Pseudohypoxic brain swelling and secondary hydrocephalus with pseudomeningocele after lumbar surgery: a case report.

BACKGROUND: Postoperative intracranial complications are rare in spine surgery not including cranial procedures. We describe an uncommon case of pseudohypoxic brain swelling (PHBS) and secondary hydrocephalus after transforaminal lumbar interbody fusion (TLIF) presenting as impaired consciousness and repeated seizures. CASE PRESENTATION: A 65-year-old man underwent L4-5 TLIF for lumbar spondylolisthesis and began experiencing generalized seizures immediately postoperatively. Computed tomography (CT) revealed diffuse cerebral edema-like hypoxic ischemic encephalopathy. He was transported to our hospital, at which time epidural drainage was halted and anti-edema therapy was commenced. His impaired consciousness improved. However, he suffered secondary hydrocephalus due to continuous bleeding from a dural defect and spinal epidural fluid collection 3 months later. Following the completion of dural repair and insertion of a ventriculoperitoneal shunt, his neurologic symptoms and neuroimaging findings improved significantly. CONCLUSIONS: PHBS can be considered in patients with unexpected neurological deterioration following lumbar spine surgery even with the absence of documented durotomy. This might be due to postoperative intracranial hypotension-associated venous congestion, and to be distinguished from the more common postoperative cerebral ischemic events-caused by arterial or venous occlusions-or anesthetics complications.

Risk Factor for Poor Patient Satisfaction After Lumbar Spine Surgery in Elderly Patients Aged Over 80 years.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To clarify the poor patient satisfaction after lumbar spinal surgery in elderly patients. SUMMARY OF BACKGROUND DATA: As the global population continues to age, it is important to consider the surgical outcome and patient satisfaction in the elderly. No studies have assessed patient satisfaction in elderly patients undergoing surgical treatment and risk factors for poor satisfaction in elderly patients after lumbar spinal surgery. MATERIALS AND METHODS: A retrospective multicenter survey was performed in 169 patients aged above 80 years who underwent lumbar spinal surgery. Patients were followed up for at least 1 year after surgery. We assessed patient satisfaction from the results of surgery by using a newly developed patient questionnaire. Patients were assessed by demographic data, surgical procedures, complications, reoperation rate, pain improvement, and risk factors for poor patient satisfaction with surgery for lumbar spinal disease. RESULTS: In total, 131 patients (77.5%, G-group) were satisfied and 38 patients (22.5%, P-group) were dissatisfied with surgery. The 2 groups did not differ significantly in baseline characteristics and surgical data. Postoperative visual analog scale score for low back pain and leg pain were significantly higher in the P-group than in the G-group (low back pain: G-group, 1.7±1.9 vs. P-group, 5.2±2.5, P<0.001; leg pain: G-group, 1.4±2.0 vs. P-group, 5.5±2.6, P<0.001). Multivariate regression analysis revealed that postoperative vertebral fracture (P=0.049; odds ratio, 3.096; 95% confidence interval, 1.004-9.547) and reoperation (P=0.025; odds ratio, 5.692; 95% confidence interval, 1.250-25.913) were significantly associated with the patient satisfaction after lumbar spinal surgery. CONCLUSIONS: Postoperative vertebral fracture and reoperation were found to be risk factors for poor patient satisfaction after lumbar spinal surgery in elderly patients, which suggests a need for careful treatment of osteoporosis in addition to careful determination of surgical indication and procedure in elderly patients. LEVEL OF EVIDENCE: Level III.

The Surgical Outcomes of Spinal Fusion for Osteoporotic Vertebral Fractures in the Lower Lumbar Spine with a Neurological Deficit.

