Placement of ilio-sacral screws in fusionless technique for pediatric neuromuscular scoliosis utilizing planning software, in conjunction with intraoperative navigation, results in a safer optimal screw: a CT-based study.

PURPOSE: The insertion of ilio-sacral (IS) screws for distal anchoring in the instrumentation of pediatric neuromuscular scoliosis (NS) presents a significant challenge, often leading to elevated rates of complications. Utilizing computed tomography (CT) navigation and preoperative planning technology is proposed as a potential solution to mitigate these challenges. This study aims to assess the precision of IS screw placement through CT-graphic measurements, both with and without preoperative planning, followed by navigated IS screw insertion, in pediatric neuromuscular scoliosis. METHODS: Thirty-two treated patients were grouped based on surgical procedure: planned (P): 19 patients (n = 38 screws) and non-planned (NP): 13 patients (n = 26 screws). All screw placements (P and NP) took place under CT navigation. IS screw trajectories of P-group were drawn preoperatively on CT images with the cranial trajectory planning program and fused with the intraoperative CT images. There are several important anatomical structures that should be avoided when placing the IS screw (L5 root, spinal canal, L5S1 facet, SI joint, neurovascular structures anteriorly to the sacrum, S1 root in the S1 foramen and the intestines). Each trajectory was evaluated based on seven radiographical parameters whom we have enlisted partially based on the essentials of a good trajectory described by Miladi et al. (1: Ilium; 2: SI joint; 3: Promontorium; 4: Sacral plate; 5: Anterior sacral cortex; 6: S1 foramen; 7: Spinal canal). An independent sample T test was executed to compare both groups. RESULTS: The trajectories in the P group showed a significantly (P < 0.05) higher overall similarity and optimality (12.1 ± 2.1 vs 9.1 ± 2.2 points) compared to the non-planned trajectory. CONCLUSIONS: Preoperative planning and navigated placement of IS screws on fusion images with intraoperative CT, results in a better trajectory of the ilio-sacral screws.

Qualitative study exploring the views of patients and healthcare providers on current rehabilitation practices after lumbar fusion surgery.

OBJECTIVES: To explore the views of patients and healthcare providers on current rehabilitation after lumbar fusion surgery (LFS) to fuel the development of a novel rehabilitation care pathway. DESIGN: A cross-sectional, qualitative study with an interpretive descriptive design. SETTING: Academic and non-academic hospital setting in Belgium. PARTICIPANTS: 31 caregivers from (non)-academic settings and 5 patients with LFS were purposefully sampled and in-depth interviewed. RESULTS: Out of the data of all interviews, participants reported opinions on 23 thematic clusters that were expressed in a time-contingent manner from the preoperative, perioperative to postoperative phase. Afterwards, themes were mapped to the Consolidated Framework for Implementation Research, with a larger role for concepts related to the innovation, inner and individual domain. As an overarching theme, the importance of an 'individualised, patient-centred rehabilitation built on a strong therapeutic alliance with an accessible interprofessional team' was stressed for patients undergoing LFS. Specifically, participants stated that a biopsychosocial approach to rehabilitation should start in the preoperative phase and immediately be continued postoperatively. No consensus was observed for movement restrictions postoperatively. Uniform communication between the involved caregivers was considered essential for optimal therapeutic alliance and clinical outcome. The precise role and competence of each member of the interprofessional team needs, therefore, to be clearly defined, respected and discussed. An accessible case manager to guide the patient trajectory and tackle problems could further support this. Interestingly, only patients, psychologists and physiotherapists addressed return to work as an important outcome after LFS. CONCLUSIONS: This qualitative study identified key experiences and points to consider in the current and future rehabilitation pathway for LFS. Future research should incorporate these findings to build a novel rehabilitation pathway for LFS and evaluate its feasibility and cost-effectiveness. TRIAL REGISTRATION NUMBER: This study was registered at clinicaltrials.gov (NCT03427294).

