scoliosis.

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To systematically evaluate whether bracing can effectively achieve curve regression in patients with adolescent idiopathic scoliosis (AIS), and to identify any predictors of curve regression after bracing.

Intra-Discal Vacuum Phenomenon (IDVP) represents an intradiscal nitrogen gas accumulation where a cavity opens in a supine position, lowering intra-discal pressure and generating a bubble. IDVP has been observed in up to 20% of elderly patients and reported in almost 50% of chronic LBP patients. With a highly accurate detection on CT, its significance lacks clarity and consideration within normative data. IDVP occurs with patterns of lumbar and/or lumbopelvic morphology and associated diagnoses. Over-60s population based sample of 2020 unrelated CT abdomen scans without acute spinal presentations, with sagittal reconstructions, inclusive of T12 to femoral heads, were analyzed for IDVP and pelvic incidence (PI). Subjects with diagnostic morphological associations of the lumbar spine, including previous fracture, autofusion, transitional vertebra and listhesis, were selected out and analyzed separately. Subjects were then equally grouped into low, medium and high PI. Prevalence of lumbar spine IDVP is 41.3%. 125 cases were excluded. 1603 subjects yielded 663 IDVP. This was increased in severity towards the lumbosacral junction (L1L2 9.4%, L2L3 10.9%, L3L4 13.7%, L4L5 19.9%, L5S1 28.5%) and those with low PI, while distribution was more even with high PI. 292 had positive diagnostic associations, which were more likely to occur at the level of isthmic spondylolisthesis, adjacent to a previous fracture or suprajacent to lumbosacral transitional vertebra (p<0.05). This study has identified normative values for prevalence and severity of IDVP in a normal aging population. Morphological patterns that influence the pattern of IVDP such as pelvic incidence and diagnostic associations provide novel insights to the function of the aging spine

The December 2023 Spine Roundup³⁶⁰ looks at: Does size matter in adolescent pedicle screws?; Effect of lumbar fusion and pelvic fixation rigidity on hip joint stress: a finite element analysis; Utility of ultrasonography in the diagnosis of lumbar spondylolysis in adolescent patients; Rett syndrome-associated scoliosis a national picture.

7% of adolescent idiopathic scoliosis (AIS) patients also present with a pars defect. To date, there are no available data on the results of fusion ending proximal to a spondylolysis in the setting of AIS. The aim of this study was to analyze the outcomes of posterior spinal fusion (PSF) in this patient cohort, to investigate if maintaining the lytic segment unfused represents a safe option. Retrospective review of all patients who received PSF for AIS, presented with a spondylolysis or spondylolisthesis and had a min. 2-years follow-up. Demographic data, instrumented levels and preoperative radiographic data were collected. Mechanical complications, coronal or sagittal parameters, amount of slippage and pain levels were evaluated. Data from 22 patients were available (age 14.4 ± 2.5 years), 18 Lenke 1–2 and four Lenke 3–6. Five patients (24%) had an isthmic spondylolisthesis, all Meyerding I. The mean preoperative Cobb angle of the instrumented curves was 58 ± 13°. For 18 patients the lowest instrumented vertebra (LIV) was the last touched vertebra (LTV); for two LIV was distal to the LTV; for two, LIV was one level proximal to the LTV. The number of segments between the LIV and the lytic vertebra ranged from 1 to 6. At the last follow-up, no complications were observed. The residual curve below the instrumentation measured 8.5 ± 6.4°, the lordosis below the instrumented levels was 51.4 ± 13°. The magnitude of the isthmic spondylolisthesis remained constant for all included patients. Three patients reported minimal occasional low back pain. The LTV can be safely used as LIV when performing PSF for the management of AIS in patients with L5 spondylolysis

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To determine whether side-bending films in scoliosis are assessed for adequacy in clinical practice; and to introduce a novel method for doing so.

The August 2023 Spine Roundup360 looks at: Changes in paraspinal muscles correspond to the severity of degeneration in patients with lumbar stenosis; Steroid injections are not effective in the prevention of surgery for degenerative cervical myelopathy; A higher screw density is associated with fewer mechanical complications after surgery for adult spinal deformity; Methylprednisolone following minimally invasive lumbar decompression: a large prospective single-institution study; Occupancy rate of pedicle screw below 80% is a risk factor for upper instrumented vertebral fracture following adult spinal deformity surgery; Deterioration after surgery for degenerative cervical myelopathy: an observational study from the Canadian Spine Outcomes and Research Network.