INTRODUCTION: Osteoporotic vertebral fracture (OVF) is the most common osteoporotic fracture, and some patients require surgical intervention to improve their impaired activities of daily living with neurological deficits. However, many previous reports have focused on OVF around the thoracolumbar junction, and the surgical outcomes of lumbar OVF have not been thoroughly discussed. We aimed to investigate the surgical outcomes for lumbar OVF with a neurological deficit. METHODS: Patients who underwent fusion surgery for thoracolumbar OVF with a neurological deficit were enrolled at 28 institutions. Clinical information, comorbidities, perioperative complications, Japanese Orthopaedic Association scores, visual analog scale scores, and radiographic parameters were compared between patients with lower lumbar fracture (L3-5) and those with thoracolumbar junction fracture (T10-L2). Each patient with lower lumbar fracture (L group) was matched with to patients with thoracolumbar junction fracture (T group). RESULTS: A total 403 patients (89 males and 314 females, mean age: 73.8 ± 7.8 years, mean follow-up: 3.9 ± 1.7 years) were included in this study. Lower lumbar OVF was frequently found in patients with lower bone mineral density. After matching, mechanical failure was more frequent in the L group (L group: 64%, T group: 39%; p < 0.001). There was no difference between groups in the clinical and radiographical outcomes, although the rates of complication and revision surgery were still high in both groups. CONCLUSIONS: The surgical intervention for OVF is effective in patients with myelopathy or radiculopathy regardless of the surgical level, although further study is required to improve clinical and radiographical outcomes. LEVEL OF EVIDENCE: Level III.

Short- versus long-segment posterior spinal fusion with vertebroplasty for osteoporotic vertebral collapse with neurological impairment in thoracolumbar spine: a multicenter study.

BACKGROUND: Vertebroplasty with posterior spinal fusion (VP + PSF) is one of the most widely accepted surgical techniques for treating osteoporotic vertebral collapse (OVC). Nevertheless, the effect of the extent of fusion on surgical outcomes remains to be established. This study aimed to evaluate the surgical outcomes of short- versus long-segment VP + PSF for OVC with neurological impairment in thoracolumbar spine. METHODS: We retrospectively collected data from 133 patients (median age, 77 years; 42 men and 91 women) from 27 university hospitals and their affiliated hospitals. We divided patients into two groups: a short-segment fusion group (S group) with 2- or 3-segment fusion (87 patients) and a long-segment fusion group (L group) with 4- through 6-segment fusion (46 patients). Surgical invasion, clinical outcomes, local kyphosis angle (LKA), and complications were evaluated. RESULTS: No significant differences between the two groups were observed in terms of neurological recovery, pain scale scores, and complications. Surgical time was shorter and blood loss was less in the S group, whereas LKA at the final follow-up and correction loss were superior in the L group. CONCLUSION: Although less invasiveness and validity of pain and neurological relief are secured by short-segment VP + PSF, surgeons should be cautious regarding correction loss.

Effect of bisphosphonates or teriparatide on mechanical complications after posterior instrumented fusion for osteoporotic vertebral fracture: a multi-center retrospective study.

BACKGROUND: The optimal treatment of osteoporosis after reconstruction surgery for osteoporotic vertebral fractures (OVF) remains unclear. In this multicentre retrospective study, we investigated the effects of typically used agents for osteoporosis, namely, bisphosphonates (BP) and teriparatide (TP), on surgical results in patients with osteoporotic vertebral fractures. METHODS: Retrospectively registered data were collected from 27 universities and affiliated hospitals in Japan. We compared the effects of BP vs TP on postoperative mechanical complication rates, implant-related reoperation rates, and clinical outcomes in patients who underwent posterior instrumented fusion for OVF. Data were analysed according to whether the osteoporosis was primary or glucocorticoid-induced. RESULTS: A total of 159 patients who underwent posterior instrumented fusion for OVF were included. The overall mechanical complication rate was significantly lower in the TP group than in the BP group (BP vs TP: 73.1% vs 58.2%, p = 0.045). The screw backout rate was significantly lower and the rates of new vertebral fractures and pseudoarthrosis tended to be lower in the TP group than in the BP group. However, there were no significant differences in lumbar functional scores and visual analogue scale pain scores or in implant-related reoperation rates between the two groups. The incidence of pseudoarthrosis was significantly higher in patients with glucocorticoid-induced osteoporosis (GIOP) than in those with primary osteoporosis; however, the pseudoarthrosis rate was reduced by using TP. The use of TP also tended to reduce the overall mechanical complication rate in both primary osteoporosis and GIOP. CONCLUSIONS: The overall mechanical complication rate was lower in patients who received TP than in those who received a BP postoperatively, regardless of type of osteoporosis. The incidence of pseudoarthrosis was significantly higher in patients with GIOP, but the use of TP reduced the rate of pseudoarthrosis in GIOP patients. The use of TP was effective to reduce postoperative complications for OVF patients treated with posterior fusion.