Three- instead of two-dimensional evaluation of key parameters alters the choice of the lowest instrumented vertebra in Lenke 1 and 2 AIS patients.

PURPOSE: Treatment of AIS, a three-dimensional spinal (3D) deformity, is guided by a two-dimensional (2D) evaluation. Novel 3D approaches that address the 2D limitations have not been adopted in AIS care due to their lengthy and complex 3D reconstruction procedures. This study aims to introduce a simple 3D method that translates the 2D key parameters (Stable vertebra (SV), Lenke lumbar modifier, Neutral vertebra (NV)) into 3D and to quantitively compare these 3D corrected parameters to the 2D assessment. METHODS: The key parameters of 79 surgically treated Lenke 1 and 2 patients were measured in 2D by two experienced spine surgeons. Next, these key parameters were measured in 3D by indicating relevant landmarks on biplanar radiographs and using the 'true' 3D CSVL which was perpendicular to the pelvic plane. Differences between the 2D and 3D analysis were examined. RESULTS: A 2D-3D mismatch was identified in 33/79 patients (41.8%) for at least one of the key parameters. More specifically, a 2D-3D mismatch was identified in 35.4% of patients for the Sag SV, 22.5% of patients for the SV and 17.7% of patients for the lumbar modifier. No differences in L4 tilt and NV rotation were found. CONCLUSION: The findings highlight that a 3D evaluation alters the choice of the LIV in Lenke 1 and 2 AIS patients. Although, the true impact of this more precise 3D measurement on preventing poor radiographic outcome needs further investigation, the results are a first step toward establishing a basis for 3D assessments in daily practice.

Monitoring the initial recovery after fusion surgery using activity trackers in adolescent idiopathic scoliosis: going in the lumbar spine decreases the daily step count.

PURPOSE: Although the functional outcome (e.g. the return to daily activities) plays an important role in the evaluation of treatment success for the paediatric patient, clinicians currently cannot make accurate and objective predictions regarding the very early (≤ 6 weeks) functional outcome and its recovery over time. The purpose of the present study is to objectively measure initial postoperative physical activity levels and examine the relationship with patient characteristics, fusion levels and pain. METHODS: Step count (SC) was obtained pre- (Pre-Op) and postoperatively (Post-3W: 3 weeks after surgery; Post-6W: 6 weeks after surgery) using an accelerometer. Patients were grouped based on LIV (thoracic (T-group) and lumbar (L-group)) and fusion length (FL ≤ 10 levels = SF-group and FL ≥ 11 levels = LF-group). Differences in the daily SC between groups (LIV and FL) and the three timepoints was investigated using a two-way ANOVA. RESULTS: The SC was significantly lower at both Post-3W (p < 0.001) and Post-6W (p < 0.001) compared to the preoperative SC, and significantly (p < 0.001) increased from Post-3W to Post-6W (Pre-Op = 13,049 ± 3214 steps/day; Post-3W = 6486 ± 2925 steps/day; Post-6W = 8723 ± 3020 steps/day). At both post-op timepoints the T-group had a higher SC compared to the L-group. CONCLUSION: A fusion surgery with the LIV at L2 or below has a negative impact on the very early postoperative activity levels. The initial functional outcome level of AIS patients was not related to the presently collected patient characteristics. This suggests that objective activity trackers provide novel information and could have an added value in very early rehabilitation programs.

Best practice rehabilitation pathway for the management of single and double-level lumbar fusion surgery: a modified Delphi Study.