The June 2023 Spine Roundup³⁶⁰ looks at: Characteristics and comparative study of thoracolumbar spine injury and dislocation fracture due to tertiary trauma; Sublingual sufentanil for postoperative pain management after lumbar spinal fusion surgery; Minimally invasive bipolar technique for adult neuromuscular scoliosis; Predictive factors for degenerative lumbar spinal stenosis; Lumbosacral transitional vertebrae and lumbar fusion surgery at level L4/5; Does recall of preoperative scores contaminate trial outcomes? A randomized controlled trial; Vancomycin in fibrin glue for prevention of SSI; Perioperative nutritional supplementation decreases wound healing complications following elective lumbar spine surgery: a randomized controlled trial.

Aims. The aim of this study was to report the long-term prognosis of patients with multiple Langerhans cell histiocytosis (LCH) involving the spine, and to analyze the risk factors for progression-free survival (PFS). Methods. We included 28 patients with multiple LCH involving the spine treated between January 2009 and August 2021. Kaplan-Meier methods were applied to estimate overall survival (OS) and PFS. Univariate Cox regression analysis was used to identify variables associated with PFS. Results. Patients with multiple LCH involving the spine accounted for 15.4% (28/182 cases) of all cases of spinal LCH: their lesions primarily involved the thoracic and lumbar spines. The most common symptom was pain, followed by neurological dysfunction. All patients presented with osteolytic bone destruction, and 23 cases were accompanied by a paravertebral soft-tissue mass. The incidence of vertebra plana was low, whereas the oversleeve-like sign was a more common finding. The alkaline phosphatase was significantly higher in patients with single-system multifocal bone LCH than in patients with multisystem LCH. At final follow-up, one patient had been lost to follow-up, two patients had died, three patients had local recurrence, six patients had distant involvement, and 17 patients were alive with disease. The median PFS and OS were 50.5 months (interquartile range (IQR) 23.5 to 63.1) and 60.5 months (IQR 38.0 to 73.3), respectively. Stage (hazard ratio (HR) 4.324; p < 0.001) and chemotherapy (HR 0.203; p < 0.001) were prognostic factors for PFS. Conclusion. Pain is primarily due to segmental instability of the spine from its destruction by LCH. Chemotherapy can significantly improve PFS, and radiotherapy has achieved good results in local control. The LCH lesions in some patients will continue to progress. It may initially appear as an isolated or single-system LCH, but will gradually involve multiple sites or systems. Therefore, long-term follow-up and timely intervention are important for patients with spinal LCH. Cite this article: Bone Joint J 2023;105-B(6):679–687

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The aim of this study was to assess the accuracy of pedicle screw placement, as well as intraoperative factors, radiation exposure, and complication rates in adult patients with degenerative disorders of the thoracic and lumbar spines who have undergone robotic-navigated spinal surgery using a contemporary system.

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Patients with differentiated thyroid carcinomas (DTCs) have a favourable long-term survival. Spinal metastases (SMs) cause a decline in performance status (PS), directly affecting mortality and indirectly preventing the use of systemic therapies. Metastasectomy is indicated, if feasible, as it yields the best local tumour control. Our study aimed to examine the long-term clinical outcomes of metastasectomy for SMs of thyroid carcinomas.

Variations in pelvic anatomy are a major risk factor for misplaced percutaneous sacroiliac screws used to treat unstable posterior pelvic ring injuries. A better understanding of pelvic morphology improves preoperative planning and therefore minimises the risk of malpositioned screws, neurological or vascular injuries, failed fixation or malreduction. Hence a classification system which identifies the clinically important anatomical variations of the sacrum would improve communication among pelvic surgeons and inform treatment strategy. 300 Pelvic CT scans from skeletally mature trauma patients that did not have pre-existing posterior pelvic pathology were identified. Axial and coronal transosseous corridor widths at both S1 and S2 were recorded. Additionally, the S1 lateral mass angle were also calculated. Pelvises were classified based upon the sacroiliac joint (SIJ) height using the midpoint of the anterior cortex of L5 as a reference point. Four distinct types could be identified:. Type-A – SIJ height is above the midpoint of the anterior cortex of the L5 vertebra. Type-B – SIJ height is between the midpoint and the lowest point of the anterior cortex of the L5 vertebra. Type-C – SIJ height is below the lowest point of the anterior cortex of the L5 vertebra. Type-D – a subgroup for those with a lumbosacral transitional vertebra, in particular a sacralised L5. Differences in transosseous corridor widths and lateral mass angles between classification types were assessed using two-way ANOVAs. Type-B was the most common pelvic type followed by Type-A, Type-C, and Type-D. Significant differences in the axial and coronal corridors was observed for all pelvic types at each level. Lateral mass angles increased from Types-A to C, but were smaller in Type-D. This classification system offers a guide to surgeons navigating variable pelvic anatomy and understanding how it is associated with the differences in transosseous sacral corridors. It can assist surgeons’ preoperative planning of screw position, choice of fixation or the need for technological assistance

