Lumbar Spinal Steroid Injections and Infection Risk after Spinal Surgery: A Systematic Review and Meta-Analysis.

Lumbar spinal steroid injections (LSSI) are universally used as preferred diagnostic or therapeutic treatment options before major spinal surgeries. Some recent studies have reported higher risks of surgical-site infection (SSI) for spinal surgeries performed after injections, while others have overlooked such associations. The purpose of this study is to systematically review the literature and perform a meta-analysis to evaluate the associations between preoperative LSSI and postoperative infection following subsequent lumbar decompression and fusion procedures. Three databases, namely PubMed, Scopus, and Cochrane Library, were searched for relevant studies that reported the association of spinal surgery SSI with spinal injections. After the comprehensive sequential screening of the titles, abstracts, and full articles, nine studies were included in a systematic review, and eight studies were included in the meta-analysis. Studies were critically appraised for bias using the validated MINOR (methodological index for non-randomized studies) score. The odds ratio (OR) and 95% confidence interval (CI) were calculated. Subgroup analysis was performed according to the time between LSSI and surgery and the type of lumbar spine surgery. Meta-analysis showed that preoperative LSSI within 30 days of lumbar spine surgery was associated with significantly higher postoperative infection compared with the control group (OR,1.79; 95% CI, 1.08-2.96). Based on subgroup analysis, lumbar spine fusion surgery within 30 days of preoperative LSSI was associated with significantly high-infection rates (OR, 2.67; 95% CI, 2.12-3.35), while no association was found between preoperative LSSI and postoperative infection for lumbar spine decompression surgeries. In summary, given the absence of high-level studies in the literature, careful clinical interpretation of the results should be performed. The overall risk of SSI was slightly higher if the spinal surgery was performed within 30 days after LSSIs. The risk was higher for lumbar fusion cases but not for decompression-only procedures.

Evaluation of accuracy of plain radiography in determining the Risser stage and identification of common sources of errors.

BACKGROUND: Risser's sign is an established radiological marker for predicting growth potential in adolescent idiopathic scoliosis, but the accuracy of Risser's staging has been debated. This research was designed to evaluate the accuracy of Risser's staging and to identify causes of errors in Risser's staging. MATERIALS AND METHODS: Plain radiographs of 89 adolescent idiopathic scoliosis patients were evaluated for Risser's stage using both the Original and French methods. A three-dimensional computed tomography (3D-CT) was used to evaluate the accuracy of the plain radiographs. Inter- and intra-observer reliability of both methods was assessed on radiographs and 3D-CT images using weighted kappa statistics. The concordance rate for Risser's staging between plain radiographs and 3D-CT images were calculated. The various sources of staging differences between the two imaging methods were noted, grouped, and analyzed to identify common error patterns. RESULTS: Intra- and inter-observer staging reliabilities on plain radiography were 0.91 and 0.94, respectively, using the Original method and 0.91 and 0.92, respectively, using the French method. Intra- and inter-observer reliabilities on 3D-CT were 0.98 and 0.99, respectively, using the Original method and 0.97 and 0.99, respectively, using the French method. Mean concordance rates between plain radiography and 3D-CT were 59.76% and 67.42% using the Original and French methods, respectively. Common sources of error leading to misinterpretation of Risser's staging were miscalculation of apophysis excursion, skip ossification, isolated non-linear ossification, micro-fusion, and pseudo-fusion. CONCLUSIONS: Risser's staging by plain radiography is reliable but not accurate. Variations in the iliac apophysis ossification and misinterpretation of apophysis fusion are the main sources of error.

Does delaying surgery in immature adolescent idiopathic scoliosis patients with progressive curve, lead to addition of fusion levels?