Surgical Treatment of Osteoporotic Vertebral Fracture with Neurological Deficit-A Nationwide Multicenter Study in Japan.

INTRODUCTION: The prevalence of patients with osteoporosis continues to increase in aging societies, including Japan. The first choice for managing osteoporotic vertebral compression fracture (OVF) is conservative treatment. Failure in conservative treatment for OVF may lead to non-union or vertebral collapse, resulting in neurological deficit and subsequently requiring surgical intervention. This multicenter nationwide study in Japan was conducted to comprehensively understand the outcomes of surgical treatments for OVF non-union. METHODS: This multicenter, retrospective study included 403 patients (89 males, 314 females, mean age 73.8 ± 7.8 years, mean follow-up 3.9 ± 1.7 years) with neurological deficit due to vertebral collapse or non-union after OVF at T10-L5 who underwent fusion surgery with a minimum 1-year follow-up. Radiological and clinical outcomes at baseline and at the final follow-up (FU) were evaluated. RESULTS: OVF was present at a thoracolumbar junction such as T12 (124 patients) and L1 (117 patients). A majority of OVF occurred after a minor trauma, such as falling down (55.3%) or lifting objects (8.4%). Short segment fusion, including affected vertebra, was conducted (mean 4.0 ± 2.0 vertebrae) with 256.8 minutes of surgery and 676.1 g of blood loss. A posterior approach was employed in 86.6% of the patients, followed by a combined anterior and posterior (8.7%), and an anterior (4.7%) approach. Perioperative complications and implant failures were observed in 18.1% and 41.2%, respectively. VAS scores of low back pain (74.7 to 30.8 mm) and leg pain (56.8 to 20.7 mm) improved significantly at FU. Preoperatively, 52.6% of the patients were unable to walk and the rate of non-ambulatory patients decreased to 7.5% at FU. CONCLUSIONS: This study demonstrated that substantial improvement in activity of daily living (ADL) was achieved by fusion surgery. Although there was a considerable rate of complications, fusion surgery is beneficial for elderly OVF patients with non-union.

Complications after spinal fixation surgery for osteoporotic vertebral collapse with neurological deficits: Japan Association of Spine Surgeons with ambition multicenter study.

BACKGROUND: There have been few reports on the incidence and risk factors of the complications after spinal fixation surgery for osteoporotic vertebral collapse (OVC) with neurological deficits. This study aimed to identify the incidence and risk factors of the complications after OVC surgery. METHODS: In this retrospective multicenter study, a total of 403 patients (314 women and 89 men; mean age 73.8 years) who underwent spinal fixation surgery for OVC with neurological deficits between 2005 and 2014 were enrolled. Data on patient demographics were collected, including age, sex, body mass index, smoking, steroid use, medical comorbidities, and surgical procedures. All postoperative complications that occurred within 6 weeks were recorded. Patients were classified into two groups, namely, complication group and no complication group, and risk factors for postoperative complications were investigated by univariate and multivariate analyses. RESULTS: Postoperative complications occurred in 57 patients (14.1%), and the most common complication was delirium (5.7%). In the univariate analysis, the complication group was found to be older (p = 0.039) and predominantly male (p = 0.049), with higher occurrence rate of liver disease (p = 0.001) and Parkinson's disease (p = 0.039) compared with the no-complication group. In the multivariate analysis, the significant independent risk factors were age (p = 0.021; odds ratio [OR] 1.051, 95% confidence interval [CI] 1.007-1.097), liver disease (p < 0.001; OR 8.993, 95% CI 2.882-28.065), and Parkinson's disease (p = 0.009; OR 3.636, 95% CI 1.378-9.599). CONCLUSIONS: Complications after spinal fixation surgery for OVC with neurological deficits occurred in 14.1%. Age, liver disease, and Parkinson's disease were demonstrated to be independent risk factors for postoperative complications.

Risk Factors for Proximal Junctional Fracture Following Fusion Surgery for Osteoporotic Vertebral Collapse with Delayed Neurological Deficits: A Retrospective Cohort Study of 403 Patients.

