Long-term Outcomes of Minimally Invasive Lateral Lumbar Interbody Fusion in the Treatment of Adult Scoliosis.

The literature has shown the importance of long-term follow-up for adults with scoliosis treated surgically because complication and revision rates are high. The goal of this study was to determine long-term outcomes and complications of lateral lumbar interbody fusion (LLIF) with posterior instrumentation for adult patients with scoliosis. A retrospective review of our institution's database was performed to identify adult patients with scoliosis treated with LLIF between 2008 and 2013 with a minimum follow-up of 4 years. Medical records were reviewed for complications and revisions. Pre- and postoperative deformity Cobb angle measurements were taken as well as pelvic incidence (PI) and lumbar lordosis (LL). Functional outcome scores, including Oswestry Disability Index and visual analog scale score for back and leg pain, were assessed preoperatively and at follow-up. Standard binomial and categorical comparative analysis was performed. The 26 patients included had a mean age of 62 years, mean follow-up of 89 months, and mean of 1.8 levels per operation. Four patients (15.4%) required revisions. Mean deformity Cobb angle was 26° preoperatively and 14° postoperatively. Mean PI-LL mismatch was 11.7° preoperatively and 5.9° postoperatively. Nineteen (73%) patients had a PI-LL mismatch greater than 10° preoperatively, whereas only 2 (7.7%) had a mismatch postoperatively. Improvement was seen in all functional outcome scores. Long-term clinical results of LLIF for adults with deformity showed a low proportion of revision in the treatment of a condition with an established high rate of revision. The ability to reduce pelvic mismatch may further reduce the rate of revision. In this study, LLIF resulted in improved functional outcomes and patient satisfaction. [Orthopedics. 2022;45(3):e134-e139.].

Primary Extramedullary, Extradural Cervical Spine Seminoma.

While extragonadal seminomas resulting in spinal cord compression are rarely reported in the literature, most have been treated with surgical decompression followed by radiation therapy. In this report, we present the unique and interesting case of a 38-year-old man who initially presented as an outpatient with a chief complaint of axial neck pain and lateral thoracic wall pain. After an extensive malignancy workup, he was diagnosed with a primary cervical spine seminoma and was treated with a C6-T1 laminectomy with posterior spinal instrumentation from C5 to T2. He has since undergone chemotherapy with cisplatin, vinblastine, and bleomycin, and at 24-month follow-up, he remains asymptomatic with no signs of recurrent disease.

Thyrotoxic Periodic Paralysis: A Spine Consultation.

As a consultant, the orthopaedic spine surgeon is often asked to evaluate patients with acute-onset extremity weakness. In some cases, patient's deficits can be attributed to nonspinal pathology; therefore, it is important to be aware of nonorthopaedic diagnoses when evaluating these patients. We report a case of thyrotoxic periodic paralysis that was initially confused by the consulting service with spinal pathology. A 32-year-old Hispanic man presented to our emergency department with rapid onset of lower extremity weakness. The consulting team ordered CT of the cervical and lumbar spine, as well as MRI of the lumbar spine which was aborted due to the patient's worsening tachycardia and chest pain. The spine service was subsequently consulted to evaluate the patient. Review of the metabolic panel revealed a low potassium, and additional testing led to the eventual diagnosis of thyrotoxic periodic paralysis. After correction of the patient's potassium, his weakness rapidly resolved, and no additional spinal workup was pursued. We describe this patient's presentation and outline the differential diagnosis for acute, nontraumatic extremity weakness, including both orthopaedic and other medical causes, that the spine surgeon should be aware of when evaluating patients with extremity weakness.

Short-Segment Fixation With Percutaneous Pedicle Screws in the Treatment of Unstable Thoracolumbar Vertebral Body Fractures.