PURPOSE: To analyze the changes in the curve extent, pattern and the fusion level in adolescent idiopathic scoliosis (AIS) patients who undergo delayed surgery instead of early surgery. METHODS: Thirty-five immature AIS patients whose radiographs demonstrated an initial primary curve of more than 40° with a subsequent increase of 10° before attaining skeletal maturity with brace were enrolled. The initial and the final radiographs taken before surgery were compared to assess the changes in curve extent, pattern and the fusion levels as recommended by King's, Lenke's and Suk's guidelines. RESULTS: The average age of 35 AIS patients was 12.7 ± 1.6 years. The time interval between initial and final radiography was 39.3 ± 20.2 months and the degree of progress of the primary curve was 13 ± 9.7°. Fusion levels changed in 33 (94.2%), 33 (94.2%) and 32 (91.4%) patients according to King's, Lenke's and Suk's guidelines, respectively. Curve pattern was changed in 2 (5.7%), 12 (34.3%) and 10 (28.6) patients by King's, Lenke's and Suk's guidelines. The mean number of levels requiring fusion increased from 9.4 ± 2.1 at initial visit to 11.1 ± 1.8 at the final follow-up using King's guidelines, 9.7 ± 2.2-11.6 ± 2.0 as per Lenke's guidelines and 9.1 ± 2.0-11.5 ± 2.3 when fusion was planned using Suk's guidelines (p < 0.001 in all guidelines). CONCLUSIONS: Delay of surgery in immature AIS patients whose Cobb's angle exceed 40° initially and showing subsequent progression of the curve, of more than 10° can lead to alterations in the curve pattern and the need for increase in fusion levels.

Short apical rib resections thoracoplasty compared to conventional thoracoplasty in adolescent idiopathic scoliosis surgery.

PURPOSE: To introduce a modified technique of thoracoplasty (short apical rib resection thoracoplasty (SARRT)) and compare its clinical, functional radiological outcomes and postoperative lung functions with conventional thoracoplasty (CT) in scoliosis surgery. METHODS: Retrospectively review of adolescent idiopathic scoliosis patients who underwent corrective surgery with thoracoplasty from 2006 to 2010 was performed. Thoracoplasty was performed in 58 patients (CT in 31 and SARRT in 27 patients). 21 patients who underwent deformity correction only, without thoracoplasty were taken as control group (non-thoracoplasty, NT). To evaluate the outcome of SARRT, radiological parameters, pulmonary functions and clinical outcomes were compared among all the three groups. RESULTS: Age, sex and scoliosis types were evenly distributed between 3 groups (p = 0.66, 0.92, 0.31). Number of levels fused, change in Cobb angle, lordosis, kyphosis, coronal balance, sagittal balance, coronal translation and sagittal translation were not significantly different among the three groups (p > 0.05 for all). There was 38.6% improvement in rib hump in NT, 44.04% in CT and 60.9% correction in SARRT group. Pulmonary complications were significantly higher in the CT group, especially in view of pleural rupture, pulmonary effusion and intercostal neuralgia (p = 0.041, 0.029, 0.049). There was no difference among three groups in postoperative pulmonary function but the score of satisfaction as sub-category in SRS-22 questionnaire was decreased in CT groups (p = 0.046). CONCLUSIONS: SAART is effective in correcting the rib deformity without altering the pulmonary functions and SAART has less number of pulmonary complications as compared to CT.

Changes in the spinopelvic parameters of elite weight lifters.

OBJECTIVE: To describe the changes in the spinopelvic parameters in weight lifters and evaluate the factors leading to spinal anatomical changes (eg, spondylolysis and listhesis). DESIGN: Case-control study. SETTING: Tertiary, institutional. PARTICIPANTS: The study group participants were practicing weight lifters in the athletes' village of the 2012 London Olympics. A total of 21 elite weight lifters were enrolled. Their data were compared with those of 45 healthy volunteers in the control group. INTERVENTIONS: Comparative radiological evaluations were performed among the 21 elite weight lifters. Spinopelvic parameters (radiographic analysis), including total (TLL), upper (ULL), and lower (LLL) lumbar lordoses, sacral slope, pelvic tilt (PT) and incidence, lumbar index, and disc angles, were assessed. MAIN OUTCOME MEASURES: The proportional ratio of ULL and LLL to TLL (ULL/TLL and LLL/TLL) was measured to describe the proportion effect. These values were compared with those of the control group. Weight lifters with and those without anatomical changes were subdivided into a deformed and nondeformed group, respectively, and further analyzed for differences. The correlation between these spinal parameters and the amount and duration of weight lifting training was also analyzed. RESULTS: Anatomical changes in the lumbar spine were seen in 6 weight lifters (28.6%, P = 0.01). The mean TLL, ULL, and LLL values (59.8, 22.6, and 37.2 degrees, respectively) were increased, whereas PT (10.3 degrees) was decreased in the athletes compared with the volunteers (P = 0.001, 0.005, 0.07, and 0.018, respectively). The ULL/TLL was higher in the deformed group than in the nondeformed group (P = 0.036). The duration and amount of weight lifting training were not correlated with the spinopelvic parameters measured in this study. CONCLUSIONS: The elite weight lifters had increased lumbar lordosis and decreased PT compared with the healthy volunteers. The ULL/TLL ratio may be used as a predictive marker for lumbar deformation.