INTRODUCTION: Approximately 3% of osteoporotic vertebral fractures develop osteoporotic vertebral collapse (OVC) with neurological deficits, and such patients are recommended to be treated surgically. However, a proximal junctional fracture (PJFr) following surgery for OVC can be a serious concern. Therefore, the aim of this study is to identify the incidence and risk factors of PJFr following fusion surgery for OVC. METHODS: This study retrospectively analyzed registry data collected from facilities belonging to the Japan Association of Spine Surgeons with Ambition (JASA) in 2016. We retrospectively analyzed 403 patients who suffered neurological deficits due to OVC below T10 and underwent corrective surgery; only those followed up for　≥2 years were included. Potential risk factors related to the PJFr and their cut-off values were calculated using multivariate logistic regression analysis and receiver operating characteristic (ROC) analysis. RESULTS: Sixty-three patients (15.6%) suffered PJFr during the follow-up (mean 45.7 months). In multivariate analysis, the grade of osteoporosis (grade 2, 3: adjusted odds ratio (aOR) 2.92; p=0.001) and lower instrumented vertebra (LIV) level (sacrum: aOR 6.75; p=0.003) were independent factors. ROC analysis demonstrated that lumbar bone mineral density (BMD) was a predictive factor (area under curve: 0.72, p=0.035) with optimal cut-off value of 0.61 g/cm2 (sensitivity, 76.5%; specificity, 58.3%), but that of the hip was not (p=0.228). CONCLUSIONS: PJFr was found in 16% cases within 4 years after surgery; independent risk factors were severe osteoporosis and extended fusion to the sacrum. The lumbar BMD with cut-off value 0.61 g/cm2 may potentially predict PJFr. Our findings can help surgeons select perioperative adjuvant therapy, as well as a surgical strategy to prevent PJFr following surgery.

Surgical outcomes of spinal fusion for osteoporotic vertebral fracture in the thoracolumbar spine: Comprehensive evaluations of 5 typical surgical fusion techniques.

BACKGROUND: A consensus on the optimal surgical procedure for thoracolumbar OVF has yet to be reached due to the previous relatively small number of case series. The study was conducted to investigate surgical outcomes for osteoporotic vertebral fracture (OVF) in the thoracolumbar spine. METHODS: In total, 315 OVF patients (mean age, 74 years; 68 men and 247 women) with neurological symptoms who underwent spinal fusion with a minimum 2-year follow-up were included. The patients were divided into 5 groups by procedure: anterior spinal fusion alone (ASF group, n = 19), anterior/posterior combined fusion (APSF group, n = 27), posterior spinal fusion alone (PSF group, n = 40), PSF with 3-column osteotomy (3CO group, n = 92), and PSF with vertebroplasty (VP + PSF group, n = 137). RESULTS: Mean operation time was longer in the APSF group (p < 0.05), and intraoperative blood loss was lower in the VP + PSF group (p < 0.05). The amount of local kyphosis correction was greater in the APSF and 3CO groups (p < 0.05). Clinical outcomes were approximately equivalent among all groups. CONCLUSION: All 5 procedures resulted in acceptable neurological outcomes and functional improvement in walking ability. Moreover, they were similar with regard to complication rates, prevalence of mechanical failure related to the instrumentation, and subsequent vertebral fracture. Individual surgical techniques can be adapted to suit patient condition or severity of OVF.