BACKGROUND: There is limited evidence to guide the rehabilitation of patients following single or double-level lumbar fusion surgery (LFS). This is reflected in extensive variability in current rehabilitation regimes and subsequent low clinical success rates, which urges a call for a consensus rehabilitation pathway. AIM: To establish consensus on the optimal pre-, peri- and postoperative rehabilitation of LFS. DESIGN: A modified Delphi Study. SETTING: Belgium and the Netherlands. POPULATION: A multidisciplinary panel of 31 experts in the field of LFS and rehabilitation participated. Nine patients validated the consensus pathway. METHODS: A three-round online Delphi questionnaire was followed by an in-person consensus meeting. In each round, experts could suggest new statements, and received group summary statistics and feedback for reconsidered statements. Consensus threshold was set at ≥75% agreement. The resulting rehabilitation pathway was validated by patients through an online questionnaire and subsequent in-person focus group. RESULTS: A total of 31 experts participated in the first online round, with 27 (87%) completing all online rounds, and 17 (55%) attending the in-person consensus meeting. Consensus was reached on 122 statements relating to pre-, peri- and postoperative rehabilitation of LFS, and validated by patients. Key components of the rehabilitation pathway included prehabilitation, education, physiotherapy in every phase, early postoperative mobilization, and little movement restrictions. Patients emphasized the need for support during the return-to-work process. CONCLUSIONS: This process resulted in 122 expert-consensus statements on best practice rehabilitation for managing LFS, validated by patients. CLINICAL REHABILITATION IMPACT: The proposed rehabilitation pathway can serve as guidance to support clinicians, reduce practice variability, and subsequently improve clinical outcomes after LFS.

Applying the ICF model in adult spinal deformity: disability in terms of participation should be incorporated in the care pathway.

PURPOSE: To investigate the participation restriction of adult spinal deformity (ASD) patients, and its relation with the impairments in body structure and function, and activity limitation, as this important information regarding the individual's perspective on the social impact of the disease on their life is presently not captured. METHODS: Forty-three ASD patients participated in the study and completed the impact on participation and autonomy (IPA) questionnaire to assess the level of participation. Activity limitations and impairments were measured with the Balance Evaluation Systems Test (BESTest) and Scoliosis Research Society-22r (SRS-22). Also, age, body height, body weight, BMI, Mini-mental state examination and Cumulative Illness Rating Scale were assessed. A univariate linear regression analysis was conducted to investigate the relationship between the IPA and the independent variables, whereas a multivariate analysis identified the significant predictive variables for the IPA questionnaire. RESULTS: The univariate analysis identified performance on the BESTest and SRS-22 as significantly (p < 0.001) related to the IPA questionnaire. The multiple regression analysis revealed that the performance on BESTest (p = 0.073) and SRS-22 (p < 0.001) independently predicted the IPA questionnaire, explaining 73.5% of its variance. CONCLUSION: To fully understand the impact of ASD on the individual's functioning, disability and health-status, it is suggested that questionnaires on participation to society should be considered, together with clinical postural tests (e.g. the BESTest) and questionnaires related to HRQOL (e.g. the SRS-22), in the ASD care path. This additional information should allow the surgeon to make a more informed selection of surgical patients.

Rehabilitation to improve outcomes of lumbar fusion surgery: a systematic review with meta-analysis.

PURPOSE: To evaluate the effectiveness of rehabilitation strategies on disability, pain, pain-related fear, and return-to-work in patients undergoing lumbar fusion surgery for degenerative conditions or adult isthmic spondylolisthesis. METHODS: Six electronic databases were systematically searched for randomized controlled trials (RCTs) evaluating the effect of rehabilitation (unimodal or multimodal). The estimated effect size was calculated for interventions with homogeneous content using a random-effects model. Certainty of evidence was assessed by GRADE. RESULTS: In total, 18 RCTs, including 1402 unique patients, compared specific rehabilitation to other rehabilitation strategies or usual care. Most described indications were degenerative disc disease and spondylolisthesis. All rehabilitation interventions were delivered in the postoperative period, and six of them also included a preoperative component. Intervention dose and intensity varied between studies (ranging from one session to daily sessions for one month). Usual care consisted mostly of information and postoperative mobilization. At short term, low quality of evidence shows that exercise therapy was more effective for reducing disability and pain than usual care (standardized mean difference [95% CI]: -0.41 [-0.71; -0.10] and -0.36 [-0.65; -0.08], four and five studies, respectively). Multimodal rehabilitation consisted mostly of exercise therapy combined with cognitive behavioral training, and was more effective in reducing disability and pain-related fear than exercise therapy alone (-0.31 [-0.49; -0.13] and -0.64 [-1.11; -0.17], six and four studies, respectively). Effects disappeared beyond one year. Rehabilitation showed a positive tendency towards a higher return-to-work rate (pooled relative risk [95% CI]: 1.30 [0.99; 1.69], four studies). CONCLUSION: There is low-quality evidence showing that both exercise therapy and multimodal rehabilitation are effective for improving outcomes up to six months after lumbar fusion, with multimodal rehabilitation providing additional benefits over exercise alone in reducing disability and pain-related fear. Additional high-quality studies are needed to demonstrate the effectiveness of rehabilitation strategies in the long term and for work-related outcomes.

