Spondylolisthesis in young patients: postoperative functional outcomes at 22-year mean follow-up.

INTRODUCTION: Previous short- and intermediate-term clinical and radiographic studies demonstrated good results in patients who underwent spine surgery for spondylolisthesis, long-term outcomes are lacking instead. Young patients are often involved in high-demanding and sport activities, therefore good/excellent functional outcomes are very important for their future quality of life. The aim of this study is to assess the long-term functional results in young patients surgically treated for developmental spondylolisthesis. MATERIALS AND METHODS: Retrospective evaluation of consecutive patients who underwent lumbar surgery for spondylolisthesis. Inclusion criteria were: spondylolisthesis from grade 1 to spondyloptosis, age at surgery < 25 years, follow-up > 15 years. The following outcomes were assessed: VAS back, VAS leg, Oswestry disability index (ODI) score, Short Form 12 (SF-12), rate of revision surgery, postoperative recovery and sport activity. RESULTS: 113 patients were enrolled. Mean age at surgery was 19.8 years and mean follow-up was 22.1 years (16-32). 16 patients (14.2%) needed revision surgery. Functional outcomes at last follow-up were: VAS back = 1.6, VAS leg = 1.4, ODI = 9.2%, SF-12 physical component summary = 50, SF-12 mental component summary = 48.7. Significant differences were assessed in terms of ODI (p = 0.047) and SF-12 PCS (p = 0.015) between group treated with instrumented and non-instrumented techniques. Among the patients who practiced a sport, 87% returned to sport postoperatively (55% at medium-high-intensity level). CONCLUSION: This study shows good long-term functional outcomes in patients surgically treated for developmental spondylolisthesis. After surgery, there is a low incidence of back pain, the residual disability is mild and almost half of patients recover the same level of sport activity. Instrumented surgical techniques developed over the years seem to be related to high revision rate, but this does not affect long-term functional results.

Adolescent Idiopathic Scoliosis Surgery: Postoperative Functional Outcomes at 32 Years Mean Follow-Up.

INTRODUCTION: Recent clinical and radiographic studies conducted over short and medium terms have demonstrated positive results in patients undergoing surgery for adolescent idiopathic scoliosis (AIS). However, the absence of long-term data, crucial for comprehending the impact on future quality of life, especially in young patients actively involved in very intense physical activities, remains a gap. This study aims to evaluate long-term functional outcomes in patients who underwent surgery for Adolescent Idiopathic Scoliosis. MATERIAL AND METHODS: Patients meeting specific criteria (diagnosis of AIS, age at surgery between 12 and 18 years, and follow-up of at least 20 years) were identified from a large spine surgery center database. A questionnaire using "Google Form" assessed various outcomes, including Visual Analog Scale (VAS) back, VAS leg, Short Form 12 score (SF-12), Scoliosis Research Society 22 score (SRS-22), incidence of spine revision surgery, postoperative high demanding activities (work and sport), and possible pregnancies was sent to the enrolled patients. The authors analyzed the results regarding all patients included and, moreover, statistical analysis categorized patients into two groups based on the surgical fusion performed: Group 1 (non-instrumented technique according to Hibbs-Risser) and Group 2 (instrumented tecnique according to Cotrel-Dubousset). RESULTS: A total of 63 patients (mean age 47.5 years) were included, with a mean follow-up of 31.9 years. Patients were, in mean, 47.5 years old. Group 1 comprised 42 patients, and Group 2 had 21 patients. Revision surgery was required in 19% of patients, predominantly for implant issues in Group 2 (11.9% vs. 33%, p < 0.05). Overall outcomes were favorable: VAS back = 3.5, VAS leg = 2.5, SRS-22 = 3.5, SF-12 Physical Component Summary = 41.1, SF-12 Mental Component Summary = 46.7, with no significant differences between the group 1 and group 2. At 5-years FU, the non-reoperation rate was higher in the non-instrumented group (97.6% vs. 71.4%, p < 0.001). By means of SRS-22, overall satisfaction was 3.7 ± 1.2 on a maximum scale of 5. More than half of women have successfully completed one pregnancy. Most patients (87.3%) maintained regular work activity. Among sport practioners, half returned to the similar preoperative level. CONCLUSIONS: This study reveals favorable long-term functional results in adolescent idiopathic scoliosis patients after surgical fusion. Mild to moderate back and leg pain were observed, but overall satisfaction, sport participation, and work activity were high. Surgical technique (non-instrumented vs. instrumented) did not significantly impact long-term results, though the instrumented fusion exhibited a higher revision rate.

