L5-S1 nonunion occurrence even after anterior column support combined with iliac screw fixation in long fusion for adult spinal deformity: CT-based analysis at 2-year follow-up.

OBJECTIVE: Iliac screw fixation and anterior column support are highly recommended to prevent lumbosacral pseudarthrosis after long-level adult spinal deformity (ASD) surgery. Despite modern instrumentation techniques, a considerable number of patients still experience nonunion at the lumbosacral junction. However, most previous studies evaluating nonunion relied only on plain radiographs and only assessed when the implant failures occurred. Therefore, using CT, it is important to know the prevalence after iliac fixation and to evaluate risk factors for nonunion at L5-S1. METHODS: Seventy-seven patients who underwent ≥ 4-level fusion to the sacrum using iliac screws for ASD and completed a 2-year postoperative CT scan were included in the present study. All L5-S1 segments were treated by interbody fusion. Lumbosacral fusion status was evaluated on 2-year postoperative CT scans using Brantigan, Steffee, and Fraser criteria. Risk factors for nonunion were analyzed using patient, surgical, and radiographic factors. The metal failure and its association with fusion status at L5-S1 were evaluated. RESULTS: Of the 77 patients, 12 (15.6%) showed nonunion at the lumbosacral junction on the 2-year CT scans. Multivariate analysis using logistic regression revealed that only higher American Society of Anesthesiologists (ASA) grade was a risk factor for nonunion (OR 25.6, 95% CI 3.196-205.048, p = 0.002). There were no radiographic parameters associated with fusion status at L5-S1. Lumbosacral junction rod fracture occurred more frequently in patients with nonunion than in patients with fusion (33.3% vs 6.2%, p = 0.038). CONCLUSIONS: Although iliac screw fixation and anterior column support have been performed to prevent lumbosacral nonunion during ASD surgery, 15.6% of patients still showed nonunion on 2-year postoperative CT scans. High ASA grade was a significant risk factor for nonunion. Rod fracture between L5 and S1 occurred more frequently in the nonunion group.

Local Infiltration Analgesia Versus Femoral Nerve Block for Pain Control in Anterior Cruciate Ligament Reconstruction: A Systematic Review With Meta-analysis.

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) is often performed on an outpatient basis; thus, effective pain management is essential to improving patient satisfaction and function. Local infiltration analgesia (LIA) and femoral nerve block (FNB) have been commonly used for pain management in ACLR. However, the comparative efficacy and safety between the 2 techniques remains a topic of controversy. PURPOSE: To compare pain reduction, opioid consumption, and side effects of LIA and FNB after ACLR. STUDY DESIGN: Systematic review; Level of evidence, 3. METHODS: A systematic search of MEDLINE, Embase, and Cochrane Library databases was performed to identify studies comparing pain on the visual analog scale (a 100-mm scale), total morphine-equivalent consumption, and side effects between the 2 techniques after ACLR at the early postoperative period. The LIA was categorized into intra-articular injection and periarticular injection, and subgroup analyses were performed comparing either intra-articular injection or periarticular injection with FNB. Two reviewers performed study selection, risk-of-bias assessment, and data extraction. RESULTS: A total of 10 studies were included in this systematic review and meta-analysis. In terms of VAS pain scores, our pooled analysis indicated that FNB was significantly more effective at 2 hours postoperatively compared with LIA (mean difference, 8.19 [95% confidence interval (CI), 0.75 to 15.63]; P = .03), with no significant difference between the 2 techniques at 4, 8, and 12 hours postoperatively; however, LIA was significantly more effective at 24 hours postoperatively compared with FNB (mean difference, 5.61 [95% CI, -10.43 to -0.79]; P = .02). Moreover, periarticular injection showed a significant improved VAS pain score compared with FNB at 24 hours postoperatively (mean difference, 11.44 [95% CI, -20.08 to -2.80]; P = .009), and the improvement reached the threshold of minimal clinically important difference of 9.9. Total morphine-equivalent consumption showed no difference between the 2 techniques, and side effects were unable to be quantified for the meta-analysis because of a lack of data. CONCLUSION: Compared with FNB, LIA was not as effective at 2 hours, comparable within 12 hours, and significantly more effective at 24 hours postoperatively for reducing pain after ACLR. Total morphine-equivalent consumption showed no significant differences between the 2 techniques.