Applying a knowledge translation framework for triaging low back pain and radicular pain at an emergency department: an iterative process within an uncontrolled before-and-after design.

BACKGROUND: Diagnostic imaging for low back pain (LBP) without any indication of a serious underlying cause does not improve patient outcomes. However, there is still overuse of imaging, especially at emergency departments (EDs). Although evidence-based guidelines for LBP and radicular pain management exist, a protocol for use at the ED in the Belgian University Hospitals Leuven was not available, resulting in high practice variation. The present paper aims to describe the process from protocol development to the iterative implementation approach and explore how it has influenced practice. METHODS: In accordance with a modified 'knowledge-to-action' framework, five steps took place within the iterative bottom-up implementation process: (1) identification of the situation that requires the implementation of evidence based recommendations, (2) context analysis, (3) development of an implementation plan, (4) evaluation and (5) sustainability of the implemented practice recommendations. Two potential barriers were identified: the high turnover of attending specialists at the ED and patients' and general practicioners' expectations that might overrule the protocol. These were tackled by educational sessions for staff, patient brochures, an information campaign and symposium for general practitioners. RESULTS: The rate of imaging of the lumbar spine decreased from over 25% of patients to 15.0%-16.4% for CT scans and 19.0%-21.8% for X-rays after implementation, but started to fluctuate again after 3 years. After introducing a compulsory e-learning before rotation and catchy posters in the ED staff rooms, rates decreased to 14.0%-14.6% for CT scan use and 12.7-13.5% for X-ray use. CONCLUSIONS: Implementation of a new protocol in a tertiary hospital ED with high turn over of rotating trainees is a challenge and requires ongoing efforts to ensure sustainability. Rates of imaging represent an indirect though useful indicator. We have demonstrated that it is possible to implement a protocol that includes demedicalisation in an ED environment and to observe changes in indicator results.

Risk and Resilience Predictors of Recovery After Spinal Fusion Surgery in Adolescents.