Clinical care of patients with unstable thoracolumbar vertebral body fractures may be challenging, especially in the setting of polytrauma patients who require other acute intervention. Compared with the traditional open approach, percutaneous short-segment fixation constructs place less surgical burden on patients regarding operative time and blood loss. Between 2008 and 2012, 32 patients with a mean age of 49 years (range, 19-80 years) underwent percutaneous short-segment fixation at the authors' institution and had a minimum of 6 months of complete clinical and radiographic follow-up. Load-sharing classification scores were determined. Outcomes evaluated included anterior body height, posterior body height, local kyphosis, regional kyphosis, thoracolumbar junctional kyphosis, mean operative time, and total blood loss. Standard binomial and categorical comparative analyses were performed. All load-sharing classification scores were 7 or less, and 11 of the 32 patients were polytrauma patients requiring surgery. No difference was seen between preoperative and late measurements of anterior body height, posterior body height, local kyphosis, regional kyphosis, or thoracolumbar junctional kyphosis. There were no complications, revisions, or anterior corpectomies. Only 2 patients (6%) underwent elective removal of hardware at 1 year. Mean operative time was 43 minutes (range, 33-56 minutes), and mean estimated blood loss was less than 50 mL. Percutaneous short-segment fixation prevented loss of vertebral body height and progression of kyphosis in the treatment of unstable thoracolumbar fractures with load-sharing classification scores of 7 or less. This study shows that these fractures with a load-sharing classification score of 6 and 7 may be stabilized using fewer screws than traditional methods in some patients and allow polytrauma patients to undergo other acute treatment. [Orthopedics. 2018; 41(6):e802-e806.].

Additional Risk Factors for Adding-On After Selective Thoracic Fusion in Adolescent Idiopathic Scoliosis: Implication of Lowest Instrumented Vertebra Angle and Lumbosacral Takeoff.

STUDY DESIGN: Retrospective chart and radiographic review. OBJECTIVE: The purpose of this study was to identify any additional risk factors adding-on after selective thoracic fusion in adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Previous studies have shown that the proper selection of lowest instrumented vertebra (LIV) is critical in preventing adding-on (AD) phenomenon after selective thoracic fusion (STF). However, even after selecting the correct LIV, AD can still occur. METHODS: This is a retrospective review of 380 consecutive AIS patients who underwent corrective surgery by a single surgeon. LIV was chosen as stable vertebra (SV) or SV-1 if intersected by the center sacral vertical line (CSVL). One hundred thirty-five patients were identified who had complete radiographic images stored in PACS. After Lenke 5, anterior or combined surgeries, TL fusion, and hybrid construct were excluded, two groups were identified out of 78 patients who received STF with all pedicle screw construct: Adding-on (AD) and Control. AD was defined as >5° angle of the superior endplate of LIV-1 to the inferior endplate of LIV+1 between postoperation and the final follow-up. We analyzed the values for the AD group and compared them with those for the control group to identify risk factors not previously defined. RESULTS: Patients with other complication and follow-up less than 2 years were excluded, and there remained 11 patients in AD (14%), and 8 in the control group. There was no significant difference between the 2 groups in terms of demographic data, LIV selection, and curve types. In AD, there was significant curve progression within fused segments. Even though lumbosacral takeoff (LSTO) was not significantly different, (LIV-H)+LSTO and LIV-H (LIV horizontal) showed significant difference. CONCLUSION: After excluding the effect of known risk factors for AD, LIV-H angle, and LIV-H mismatch with LSTO were found to be the additional risk factors for AD. In addition to consideration of other risk factors such as LIV selection or Risser stage, these risk factors should be considered.

Unplanned Reoperations Affect Long-Term Outcomes in Adult Spinal Deformity Patients Undergoing Long Fusions to the Sacrum.