Radiologic prognostic factors of curve progression in early degenerative lumbar scoliosis.

OBJECTIVE: Several radiological parameters related to the aging spine have been reported as progression factors of early degenerative lumbar scoliosis (DLS). However, it has not been determined which factors are the most important. In this study the authors aimed to determine the risk factors associated with curve progression in early DLS. METHODS: Fifty-one patients with early DLS and Cobb angles of 5°-15° were investigated. In total, 7 men and 44 women (mean age 61.6 years) were observed for a mean period of 13.7 years. The subjects were divided into two groups according to Cobb angle progression (≥ 15° or < 15°) at the final follow-up, and radiological parameters were compared. The direction of scoliosis, apical vertebral level and rotational grade, lateral subluxation, disc space difference, osteophyte difference, upper and lower disc wedging angles, and relationship between the intercrest line and L5 vertebra were evaluated. RESULTS: During the follow-up period, the mean curve progression increased from 8.8° ± 3.2° to 19.4° ± 8.9°. The Cobb angle had progressed by ≥ 15° in 17 patients (33.3%) at the final follow-up. In these patients the mean Cobb angle increased from 9.4° ± 3.4° to 28.8° ± 7.5°, and in the 34 remaining patients it increased from 8.5° ± 3.1° to 14.7° ± 4.8°. The baseline lateral subluxation, disc space difference, and upper and lower disc wedging angles significantly differed between the groups. In multivariate logistic regression analysis, only the upper and lower disc wedging angles were significantly correlated with curve progression (OR 1.55, p = 0.035, and OR 1.89, p = 0.004, respectively). CONCLUSIONS: Asymmetrical degenerative change in the lower apical vertebral disc, which leads to upper and lower disc wedging angles, is the most substantial factor in predicting early DLS progression.

Failure Types and Related Factors of Spinopelvic Fixation After Long Construct Fusion for Adult Spinal Deformity.

BACKGROUND: Rigid internal fixation of the spine is an essential part of adult spinal deformity (ASD) surgery. Despite the use of pelvic fixation and anterior column support, spinopelvic fixation failure (SPFF) still remains an issue. Few studies have evaluated the types of such failure or its related factors. OBJECTIVE: To classify the types of SPFF and investigate its risk factors, including the fusion status at L5-S1 on CT scan. METHODS: The study cohort consisted of ninety-eight ASD patients who underwent more than 4-level fusions to the sacrum with interbody fusion at L5-S1. Patients with SPFF were divided into the two groups: above-S1 and below-S1 failure groups. The patient, surgical, and radiographic variables in each group were compared to those of the no-failure group. The L5-S1 fusion status was assessed using 2-yr computed tomography (CT) scan. Univariate and multivariate analyses were performed to determine the risk factors for each failure group. RESULTS: The mean age was 68.5 yr. Follow-up duration was 55.7 mo. The SPFF developed in 46 (46.9%) patients at 32.7 mo postoperatively. There were 15 patients in the above-S1 failure group and 31 patients in the below-S1 failure group. Multivariate analysis revealed that nonunion at L5-S1 was a single risk factor for above-S1 failure. In contrast, the risk factors for below-S1 failure included a greater number of fused segments and postoperative less thoracic kyphosis. CONCLUSION: SPFF develops in different patterns with different risk factors. Above-S1 SPFF was associated with nonunion at L5-S1, while below-S1 SPFF was associated with mechanical stress.

Secondary Cervicothoracic Scoliosis in Congenital Muscular Torticollis.