Effect of Body Mass Index Percentile on Clinical and Radiographic Outcome and Risk of Complications after Posterior Instrumented Fusion for Adolescent Idiopathic Scoliosis: A Retrospective Cohort Study.

BACKGROUND: The aim of this study is to evaluate the effect of body mass index percentile (BMI%) at postoperative and medium follow-up in AIS patients undergoing posterior instrumented fusion (PSF). METHODS: We analyzed 87 clinical records of patients (19 male, 68 female) who underwent PSF. The patients were divided into four groups considering BMI%: underweight (UW), normal weight (NW), overweight (OW), and obesity (OB). Demographic, clinical (SRS-22), and radiographic data were collected. The primary outcome was to assess both the surgical and clinical outcomes, whilst the secondary outcome was to compare the radiological findings among the studied groups. Follow-ups were set preoperatively, at 6 months and 5 years. RESULTS: Our results did not show significant differences of clinical outcomes among the studied groups, except for a longer surgical time and a higher hemoglobin decrease in UW and OB patients (p = 0.007). All BMI categories showed similar radiographic outcomes, with no statistical significance at final follow-up. OB patients showed a worse percentage of major curve correction compared to baseline and to UW and OW patients. CONCLUSIONS: The present study does not underline substantial differences in clinical and radiographic results among any of the studied groups. However, UW and OB patients showed a worse postoperative progress. Counseling should be provided for patients and families and the achievement of a normal BMI% should be recommended.

Mechanical Complications in Adult Spine Deformity Surgery: Retrospective Evaluation of Incidence, Clinical Impact and Risk Factors in a Single-Center Large Series.

The advancement of deformity-specific implants and surgical techniques has improved the surgical treatment of Adult Spine Deformity (ASD), allowing surgeons to treat more complex deformities. Simultaneously, high rates of medical and surgical complications have been reported. The aim of this study is to describe the risk factors, the rate and the clinical impact of mechanical complications in ASD surgery. A retrospective review of a large, single-center database of consecutive ASD patients was conducted. Inclusion criteria were as follows: Cobb coronal curve > 20° or alteration of at least one of sagittal vertical axis (SVA > 40 mm), thoracic kyphosis (TK > 60°), pelvic tilt (PT > 20°) and pelvic incidence minus lumbar lordosis mismatch (PI-LL > 10°), at least four levels of posterior instrumented fusion and 2-year follow-up. At the baseline and at each follow-up end point, the authors collected clinical and radiographic outcomes and recorded any mechanical complications that occurred. One hundred and two patients were enrolled. Clinical outcomes significantly were improved at the last follow-up (mean 40.9 months). Postoperative mechanical complications occurred in 15 patients (14.7%); proximal junctional disease was the most common complication (60%) and the revision rate was 53.3%. Patients who experienced mechanical complications were older (61.2 vs. 54.8 years, p = 0.04); they had also a higher rate of pelvic fusion and posterior-only approach, a lower LL (-37.9 vs. -46.2, p = 0.02) and a higher PT (26.3 vs. 19.8, p = 0.009), TK (41.8 vs. 35.7, p = 0.05), PI-LL (12.9 vs. 5.4, p = 0.03) and Global Alignment and Proportion score (6.9 vs. 4.3, p = 0.01). This study showed a significant improvement in pain and disability after ASD surgery. Regarding the risk of developing a mechanical complication, not only postoperative radiographic parameters affected the risk but also patient age and surgical features.