The current study aims to compare the clinico radiological outcomes between Non-Fusion Anterior Scoliosis (NFASC) Correction and Posterior Spinal Fusion (PSF) for Lenke 5 curves at 2 years follow up. Methods:38 consecutive Lenke 5 AIS patients treated by a single surgeon with NFASC (group A) or PSF (group B) were matched by age, Cobb's angle, and skeletal maturity. Intraoperative blood loss, operative time, LOS, coronal Cobbs, and SRS22 scores at 2 years were compared. Flexibility was assessed by modified Schober's test. Continuous variables were compared using student t-tests and categorical variables were compared using chi-square. The cohort included 19 patients each in group A and B . Group A had M:F distribution of 1:18 while group B had 2:17. The mean age in group A and group B were 14.8±2.9 and 15.3±3.1 years respectively. The mean follow-up of patients in groups A and B were 24.5±1.8 months and 27.4±2.1 months respectively. Mean pre-op thoracolumbar/lumbar (TL/L) cobbs for group A and group B were 55°±7° and 57.5°±8° respectively. At two years follow up, the cobbs for group A and B were 18.2°±3.6° and 17.6°±3.5° respectively (p=0.09). The average operating time for groups A and B were 169±14.2 mins and 219±20.5 mins respectively (p<0.05). The average blood loss of groups A and B were 105.3±15.4 and 325.3±120.4 respectively (p<0.05). The average number of instrumented vertebra between groups A and B were 6.2 and 8.5 respectively (p<0.05). The average LOS for NFASC and PSF was 3.3±0.9 days and 4.3±1.1 days respectively (p<0.05). No statistically significant difference in SRS 22 score was noted between the two groups. No complications were recorded. Our study shows no significant difference in PSF and NFASC in terms of Cobbs correction and SRS scores, but the NFASC group had significantly reduced blood loss, operative time, and fewer instrumented levels. NFASC is an effective alternative technique to fusion to correct and stabilize Lenke 5 AIS curves with preservation of spinal motion

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To determine the major risk factors for unplanned reoperations (UROs) following corrective surgery for adult spinal deformity (ASD) and their interactions, using machine learning-based prediction algorithms and game theory.

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The optimal procedure for the treatment of ossification of the posterior longitudinal ligament (OPLL) remains controversial. The aim of this study was to compare the outcome of anterior cervical ossified posterior longitudinal ligament en bloc resection (ACOE) with posterior laminectomy and fusion with bone graft and internal fixation (PTLF) for the surgical management of patients with this condition.

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Internal hemipelvectomy without reconstruction of the pelvis is a viable treatment for pelvic sarcoma; however, the time it takes to return to excellent function is quite variable. Some patients require greater time and rehabilitation than others. To determine if psoas muscle recovery is associated with changes in ambulatory function, we retrospectively evaluated psoas muscle size and limb-length discrepancy (LLD) before and after treatment and their correlation with objective functional outcomes.

Dysmorphic pelves are a known risk factor for malpositioned iliosacral screws. Improved understanding of pelvic morphology will minimise the risk of screw misplacement, neurovascular injuries and failed fixation. Existing classifications for sacral anatomy are complex and impractical for clinical use. We propose a CT-based classification using variations in pelvic anatomy to predict the availability of transosseous corridors across the sacrum. The classification aims to refine surgical planning which may reduce the risk of surgical complications. The authors postulated 4 types of pelves. The “superior most point of the sacroiliac joint” (sSIJ) typically corresponds with the mid-lower half of the L5 vertebral body. Hence, “the anterior cortex of L5” (L5. a. ) was divided to reference 3 distinct pelvic groups. A 4. th. group is required to represent pelves with a lumbosacral transitional vertebra. The proposed classification:. A – sSIJ is above the midpoint of L5. a. B – sSIJ is between the midpoint and the lowest point of L5. a. C – sSIJ is below the lowest point of L5. a. D – pelves with a lumbosacral transitional vertebra. Specific measures such as the width of the S1 and S2 axial and coronal corridors and the S1 lateral mass angles were used to differentiate between pelvic types. Three-hundred pelvic CT scans were classified into their respective types. Analysis of the specific measures mentioned above illustrated the significant difference between each pelvic type. Changes in the size of S1 and S2 axial corridors formed a pattern that was unique for each pelvic type. The intra- and inter-observer ratings were 0.97 and 0.95 respectively. Distinct relationships between the sizes of S1 and S2 axial corridors informed our recommendations on trans-sacral or iliosacral fixation, number and orientation of screws for each pelvic type. This classification utilises variations in the posterior pelvic ring to offer a planning guide for the insertion of iliosacral screws