OBJECTIVE: This prospective study examined risk and resilience predictors of pain and functional recovery in the first 6 months after spinal fusion surgery in adolescents. METHODS: Adolescents with adolescent idiopathic scoliosis undergoing spinal fusion surgery (n=100, aged 12 to 18 y, 77% girls) completed assessments before surgery and at 3 weeks, 6 weeks, and 6 months after surgery. Recovery trajectories in pain, health-related quality of life (HRQOL), and objectively registered physical activity were identified. Presurgical pain catastrophizing and pain intensity (risk), and psychological flexibility, and postsurgical pain acceptance (resilience) were examined as predictors of recovery. RESULTS: Latent growth class analyses revealed 4 distinct pain recovery trajectories (ie, Severe-Moderate [11%, n=9], Mild-No [58%, n=49], Moderate-Mild [24%, n=20], and Moderate-Severe [7%, n=6] pain trajectory), 2 HRQOL recovery trajectories; 2 trajectories characterizing recovery in average daily physical activity at moderate-to-vigorous intensity (MVPA); and 3 trajectories characterizing recovery in total physical activity volume characterized by the average daily number of steps. Subsequent multivariate analyses of variance revealed that presurgical pain intensity (partial η2=0.21, P<0.001) and pain catastrophizing (partial η2=0.13, P<0.01) were both predictive of poorer recovery in HRQOL, and pain catastrophizing additionally predicted poorer pain recovery (partial η2=0.15, P<0.05). Psychological flexibility (partial η2=0.25, P<0.001) and postsurgical pain acceptance (partial η2=0.07, P<0.05) were predictive of more favorable recovery trajectories in HRQOL, and psychological flexibility additionally predicted more favorable recovery trajectories in postsurgical pain (partial η2=0.15, P<0.05). Daily MVPA trajectories were not significantly predicted by any of the hypothesized factors, while presurgical pain catastrophizing levels were predictive of a delayed recovery trajectory in the daily amount of steps (partial η2=0.17 P<0.01). CONCLUSIONS: Presurgical screening could include assessment of pain intensity, pain catastrophizing, psychological flexibility, and pain acceptance to identify adolescents who are at risk for poorer recovery. These are potentially modifiable factors that can be targeted in presurgical interventions to prevent poor and foster adaptive outcomes after major surgery in adolescents.

Intra operative assessment of the coronal balance in spinal deformity surgery : a technical note and retrospective study.

Obtaining a spine that is well balanced after fusion for scoliotic deformity is primordial for the patients' quality of life. A simple T-shaped instrument combined with standard intraoperative fluoroscopy can be of great help to evaluate the coronal alignment quickly. The aim of this study was to evaluate if a T-shaped device could predict the postoperative coronal balance. Before finalization of the rod fixation, the balance was checked by verifying the relationship between the T-shaped instrument and the upper instrumented vertebra (UIV), and final adjustments were made to correct the coronal balance. A retrospective study was conducted on 48 patients who underwent surgery to correct scoliotic deformity. Intraoperative and postoperative coronal alignment was measured independently by two observers. The mean intraoperative horizontal offset measured between T-shaped instrument and the center of the UIV was 1,69mm to the right with a standard deviation (SD) of 12,43 mm. On postoperative full spine radiographs, the mean offset between the centra sacral vertical line and the center of the UIV was 2,44mm to the left with a SD of 13,10mm. There is no significant difference in coronal balance between both measurements (p=0,12). With this technique we were able to predict the postoperative coronal balance in all but one patient (97,92%). We conclude that the use of a simple T-shaped instrument can provide adequate intraoperative assessment of coronal balance in correcting scoliotic deformity. Level of evidence : IV - case series.

The prevalence of scoliosis within Belgian myelomeningocele population and the correlation with ambulatory status and neurological comorbidities: a chart audit.

STUDY DESIGN: Retrospective chart audit. OBJECTIVES: Firstly determining the prevalence of scoliosis in myelomeningocele (MMC) patients of the University Hospitals Leuven. Secondly analyzing whether there are differences concerning distribution of radiological level, ambulatory status, hydrocephalus, tethered cord, and syringomyelia in MMC patients with/without scoliosis. SETTING: University Hospitals Leuven, spina bifida convention. METHODS: The following data were collected: age, gender, radiograph type, age at the time of the radiograph, position during radiograph, presence of fusion, age at the time of fusion, diagnosis of hydrocephalus, tethered cord, or syringomyelia, radiological level of MMC, ambulatory status, main Cobb angle, main curve convexity, and main curve location. Correlation between prevalence of scoliosis and ambulatory status, neurological comorbidities, and radiological level were investigated. RESULTS: There were 116 patients remaining, after excluding patients without MMC or useful images. The scoliosis prevalence in MMC patients was 78.4% (95% CI, 71.0-85.8) for Cobb angle ≥10°; 60.3% (95% CI, 51.4-69.2) for ≥20°, 52.6% (95% CI, 43.5-61.7) for ≥30°, and 36.6% (95% CI, 27.7-45.5) for an angle ≥40°. Wheelchair users had 4 to 8 times more chance of having scoliosis than patients able to walk on all surfaces without aid. Thoracolumbar and lumbar radiological levels had a slightly higher prevalence of scoliosis than sacral levels. CONCLUSIONS: The high prevalence of scoliosis warrants a thorough screening and follow-up for MMC. There was no statistically significant difference between hydrocephalus, tethered cord, or syringomyelia regarding scoliosis. Future studies should focus on the interactions of the neurological comorbidities associated with MMC and scoliosis.