Sagittal profile modifications in hybrid versus all screw technique in adolescent idiopathic scoliosis.

Aim of the study was to evaluate sagittal parameters modifications, with particular interest in thoracic kyphosis, in patients affected by adolescent idiopathic scoliosis (AIS) comparing hybrid and all-screws technique. From June 2010 to September 2018, 145 patients were enrolled. Evaluation included: Lenke classification, Risser scale, coronal Cobb angle, thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS). Patients were divided in two groups (1 all-screws and 2 hybrid); a further division, in both groups, was done considering preoperative TK values. Descriptive and inferential statistical analysis was conducted. 99 patients were in group 1, 46 in group 2 (mean follow-up 3.7 years). Patients with a normo-kyphotic profile developed a little variation in TK (Δ pre-post = 2.4° versus - 2.0° respectively). Hyper-kyphotic subgroups had a tendency of restoring a good sagittal alignment. Hypo-kyphotic subgroups, patients treated with all-screw implants developed a higher increase in TK mean Cobb angle (Δ pre-post = 10°) than the hybrid subgroup (Δ pre-post = 5.4°) (p = 0.01). All-screws group showed better results in restoring sagittal alignment in all subgroups compared to hybrid groups, especially in hypo-TK subgroup, with the important advantage to give better correction on coronal plane.

Clinical Relevance of Preoperative MRI in Adolescent Idiopathic Scoliosis: Is Hydromyelia a Predictive Factor of Intraoperative Electrophysiological Monitoring Alterations?

STUDY DESIGN: This was a prospective cohort study. OBJECTIVES: The main objectives of this study were to evaluate the prevalence and clinical relevance of neuroaxial anomalies in adolescent idiopathic scoliosis (AIS) patients as well as to evaluate different clinical and radiologic variables as potential predictors of the presence of a magnetic resonance imaging (MRI) abnormality. SUMMARY OF BACKGROUND DATA: The usefulness of preoperative magnetic resonance imaging in AIS is still debated in the literature as well as the clinical relevance of the neuroaxial anomalies detected. MATERIALS AND METHODS: We performed an analysis on 88 patients affected by AIS with normal neurological examination undergoing a posterior arthrodesis intervention. Patients were stratified according to the presence and type of neuroaxial abnormalities and were compared by age, sex, Risser grading, Lenke curve type, coronal and sagittal curve parameters, presence of alterations at intraoperative neuromonitoring, and "pain" and "function" scores at the SRS-22 test. RESULTS: Neuroaxial abnormalities were reported in 23 patients (26.14%): 14 hydromyelias, 7 syringomyelias, 1 case of Chiari I syndrome, and 1 case of spinal ependymoma. Age, sex, Risser grading, curve type, and coronal and sagittal curve parameters did not differ between normal patients and patients with any neuroaxial abnormality. Alterations of motor-evoked potential/somatosensory-evoked potential monitoring during surgery were reported in 23 patients; the difference in their incidence between normal (20%) and hydromyelia (64%) patients was significant (P<0.01). In evaluating the subareas of the SRS-22 test, we found that the "function" scores differed significantly by comparing normal (21.5±1.6) and hydromyelia (20.4±1.8) patients (P<0.05). CONCLUSIONS: The prevalence of neuroaxial abnormalities in AIS patients is relatively high, but we could not identify any definitive clinical or radiologic predictor of their presence. Hydromyelia was correlated with intraoperative motor-evoked potential/somatosensory-evoked potential electrophysiological alterations.

Thoraco-lumbar selective fusion in adolescent idiopathic scoliosis with Lenke C modifier curves: clinical and radiographic analysis at 10-year follow-up.