Correlation of Lower Instrumented Vertebra With Spinal Mobility and Health-related Quality of Life After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: This is a retrospective single-center and single-surgeon study. OBJECTIVE: We investigated the correlation between lower instrumented vertebra (LIV) and spinal mobility 2 years after posterior spinal fusion with pedicle screws for adolescent idiopathic scoliosis (AIS) for optimal LIV selection. SUMMARY OF BACKGROUND: Spinal motion can become limited in scoliosis patients who undergo posterior spinal fusion. However, few reports exist on spinal mobility after posterior spinal fusion for AIS and the relationship between the LIV and mobility is unknown. We hypothesize that mobility limitation increases as the LIV is moved inferiorly. DATA: Of 72 consecutive patients who received posterior spinal fusion using pedicle screws for AIS between October 2009 and August 2015, 66 patients (5 male and 61 female, mean age: 14.9 y) were enrolled. MATERIALS AND METHODS: In total, 66 patients were retrospectively reviewed after stratification according to LIV level. Follow-up rate was 91.7%. Patients were examined for the fingertip-to-floor distance (FFD) before and 2 years after surgery. FFD was measured from the tips of the middle fingers to the floor with the barefoot subject bent maximally forward and the feet together and knees straight. Clinical outcome was assessed using Scoliosis Research Society-22 patient questionnaire (SRS-22r) scores and a visual analog scale for low back pain before and at 2 years postoperatively. RESULTS: The median number of fused vertebrae was 9 (range: 4-15). The LIV was T11-12 in 15 patients, L1 in 11 patients, L2 in 10 patients, and L3 in 30 patients. The median decrease in FFD according to LIV at 2 years after surgery was T11-12: 0 cm, L1: 0 cm, L2: 5.5 cm, and L3: 10 cm. Thus, limited FFD became significantly more severe as the LIV was moved downwards (P<0.01). There were no significant correlations between limited FFD and SRS-22r or pain visual analog scale scores at 2 years postoperatively. CONCLUSIONS: FFD became significantly more restricted as the LIV was moved inferiorly but clinical results appeared unaffected by limited FFD.

Ten-Year Results of Reconstruction for Rheumatoid Cervical Spine Lesions and Occurrence Factor of Subaxial Subluxation.

Study Design: Retrospective chart review. Purpose: This study evaluated long-term surgical outcomes of computer-assisted reconstruction using transarticular or cervical pedicle screws for cervical spine lesions caused by advanced rheumatoid arthritis (RA). Overview of Literature: We routinely employ C1-C2 transarticular and cervical pedicle screw instrumentation to reconstruct advanced and unstable RA cervical lesions. However, few reports are available on the long-term results of surgical reconstruction for rheumatoid cervical disorders, particularly regarding cervical pedicle screw fixation. Methods: Six subjects (all female) with RA cervical lesions who underwent atlantoaxial or occipitocervical fixation and were followed for at least 10 years were retrospectively studied. A frameless, stereotactic, optoelectronic, computed tomography-based image guidance system was used for correct screw placement. Variables including the Japanese Orthopaedic Association score, EuroQol, Ranawat value, and C2-C7 angle before and 2, 5, and 10 years after surgery were assessed along with the occurrence of subaxial subluxation (SAS). Results: Mean age at initial surgery was 58.2±7 years (range, 51-68 years), and mean follow-up period was 141±11 months (range, 122-153 months). Lesions included atlantoaxial subluxation (AAS, n=2) and AAS+vertical subluxation (n=4). Mean C2-C7 lordotic angle before and 2, 5, and 10 years after surgery was 20.1°±6.1°, 21.0°±4.0°, 18.8°±4.7°, and 17.8°±5.3°, respectively. SAS did not occur in cases maintaining the C2-C7 lordotic angle. In two cases where the C2-C7 lordotic angle declined from 5 years postoperatively, SAS occurred at the C2-C3 level in one and at the C4-C5 level in the other, both of which required reoperation. Conclusions: Patients with rheumatoid cervical lesions who undergo atlantoaxial or occipitocervical fixation using C1-C2 transarticular or pedicle screws carry a risk of SAS for up to 10 years postoperatively, which may require reoperation.

Surgical outcomes of spinal fusion for osteoporotic thoracolumbar vertebral fractures in patients with Parkinson's disease: what is the impact of Parkinson's disease on surgical outcome?

BACKGROUND: To date, there have been little published data on surgical outcomes for patients with PD with thoracolumbar OVF. We conducted a retrospective multicenter study of registry data to investigate the outcomes of fusion surgery for patients with Parkinson's disease (PD) with osteoporotic vertebral fracture (OVF) in the thoracolumbar junction. METHODS: Retrospectively registered data were collected from 27 universities and their affiliated hospitals in Japan. In total, 26 patients with PD (mean age, 76 years; 3 men and 23 women) with thoracolumbar OVF who underwent spinal fusion with a minimum of 2 years of follow-up were included (PD group). Surgical invasion, perioperative complications, radiographic sagittal alignment, mechanical failure (MF) related to instrumentation, and clinical outcomes were evaluated. A control group of 296 non-PD patients (non-PD group) matched for age, sex, distribution of surgical procedures, number of fused segments, and follow-up period were used for comparison. RESULTS: The PD group showed higher rates of perioperative complications (p < 0.01) and frequency of delirium than the non-PD group (p < 0.01). There were no significant differences in the degree of kyphosis correction, frequency of MF, visual analog scale of the symptoms, and improvement according to the Japanese Orthopaedic Association scoring system between the two groups. However, the PD group showed a higher proportion of non-ambulators and dependent ambulators with walkers at the final follow-up (p < 0.01). CONCLUSIONS: A similar surgical strategy can be applicable to patients with PD with OVF in the thoracolumbar junction. However, physicians should pay extra attention to intensive perioperative care to prevent various adverse events and implement a rehabilitation regimen to regain walking ability.