The Transverse Gravitational Deviation Index, a Novel Gravity Line-Related Spinal Parameter, Relates to Balance Control and Health-Related Quality of Life in Adults With Spinal Deformity.

STUDY DESIGN: Prospective cross-sectional case-control study design. OBJECTIVE: This study aims to analyze the relation between balance control as well as health-related quality of life (HRQOL) in patients with adult spinal deformity (ASD), with a novel gravity line (GL)-related 3D spinal alignment parameter, the transverse gravitational deviation index (TGDI), defined to quantify the transverse plane position of any vertebra with respect to the GL. SUMMARY OF BACKGROUND DATA: Demographic data and balance control have both been identified as important determinants of HRQOL in ASD patients during a preoperative setting. Therefore, a better understanding of the relation between spinal alignment and balance is required. METHODS: After informed consent, 15 asymptomatic healthy volunteers (mean age 60.1 ±â€Š11.6 years old) and 55 ASD patients (mean age 63.5 ±â€Š10.1 years old) were included. Relation between performance on BESTest as well as core outcome measures index (COMI) with spinopelvic alignment was explored using General Linear Modeling (GLM). A P-value ≤0.05 was considered statistically significant. RESULTS: The L3 TGDI was identified to relate to balance control in the total ASD population after correction for confounding demographic factors (P = 0.001; adjusted R = 0.500) and explained 19% of the observed variance in balance performance. In addition, COMI is related to L3 TGDI in a subgroup of ASD patients with combined coronal and sagittal malalignment of L3 (P = 0.027; slope B = 0.047), despite significant influence of age (P = 0.020). CONCLUSION: In ASD patients with a combined coronal and sagittal malalignment of the L3 vertebra, both the level of balance impairment as well as HRQOL are related to the distance component of the L3 TGDI, that is, the offset between the center of the L3 vertebral body and the GL in the transverse plane. LEVEL OF EVIDENCE: 2.

The Prevalence of Scoliosis in Spina Bifida Subpopulations: A Systematic Review.

Prevalence of scoliosis within spina bifida subpopulations is important for diagnostics and therapeutic purposes. This review determined the prevalence of scoliosis within spina bifida subpopulations by means of a systematic literature review by using the following databases: Medline PubMed, Embase, Cochrane, and Pedro. All Dutch- and English-written literature using the MESH terms "spinal dysraphism," "neural tube defects," and "scoliosis" was analyzed using the exclusion criteria: animal studies, case reports, studies regarding the prevalence of spina bifida among patients with scoliosis, studies with inclusion of patients with scoliosis of less than 11 degrees without possibility to identify subgroups with scoliosis of greater than 10 degrees, studies without an own study group, articles comprising the same patient group as another article, neural tube defects besides spina bifida, and articles without specification of spina bifida subtype. It resulted in six articles, two concerning diastematomyelia (103 patients, 82 females and 21 males) and four about myelomeningocele (479 patients, 283 females and 196 males) with an overall weighted prevalence of scoliosis (20-degree Cobb angle cutoff) of 44.4% and 52.5%, respectively. It can be concluded that most studies have a lot of methodological flaws, so there is a need for further research with standardization of data collection to allow comparison of different data.

Staged insertion of growing rods in severe scoliosis.