PURPOSE: To examine the radiological and clinical outcomes of a single-center case series of selective thoracic fusions (STF) in adolescent idiopathic scoliosis with Lenke C modifier curves, with a long-term follow-up. METHODS: We evaluated at 6 months and 10 years different radiological parameters on both thoracic and lumbar districts: coronal curves, sagittal curves, apical vertebral translation (AVT), and apical vertebral rotation (AVR). The clinical outcome was determined using the SRS 22 score. Data were also analyzed dividing the patients by their Risser and Lenke scores. RESULTS: In examining 90 patients we reported a radiological benefit from STF on both thoracic and lumbar districts. The corrections in the values of both coronal curves, AVT, and AVR are relevant at 6 months and do not significantly vary at the latest follow-up. Sagittal curves are not relevantly affected at any time point. All the SRS 22 score evaluations showed significant improvement at 6 months, in particular, the self-image analysis. A further improvement was also reported at 10 years, in particular in pain and function scores. At no time point were significant differences retrieved by comparing SRS 22 results as divided by Risser or Lenke grading systems. CONCLUSIONS: STF is an effective treatment option both in clinical and radiographical terms. The results at 10-year follow-up confirm both the stability of the correction and the improvement of the clinical outcome scores. Risser and Lenke grading systems are not relevant variables predictive of clinical efficacy.

Biomechanical and clinical study of single posterior oblique cage POLIF in the treatment of degenerative diseases of the lumbar spine.

INTRODUCTION: Aim of the study was to evaluate the biomechanical stability and the clinical efficacy of a lumbar interbody fusion obtained by single oblique cage implanted by a posterior approach. METHOD: Through the realization of three finite element models (FEMs), the biomechanics of POLIF was compared to PLIF and TLIF. Ninety-four patients underwent interbody fusion by POLIF with instrumented posterolateral fusion. Clinical and radiographic outcomes were evaluated at regular intervals for at least 6 months. RESULTS: The FEMs showed no statistically significant differences in stability in compression and flexion-extension. Mean preoperative VAS score was 7.1, decreased to 2.1 at follow-up. Mean preoperative SF-12 value was 34.5 %, increased to 75.4 % at follow-up. All patients showed a good fusion rate and no hardware failure. DISCUSSION: POLIF associated to instrumented posterolateral fusion is a viable and safe surgical technique, which ensures a biomechanical stability similar to other surgical techniques.

Higher risk of dural tears and recurrent herniation with lumbar micro-endoscopic discectomy.

Existing studies on micro-endoscopic lumbar discectomy report similar outcomes to those of open and microdiscectomy and conflicting results on complications. We designed a randomised controlled trial to investigate the hypothesis of different outcomes and complications obtainable with the three techniques. 240 patients aged 18-65 years affected by posterior lumbar disc herniation and symptoms lasting over 6 weeks of conservative management were randomised to micro-endoscopic (group 1), micro (group 2) or open (group 3) discectomy. Exclusion criteria were less than 6 weeks of pain duration, cauda equina compromise, foraminal or extra-foraminal herniations, spinal stenosis, malignancy, previous spinal surgery, spinal deformity, concurrent infection and rheumatic disease. Surgery and follow-up were made at a single Institution. A biomedical researcher independently collected and reviewed the data. ODI, back and leg VAS and SF-36 were the outcome measures used preoperatively, postoperatively and at 6-, 12- and 24-month follow-up. 212/240 (91%) patients completed the 24-month follow-up period. VAS back and leg, ODI and SF36 scores showed clinically and statistically significant improvements within groups without significant difference among groups throughout follow-up. Dural tears, root injuries and recurrent herniations were significantly more common in group 1. Wound infections were similar in group 2 and 3, but did not affect patients in group 1. Overall costs were significantly higher in group 1 and lower in group 3. In conclusion, outcome measures are equivalent 2 years following lumbar discectomy with micro-endoscopy, microscopy or open technique, but severe complications are more likely and costs higher with micro-endoscopy.

Long-term results of pediculo-body fixation and posterolateral fusion for lumbar spondylolisthesis.