Intraoperative airway obstruction in a Duchenne muscular dystrophy patient.

PURPOSE: To report a complication of airway obstruction during spinal deformity correction surgery in Duchenne muscular dystrophy (DMD) patient, due to lordoscoliosis, airway malacia, and prone surgical positioning, which was rectified by changing the position of the patient and surgery was successfully completed. CASE DESCRIPTION: A 15-year-old boy was diagnosed with DMD and admitted for surgical treatment of thoracolumbar scoliosis. The patient's preoperative Cobb's angle was 79° and the kyphotic angle was -19°. During the initial period of surgery, while in the prone position, peak inspiratory pressure (PIP) suddenly increased from 20-21 to 38-41 cmH2O, wheezing sounds were heard on auscultation of both lungs, and his blood pressure began to fall. Under suspicion of airway problem, intraoperative fiberoptic bronchoscopy was performed which confirmed airway obstruction. Attributing patient's prone position as the cause of airway obstruction, the surgical position of the patient was changed from prone to semi-lateral. After this change, the PIP stabilized to within normal limits (20-23 cmH2O). The surgical correction was successfully completed with a posterior-only pedicle screw by the free-hand technique, with the patient in the semi-lateral position for the rest of surgery. CONCLUSIONS: Lordoscoliosis and airway malacia in a patient with DMD can lead to occlusion of the tracheobronchial lumen when the patient is in the prone position. Changing the patient's position from prone to semi-lateral can be of help to reverse this airway obstruction and complete the surgery. Pedicular screw insertion can be safely and effectively carried out in this position using free-hand technique.

Isolated percutaneous thoracoplasty procedure for skeletally mature adolescent idiopathic scoliosis patients, with rib deformity as their only concern: short-term outcomes.

STUDY DESIGN: Prospective case series study. OBJECTIVE: To study the effect of percutaneous thoracoplasty-only procedure on curve pattern in mature adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: The rib hump prominence on the convex side is the major cosmetic concern among patients with AIS. Thoracoplasty combined with spinal fusion is a commonly used procedure in scoliosis. However, there are no studies regarding the effect of isolated thoracoplasty procedure on curve pattern in skeletally matured patients with AIS. METHODS: The study involved 7 skeletally matured female patients with AIS. The convex rib hump deformity was measured preoperatively using hump height and hump angle. We performed thoracoplasty without spinal fusion in patients with the Cobb angle less than 40° but with prominent hump deformity. Thoracoplasty was performed percutaneously using 1 or 2 transverse incisions along the rib hump, and apex portions of the deformed ribs were resected. The Cobb angle was measured before surgery, immediately after surgery, and at final follow-up visit. In all cases, clinical satisfaction was assessed using the Scoliosis Research Society Instrument (SRS-22 questionnaires) and trunk appearance perception scale before surgery and at final follow-up visit. RESULTS: The mean patient age was 20.24 years and an average of 4 ribs were resected. The mean preoperative hump height and hump angle of 38.14 mm and 14.14° improved to 11.70 mm and 11.42° respectively, after surgery (P = 0.018 and 0.042). Preoperative and the final follow-up mean Cobb angles were 35.43° and 45.00°, respectively (P = 0.028). On average, the mean thoracic curve progressed by 9.57°. Preoperative Scoliosis Research Society Instrument SRS-22 questionnaires and trunk appearance perception scale scores of 4.09 and 2.57 respectively improved to and 4.26 and 3.66 after surgery (P = 0.126 and 0.014). CONCLUSION: Percutaneous thoracoplasty-only procedure gives significant rib humps correction and satisfactory clinical outcome. However, progression of the curve was observed after surgery. This suggests that the convex ribs function as a buttress for curve progression.