PURPOSE: The objective of this retrospective chart and radiographic review was to present the clinical outcomes and complication rate of a staged approach to modern dual growing-rod (GR) surgery when treating children with severe early onset scoliosis. METHODS: Fifteen patients received a 6-mm dual GR system. During Stage 1, pairs of end vertebra were exposed in a subperiosteal fashion, instrumented, grafted, and fused. Stage 2 was performed, on average, 5 months later (range 8-35 weeks) and the fused foundations were connected with two growing rods under skull-femoral traction. Clinical and operative notes were reviewed and all complications were recorded. Radiographic measurements were assessed at pre-index, with intraoperative traction during Stage 1, post-Stage 2 and at most recent follow-up. Statistical analyses were performed to evaluate change in scoliosis and kyphosis. RESULTS: At initial surgery, the average age was 8.17 ± 1.5 years. The mean Cobb angle was 88.1° ± 14.0°, corrected to 60.3° ± 8.7° (p < 0.001) with intraoperative traction in Stage 1, preserved after Stage 2 instrumentation (59.5° ± 9.6°, p = 0.69), and maintained with subsequent lengthenings (60.6° ± 12.8°, p = 0.73). Hyperkyphosis (11/15 patients) improved from 70.8° ± 15.7° to 46.6° ± 9.7° (p < 0.001). At minimum 2-year follow-up (range 24-80 months, mean 49.5), the complication rate was 14 (0.93 complications/patient), including 6 rod breakages, 6 superficial infections, and 2 deep infections. No anchor migration or pull-out was noted. Seven patients have undergone definitive posterior spinal fusion. CONCLUSIONS: Staged insertion of dual GR systems permits strong distraction, with acceptable correction of severe deformities and minimal complications. These slides can be retrieved under Electronic Supplementary Material.

Performance on Balance Evaluation Systems Test (BESTest) Impacts Health-Related Quality of Life in Adult Spinal Deformity Patients.

STUDY DESIGN: Prospective single-center study. OBJECTIVE: Study investigates how dynamic balance performance complements 2D static radiographic measurements and demographics in terms of understanding health-related quality of life in adult spinal deformity (ASD) patients. SUMMARY OF BACKGROUND DATA: Recent insights suggest that demographic variables have a stronger impact on health-related quality of life than 2D radiographic spinopelvic parameters in ASD patients. METHODS: Nine healthy volunteers and 36 ASD patients following inclusion criteria were recruited. Demographics, Scoliosis Research Society Score-22r (SRS-22r), Oswestry Disability Index (ODI), Core Outcome Measures Index (COMI), 2D radiographic spinopelvic measurements, and performance on Balance Evaluation Systems Test (BESTest), and Trunk Control Measurement Scale (TCMS) were determined for each subject. Nonparametric tests, Spearman correlations, univariate, and stepwise-like linear multivariate regression analysis were performed. RESULTS: BESTest and TCMS had significant lower values in the ASD group versus the control group (P = 0.000). In the ASD group, Cumulative Illness Rating Scale (CIRS) correlated fair to ODI, COMI (0.441 ≥ r ≥ 0.383, P < 0.021) and to SRS-22-r (r = -0.335, P = 0.046), Mini Mental State Examination correlated fair to COMI (r = -0.352, P = 0.035), "Pelvic Incidence minus Lumbar Lordosis" correlated fair to ODI (r = 0.361, P = 0.031), BESTest correlated moderate to ODI and COMI (r ≤ -0.505; P ≤ 0.002), TCMS correlated fair to ODI (r = -0.356; P = 0.033). CIRS and BESTest were significant predictive variables for COMI based on univariate analysis in ASD patients. Multivariate regression analysis including demographics, 2D static radiographic parameters, and dynamic balance scales identified BESTest as single independent variable (P = 0.000) to predict COMI (adjusted R = 0.285) in ASD patients. CONCLUSION: BESTest has a higher potential than demographic and 2D radiographic spinopelvic parameters to predict quality of life in ASD patients. Further research is necessary to identify the impact of ASD on quality of life. LEVEL OF EVIDENCE: 3.