Two-stage posterior spinal fusion for early-onset scoliosis: Two case reports.

RATIONALE: Fusionless techniques for early-onset scoliosis (EOS) have evolved to allow near-normal growth while maintaining the correction achieved during the initial surgery. However, such procedures require repeated surgeries and have increased complication rates. We have developed a 2-stage fusion technique using pedicle screws for EOS to reduce patient burden and complication risk. This series describes the clinical and radiological features of 2 patients with EOS who received 2-stage posterior spinal fusion. This surgical method for EOS represents the first of its kind. PATIENT CONCERNS: Case 1 was a 10-year-old girl who was diagnosed as having scoliosis with Prader Willi syndrome at the age of 2 years. Her preoperative major curve Cobb angle was 100 degrees at age 10 years. Case 2 was an 11-year-old boy who was found to have scoliosis with 22q11.2 deletion syndrome at the age of 4 years. His preoperative major curve Cobb angle was 77 degrees at age 11 years. DIAGNOSIS: Whole-spine radiographs were performed to diagnose scoliosis. INTERVENTIONS: Both patients received 2-stage posterior spinal fusion. OUTCOMES: Postoperative Cobb angle of the major curve improved to 46 and 48 degrees, respectively. Thoracic height respectively improved from 160 and 148 mm before surgery to 206 and 211 mm at final follow-up. Surgical outcome as evaluated by Scoliosis Research Society-22 patient questionnaires revealed acceptable results without any severe complications. LESSONS: Based on the present case report, 2-stage posterior spinal fusion for EOS achieves good radiological and clinical outcomes without severe complications.

Prediction of Spontaneous Lumbar Curve Correction After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis Lenke Type 1 Curves.

STUDY DESIGN: This is a retrospective single-center and single-surgeon study. OBJECTIVE: The present study examined for preoperative parameters having the highest correlation with compensatory thoracolumbar/lumbar (TL/L) curve correction 2 years after surgery in adolescent idiopathic scoliosis (AIS) patients with Lenke type 1 curves. SUMMARY OF BACKGROUND: Several parameters have been considered to evaluate the flexibility of compensatory TL/L curve in AIS patients with Lenke type 1 curves. However, the imaging position with the strongest correlation with postoperative spontaneous TL/L curve correction is unknown. DATA: In total, 37 patients with AIS Lenke type 1 curves who had undergone skip pedicle screw fixation were followed for a 2-year period were enrolled. MATERIALS AND METHODS: TL/L Cobb angles measured at the standing posteroanterior view, supine position, supine position with maximum bending, supine position with traction, prone position, and prone-push position were determined before surgery. Using TL/L Cobb angles determined 2 years postoperatively, correlations between preoperative and postoperative Cobb angles were calculated for each position using the Spearman rank-correlation coefficient, linear regression analysis, and paired t tests. RESULTS: Mean preoperative mean±SD TL/L Cobb angle was significantly improved from 31±9 to 13±8 degrees at the study end point. In analyses of correlations between postoperative TL/L Cobb angle and preoperative parameters, the supine position with traction was most strongly associated with TL/L curve correction rate at 2 years after surgery (r=0.72; P<0.01), with paired t tests revealing a significant mean difference of 3.1 degrees. CONCLUSIONS: Preoperative Cobb angle evaluated at the supine position with traction had the strongest correlation with spontaneously corrected TL/L curve Cobb angle after selective thoracic fusion for AIS Lenke type 1 curves. Accordingly, it may be sufficient to evaluate TL/L curve correction at this position only to reduce radiation exposure and operative time.