Grob et al. (Eur Spine J 5:281-285, 1996) illustrated a new fixation technique in inveterate cases of grade 2-3 spondylolisthesis (degenerative or spondylolytic): a fusion without reduction of the spondylolisthesis. Fixation of the segment was achieved by two cancellous bone screws inserted bilaterally through the pedicles of the lower vertebra into the body of the upper slipped vertebra. Since 1998 we have been using this technique according to the authors' indications: symptomatic spondylolisthesis with at least 25% anterior slippage and advanced disc degeneration. Afterwards this technique was used also in spondylolisthesis with low reduction of the disc height and slippage less than 25%. In every case we performed postero-lateral fusion and fixation with two AO 6.5 Ø thread 16 mm cancellous screws. From 1998 to 2002 we performed 62 fusions for spondylolisthesis with this technique: 28 males (45.16%) and 34 females (54.84%), mean age 45 years (14-72 years). The slipped vertebra was L5 in 57 cases (92%), L4 in 2 cases (3.2%), L3 in 1 case (1.6%), combined L4 and L5 in 2 cases (3.2%). In all cases there was an ontogenetic spondylolisthesis with lysis. Lumbar pain was present in 22 patients and lumbar-radicular pain was present in 40 patients. The mean preoperative VAS was 6.2 (range 5-8) for lumbar pain, and 5.5 (range 4-7) for leg pain. The fusion area was L5-S1 in 53 cases (85.5%), L3-L4 in 1 case (1.6%), L4-S1 in 8 cases (12.9%). A decompression of the spinal canal by laminectomy was performed in 33 procedures (53%). When possible a bone graft was done from the removed neural arc, and from the posterior iliac crest in the other cases. The mean blood loss was about 254 ml (100-1,000). The mean operative time was 75 min (range 60-90). The results obtained by computerized analysis at follow-up at least 5 years after surgery showed a significant improvement in preoperative symptoms. The patients were asymptomatic in 52 cases (83.9%); strained-back pain was present in 8 cases (12.9%), and there was persistent lumbar-radicular pain in 2 cases (3.2%). The mean ODI score was 2.6%, the mean VAS back pain was 1.3, the mean VAS leg pain 0.7. Some complications were observed: a nerve root compression by a screw invasion of intervertebral foramen, resolved by screw removal; an iliac artery compression by a lateral exit screw from pediculo, resolved by screw removal; a deep iliac vein phlebitis with thrombosis caused by external compression due to a wrong intraoperative position, treated by medicine. Two cases of synthesis mobilization and two cases of broken screws was detected. No cases of pseudoarthrosis and immediate or late superficial or deep infection were observed. The analysis of the long-term results of the spondylolisthesis surgical treatment with direct pediculo-body screw fixation and postero-lateral fusion gave a very satisfactory response. The technique is reliable in allowing an optimal primary stability, creating the best biomechanical conditions to obtain a solid fusion.

Molecular analysis of post-harvest withering in grape by AFLP transcriptional profiling.

Post-harvest withering of grape berries is used in the production of dessert and fortified wines to alter must quality characteristics and increase the concentration of simple sugars. The molecular processes that occur during withering are poorly understood, so a detailed transcriptomic analysis of post-harvest grape berries was carried out by AFLP-transcriptional profiling analysis. This will help to elucidate the molecular mechanisms of berry withering and will provide an opportunity to select markers that can be used to follow the drying process and evaluate different drying techniques. AFLP-TP identified 699 withering-specific genes, 167 and 86 of which were unique to off-plant and on-plant withering, respectively. Although similar molecular events were revealed in both withering processes, it was apparent that off-plant withering induced a stronger dehydration stress response resulting in the high level expression of genes involved in stress protection mechanisms, such as dehydrin and osmolite accumulation. Genes involved in hexose metabolism and transport, cell wall composition, and secondary metabolism (particularly the phenolic and terpene compound pathways) were similarly regulated in both processes. This work provides the first comprehensive analysis of the molecular events underpinning post-harvest withering and could help to define markers for different withering processes.