BACKGROUND: Although secondary cervicothoracic scoliosis frequently occurs in patients with congenital muscular torticollis (CMT), the relationship between scoliosis and CMT has not been evaluated. This study aims to evaluate the effects of surgical release of sternocleidomastoid (SCM) muscle on secondary cervicothoracic scoliosis in patients with CMT and determine factors affecting the improvement of scoliosis after surgical release of SCM muscle. METHODS: Eighty-seven of the 106 patients, confirmed as having secondary cervicothoracic scoliosis with CMT with a minimum 1-year follow-up, were included in this study. Preoperative and last follow-up radiologic outcomes were assessed for the cervicomandibular angle (CMA), Cobb angle of the cervicothoracic scoliosis, and direction of convexity in the scoliosis curve. Patients were divided into two groups to assess the improvement of Cobb angle according to residual growth potential; age ≤ 15 years and > 15 years. The improvement of Cobb angle after surgical release was compared in the two groups. Correlation analysis and multivariable regression analysis were performed to determine the factors affecting the improvement of scoliosis. RESULTS: All the radiologic parameters, such as the Cobb angle and CMA, improved significantly after surgical release (p < 0.001). The improvement of Cobb angle was significantly higher in age ≤ 15 years than in age > 15 years (p < 0.001). The improvement of Cobb angle was significantly correlated with age (r = -0.474, p < 0.001) and the preoperative Cobb angle (r = 0.221, p = 0.036). In multivariable regression analysis, age and preoperative Cobb angle were shown to be predisposing factors affecting the improvement of scoliosis. CONCLUSIONS: The results showed that SCM release can be a beneficial treatment for secondary cervicothoracic scoliosis. The improvement of scoliosis was greater when the SCM release was performed before the patient reached the end of growth.

Minimum Three-year Follow-up of Specific Functional Disabilities After Multilevel Lumbar Fusion: Comparison of Long-level and Short-level Fusion.

STUDY DESIGN: Retrospective case-control study. OBJECTIVE: To evaluate specific functional disabilities after short- and long-level lumbar fusion. SUMMARY OF BACKGROUND DATA: The Oswestry Disability Index (ODI) cannot represent all types of functional disabilities observed after lumbar fusion and a region-specific Functional Disability Index (SFDI) is necessary. METHODS: We examined the differences in postoperative functional disability between 81 patients who underwent ≥3-level lumbar fusion (group I) and 70 age- and sex-matched patients who underwent one- or two-level lumbar fusion (group II). The ODI and Visual Analogue Scale (VAS) were assessed pre- and postoperatively. The SFDI was assessed after lumbar fusion. We evaluated intergroup differences in postoperative VAS, ODI, and SFDI scores during 3-year follow-up. Each mean score was evaluated separately for the 10 ODI and the 12 SFDI items, and we evaluated the changes observed in these scores over the 3-year follow-up. RESULTS: The mean intergroup preoperative ODI and VAS scores were similar. The mean postoperative intergroup VAS scores were similar; however, the mean postoperative ODI and SFDI scores were significantly higher in group I than in group II at 1-year (P<0.001, P<0.001, respectively) and 3-year follow-up (P = 0.037, P<0.001, respectively). Among 10 ODI items, group I showed significant disability with regard to six items at the 1-year follow-up compared with group II, but only showed significant disability with regard to one item at the 3-year follow-up. Among the 12 SFDI items, group I showed significant disability with regard to all 12 items at 1-year follow-up compared with group II, as well as significant disability with regard to nine items at 3-year follow-up. CONCLUSION: The SFDI is more sensitive than the ODI in assessing functional disabilities based on the levels of fusion. Most SFDI items indicated continued significant disability in patients with long-level lumbar fusion even 3 years postoperatively. LEVEL OF EVIDENCE: 3.

A Comparative Study to Evaluate the Risk Factors for Medium-Sized Rotator Cuff Tear in Patients Younger Than 50 Years of Age.