How Much Surface Registration Accuracy is Required Using Ct-based Navigation System in Adolescent Idiopathic Scoliosis Surgery?

STUDY DESIGN: Retrospective, single-center, single-surgeon study. OBJECTIVE: This study investigated screw perforation rate according to surface registration accuracy in pedicle screw fixation using a CT-based navigation system for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Posterior spinal fusion for scoliosis correction using pedicle screws is widely adopted but carries a risk of serious neurovascular or visceral structure events. To attempt to avoid these complications, we have been using a computed tomography (CT)-based navigation system during screw insertion, although insufficient surface registration accuracy may be a reason for some screw perforations. METHODS: We evaluated 116 AIS patients (9 male and 107 females; mean±standard deviation age: 15.2±2.3 y) who had received pedicle screw fixation guided by a CT-based navigation system between August 2007 and December 2017. Screw perforation rate was evaluated in relation to surface registration accuracy and cut-off values were determined by receiver operating characteristic (ROC) curves. RESULTS: A total of 1553 pedicle screws were inserted into T2-L4 vertebrae using CT-based navigation system. The respective overall perforation rates for grade 2 or 3 and grade 3 perforations by surface registration accuracy were 0.2 mm: 0% and 0%; 0.3 mm: 3.5% and 0%; 0.4 mm: 3.5% and 0.8%; 0.5 mm: 8.0% and 3.5%; 0.6 mm: 6.7% and 2.7%; 0.7 mm: 8.9% and 3.8%; 0.8 mm: 9.3% and 6.7%; and 0.9 mm: 9.3% and 4.7%. ROC curve analysis revealed a cut-off surface registration accuracy of 0.5 mm. The major screw perforation rate for a surface registration accuracy of ≥0.5 mm was significantly higher than that for <0.5 mm (P<0.01). CONCLUSIONS: Analysis of screw perforation rate according to surface registration accuracy demonstrated a clinical cut-off of 0.5 mm. Thus, surface registration accuracy should optimally be <0.5 mm for scoliosis surgery with CT-based navigation system.

Determination of optimal screw number based on correction angle for main thoracic curve in adolescent idiopathic scoliosis.

BACKGROUND: Reducing the number of screw insertions while maintaining good clinical outcomes can improve the efficiency and cost-effectiveness of scoliosis surgery. However, the optimal minimum number of pedicle screws remains unclear. This study searched for factors to estimate the fewest number of pedicle screws required between end vertebrae in relation to preoperative main thoracic curve flexibility. METHODS: Sixty-nine subjects (4 male and 65 female, mean age: 14.8 ± 2.5 years) who underwent skip pedicle screw fixation for Lenke type 1-4 or 6 curves and were followed for at least 1 year were enrolled. Intervention technique was selected according to the size and flexibility of the preoperative main thoracic curve. Surgery-related variables included pedicle screw number, rod material and diameter, and extent of Ponte osteotomy. The effect on postoperative correction angle (i.e., the difference between the preoperative supine position maximum bending and postoperative standing Cobb angles of the main thoracic curve) according to surgical intervention technique was estimated using multiple linear mixed regression models with the preoperative supine position maximum bending correction angle (i.e., the difference between the standing preoperative and supine position maximum bending Cobb angles) as a random effect. RESULTS: The preoperative maximum bending correction angle was 8-42° and had a moderate negative correlation with postoperative correction angle (r = -0.65, P < 0.01). Multivariate analysis revealed a 1.7° (95% CI 0.7-2.6; P < 0.01) correction gain per single-screw insertion and a 1.8° (95% CI 0.5-3.1; P < 0.01) gain per intervertebral level in Ponte osteotomy. CONCLUSIONS: The number of pedicle screws necessary to correct main thoracic adolescent idiopathic scoliosis curves can be estimated by calculating correction gains of 1.7° per pedicle screw and 1.8° per Ponte osteotomy intervertebral level. Based on these results, it may be possible to reduce invasiveness and cost for patients requiring a smaller degree of correction.

Can surgery for adolescent idiopathic scoliosis of less than 50 degrees of main thoracic curve achieve good results?