STUDY DESIGN: Retrospective clinical cohort study. OBJECTIVE: To compare the long-term complications and outcomes scores of primary and revision surgeries for adult spinal deformity of patients treated with long fusions to the sacrum. SUMMARY OF BACKGROUND DATA: Long fusions in patients with adult spinal deformity are fraught with complications and the need for reoperation that can significantly impact patient health-related quality of life. METHODS: Data from 134 consecutive patients who underwent spinal fusion from the thoracic spine to the sacropelvis and had a minimum of 5-year follow-up were analyzed. Patients were classified as primary surgery (PS) and index revision (IR) surgery; they were then subdivided based on whether they returned to the operating room (RTO) or not (NRTO). RTO complications were classified as 1) infection, 2) neurologic, 3) fusion status, 4) implants, and 5) global alignment and stratified as <6 months, <2 years, and >2 years. Final Scoliosis Research Society Patient Questionnaire (SRS 22r) and Oswestry Disability Index (ODI) scores were compared between subgroups. RESULTS: Seventy-one PS and 63 IR were included in the analysis. Mean age at surgery was 54.9 years (30-78), mean follow-up 5.8 years (4.9-12.8). RTO rates were 21.1% and 34.9%, respectively, for PS and IR (p = .16). 43.8% of patients requiring reoperation did so on multiple occasions. Fifty PS and 41 IR cases had complete SRS 22 and ODI scores. Final SRS 22 total scores were 3.74 and 3.41 (p = .02) for the respective groups. ODI scores were 25.4% and 34.0% (p = .02). CONCLUSIONS: Both groups had a significant number of revision surgeries performed by 5 years of follow-up. Unplanned reoperation significantly affected ODI and SRS 22 outcomes scores in the individual domains of pain, function, and overall satisfaction as well as total score at the 5-year follow-up regardless of PS or IR status. Overall, the PS group had improved outcomes when compared to the IR group.

Risk Factors Associated with Adjacent and Remote- Level Pathologic Vertebral Compression Fracture Following Balloon Kyphoplasty: 2-Year Follow-Up Comparison Versus Conservative Treatment.

Vertebral compression fractures are a significant source of morbidity and mortality among patients of all age groups. These fractures result in both acute and chronic pain. Patients who sustain such fractures are known to suffer from more comorbidities and have a higher mortality rate compared with healthy people in the same age group. In recent years, balloon kyphoplasty has become a popular method for treating vertebral compression fractures. However, as longer-term follow-up becomes available, the effects of cement augmentation on adjacent spinal segments require investigation. Here, we have performed a retrospective chart review of 258 consecutive patients with pathologic vertebral compression fractures secondary to osteoporosis, treated by either conservative measures or balloon kyphoplasty with polymethylmethacrylate cement augmentation. Multivariate analysis of patient comorbidities was performed to assess the risks associated with subsequent adjacent and remote compression fracture at a minimum of 2 years follow-up. A total of 258 patients had 361 vertebral compression fractures. A total of 121 patients were treated nonoperatively and 137 underwent balloon kyphoplasty with polymethylmethacrylate cement augmentation. The mean follow-up for both cohorts was 2.7 years (range, 2-6 years). The kyphoplasty cohort was significantly older than the nonoperative cohort (mean age, 78.5 versus 74.2 years; p = 0.02), had 24 more patients with diabetes mellitus (37 versus 13; p = 0.05), and had 34 more patients with a history of smoking (50 versus 16; p = 0.05). However, the kyphoplasty cohort had less patients with a history of non-steroidal anti-inflammatory drug (NSAID) use (45 versus 71; p = 0.07). There were no demographic differences between groups in patients with secondary fractures. Nonoperative treatment was identified as a statistically significant independent risk factor for subsequent vertebral compression fracture [odds ratio (OR), 2.28]. Univariate analysis identified age, diabetes mellitus, smoking, NSAID usage, and female gender as risk factors for subsequent vertebral compression fracture. When adjusted for multivariate analysis, no individual factor demonstrated increased risk for subsequent fracture. Patients diagnosed with vertebral compression fractures secondary to osteoporosis suffer from multiple medical comorbidities. No particular comorbidity was identified as solely attributable for increased risk of subsequent remote or adjacent compression fractures. Patients in this series treated with nonoperative (conservative) management had a 2.28 times greater risk for a subsequent vertebral compression fracture than patients treated with balloon kyphoplasty and polymethylmethacrylate cement augmentation.