PURPOSE: The purpose of this study was to evaluate preoperative and intraoperative factors associated with rotator cuff tears (RCTs) among patients younger than 50 years and to compare arthroscopic rotator cuff repair (RCR) results in patients younger than 50 years (group A) and patients older than 70 years (group B). We also analyzed the results after arthroscopic RCR in these 2 age groups. METHODS: Data were collected from 56 patients allocated to group A and 55 patients allocated to group B who had medium-sized RCTs and had undergone arthroscopic RCR between January 2006 and August 2015. Preoperative variables included demographic data, radiologic data, and surgical procedure. We evaluated fatty degeneration on preoperative magnetic resonance imaging (MRI) and intraoperative variables, including concomitant subscapularis repair, as well as repair technique. Pain visual analog scale, functional visual analog scale, American Shoulder and Elbow Surgeons, and Constant scores were documented to compare functional results in each age group. Postoperative MRI scans were conducted to evaluate the retear rate after RCR after a mean postoperative duration of 5.4 months (range, 2-48 months). RESULTS: Multivariate regression analysis showed acute-on-chronic injury and a history of hypertension were independent factors for differentiation of the groups. Stepwise regression analysis found sex, hypertension, and fatty infiltration of the supraspinatus and infraspinatus to be comparable factors for each group. All patients showed improved results after arthroscopic RCR, but there was no difference between the 2 groups in functional outcomes. However, cuff retears on postoperative MRI scans were found in only 3.9% of the patients in group A versus 16% of the patients in group B. CONCLUSIONS: The results of this study showed that sex, acute-on-chronic injury, and preoperative fatty infiltration of the rotator cuff were significant factors affecting medium-sized RCTs in patients younger than 50 years. In addition, there were no significant differences in functional outcomes after arthroscopic RCR in both groups at 2 years, but postoperative MRI showed a lower retear rate in group A. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Mini-Open Anterior Lumbar Interbody Fusion Combined with Lateral Lumbar Interbody Fusion in Corrective Surgery for Adult Spinal Deformity.

STUDY DESIGN: Prospective observational study. PURPOSE: To introduce the techniques and present the surgical outcomes of mini-open anterior lumbar interbody fusion (ALIF) at the most caudal segments of the spine combined with lateral lumbar interbody fusion (LLIF) for the correction of adult spinal deformity. OVERVIEW OF LITERATURE: Although LLIF is increasingly used to correct adult spinal deformity, the correction of sagittal plane deformity with LLIF alone is reportedly suboptimal. METHODS: Thirty-two consecutive patients with adult spinal deformity underwent LLIF combined with mini-open ALIF at the L5-S1 or L4-S1 levels followed by 2-stage posterior fixation. ALIF was performed for a mean 1.3 levels and LLIF for a mean 2.7 levels. Then, percutaneous fixation was performed in 11 patients (percutaneous group), open correction with facetectomy with or without laminectomy in 16 (open group), and additional pedicle subtraction osteotomy (PSO) in 5 (PSO group). Spinopelvic parameters were compared preoperatively and postoperatively. Hospitalization data and clinical outcomes were recorded. RESULTS: No major medical complications developed, and clinical outcomes improved postoperatively in all groups. The mean postoperative segmental lordosis was greater after ALIF (17.5°±5.5°) than after LLIF (8.1°±5.3°, p <0.001). Four patients (12.5%) had lumbar lordosis with a pelvic incidence of ±9° preoperatively, whereas this outcome was achieved postoperatively in 30 patients (93.8%). The total increase in lumbar lordosis was 14.7° in the percutaneous group, 35.3° in the open group, and 57.0° in the PSO group. The ranges of potential lumbar lordosis increase were estimated as 4°-25°, 23°-42°, and 45°-65°, respectively. CONCLUSIONS: Mini-open ALIF combined with LLIF followed by posterior fixation may be a feasible technique for achieving optimal sagittal balance and reducing the necessity of more extensive surgery.