BACKGROUND: It is generally recognized that the main thoracic curve Cobb angle threshold for surgical correction is approximately 50 degrees in patients with adolescent idiopathic scoliosis (AIS). Although AIS with a Cobb angle of <50 degrees is sometimes treated surgically to improve cosmesis, the precise outcomes are unclear. This study analyzed the postoperative results for AIS with a main thoracic curve of 50 degrees. METHODS: Thirty-nine consecutive patients with Lenke type 1-2 curves underwent posterior spinal fusion for AIS. These subjects were divided into the <50 degrees of main thoracic curve group (n = 14) and the ≥50 degrees group (n = 25). Clinical and radiographic data were compared. RESULTS: The mean Cobb angle of the main thoracic curve before and at 2 years after surgery for the <50 degrees and ≥50 degrees groups was 44.5 and 60.3 degrees (p < 0.001) and 14.0 and 19.5 degrees (p = 0.016), respectively. Preoperatively, both groups had comparable Scoliosis Research Society-22 (SRS-22) scores (all p > 0.05). Patients with a Cobb angle of <50 degrees displayed significantly milder postoperative pain (4.7 vs. 4.3, p = 0.031), with no remarkable differences in other SRS-22 domain scores. These patients also had a significantly shorter operative time (194 vs. 235 min, p = 0.021) and fused level (9.2 vs. 10.8 vertebrae, p = 0.006) along with similar correction rate (68.1 vs. 65.8%, p = 0.622) and blood loss volume (932 vs. 1009 ml, p = 0.715). CONCLUSIONS: Surgical correction of AIS with <50 degrees of main thoracic curve may less invasively achieve results that are comparable with those for AIS with 50 degrees or more, including improvements in self-image.

Mid-term results of computer-assisted skip pedicle screw fixation for patients with Lenke type 1 and 2 adolescent idiopathic scoliosis: A minimum five-year follow-up study.

PURPOSE: In skip pedicle screw fixation for adolescent idiopathic scoliosis (AIS), the mid-term effects of reducing screw number on correction and clinical results are uncertain. We clarified the mid-term outcomes of this technique in patients with Lenke type 1 and 2 AIS. METHODS: Thirty-four patients who underwent skip pedicle screw fixation (mean screw density: 1.35 screws) for Lenke type 1 and 2 AIS were retrospectively reviewed. The follow-up period was at least 5 years (mean follow-up period: 6.1 years), and the follow-up rate was 89.5%. Radiological parameters and clinical symptoms were evaluated before, immediately after, and at 2 years and 5 years after surgery. RESULTS: The mean Cobb angle of the main thoracic (MT) curve before, immediately after, at 2 years after surgery, and at the final 5-year minimum follow-up was 52.5°, 16.4°, 20.5°, and 19.4°, respectively. The Cobb angle of the MT curve was significantly improved immediately after, at 2 years after surgery, and at the final follow-up compared with that before surgery (p < 0.01). The mean correction rate immediately after surgery was 69.0% and the rate of correction loss at the final follow-up was 8.3%. All Scoliosis Research Society-22 patient questionnaire (SRS-22r) sub scores 5 years after surgery were significantly improved compared with those beforehand (p < 0.01). CONCLUSIONS: Correction using skip pedicle screw fixation in AIS was well maintained from the initial follow-up measurements to the final follow-up. The SRS-22r sub scores at the final follow-up were significantly improved over preoperative levels.

Posterior spinal fusion for scoliosis after Fontan procedure: A case series.

BACKGROUND: As the surgical treatment of scoliosis after a Fontan procedure is very challenging due to the risk of various perioperative complications, case reports are scarce. We herein describe three patients who were successfully treated for scoliosis following a Fontan procedure and discuss their clinical and radiological outcomes. METHODS: We retrospectively reviewed three cases of scoliosis treated by posterior spinal fusion after a Fontan procedure. RESULTS: Mean preoperative major curve Cobb angle was 83.7°, mean surgical time was 233.0 min, and mean blood loss was 1167 g. The mean correction rate of the major curve was 48.0%. Surgical outcome as evaluated by Scoliosis Research Society-22 patient questionnaires revealed acceptable results without any severe complications. CONCLUSIONS: Corrective surgery for scoliosis after a Fontan procedure becomes a stronger option if cardiac insufficiency is prevented during the perioperative period and a conservative plan is carried out with minimal invasiveness and operation time.