Subaxial rotational vertebral artery syndrome: resection of the uncinate process and anterior fusion can be sufficient!: case report and review of the literature.

STUDY DESIGN: A case report on rotational vertebral artery syndrome (RVAS) and surgical treatment. OBJECTIVE: To illustrate a safe treatment option of RVAS with diminished risk of iatrogenic damage to the vertebral artery. SUMMARY OF BACKGROUND DATA: RVAS is an uncommon cause of symptomatic transient vertebrobasilar insufficiency induced by physiological head rotation with temporary significant external compression of the dominant subaxial vertebral artery. Previous reports state that the treatment of choice consists of decompression of the vessel with resection of the anterior rim of the transverse process and any fibrotic sheet or intertransverse muscle, if necessary, combined with an anterior cervical discectomy and fusion (ACDF) with uncus resection. METHODS: This is a case report on RVAS and its surgical treatment. The diagnosis of RVAS due to an osteophyte of the uncinate process at level C5/C6 was confirmed using computed tomographic angiography. We performed a classic ACDF using the contralateral approach with complete resection of the uncovertebral joint at the pathologic site. RESULTS: In our case, the symptoms of transient vertebrobasilar insufficiency induced by head rotation completely resolved postoperatively, and computed tomographic angiography images at 3 months postoperatively showed good bony ingrowth and restoration of vertebral artery patency during extreme rotation. CONCLUSIONS: Classic ACDF with complete resection of the uncovertebral joint is a safe treatment option for RVAS in the subaxial cervical spine. Fusion at the pathologic level will eliminate rotation and prevent further formation of osteophytes at the operated level. Unroofing of the vertebral artery seems not always necessary, diminishing the surgical risk.

A cervical "zero-profile" cage with integrated angle-stable fixation: 24-months results.

The purpose of this prospective mono-centric case series study is to investigate the mid-term (minimum follow-up 24 months) safety and efficacy using a new "zero-profile" stand-alone cage with integrated angle-stable fixation in single- and multilevel anterior cervical fusions. 53 consecutive patients with radiculopathy/myelopathy at one to three levels underwent an anterior cervical discectomy and fusion procedure using the "zero-profile" implant (97 levels operated). A CT-scan at 12-months was taken to assess fusion status, implant failure, subsidence and migration. The overall fusion rate was 97%. 3 out of 45 patients (6.6%) complained about mild dysphagia related symptoms at 24 months follow-up . There was no recorded incidence of hardware failure. The new cervical stand-alone anterior fusion device allows a safe anterior cervical decompression and stabilisation, a low rate of chronic dysphagia and achieves a high fusion rate. Prospective randomised trials are necessary to confirm these results.

Postsurgical Parsonage-Turner syndrome: a challenging diagnosis.

Parsonage-Turner syndrome (PTS) is a distinct clinical syndrome, characterized by acute and severe (mostly) unilateral shoulder pain, followed by paresis and atrophy of the shoulder girdle, while the pain decreases. Most authors consider it as an immune-mediated disorder. PTS is notoriously unrecognised and is usually diagnosed with delay. A PTS may also occur following a surgical procedure. Postsurgical PTS is an under-recognised and challenging clinical entity, as illustrated in the case reported here of a 59-year-old man, 4 weeks after anterior discectomy and fusion C5C7. In such cases, the differential diagnosis must be made with a complication of surgery, such as postoperative C5 palsy due for instance to a migrated bone graft. Arguments for PTS are: a certain delay between surgery and symptoms, intolerable pain followed by weakness and improvement of pain complaints, divergent distribution of weakness, sensory deficit and pain, which may be confirmed by electrodiagnosis. Early recognition of postsurgical PTS may avoid unnecessary investigations or surgical exploration. It allows to treat the patient properly, leading to greater satisfaction of both surgeon and patient; pain management, physical therapy and reassurance are the cornerstones.

The risk of bearing dislocation in lateral unicompartmental knee arthroplasty using a mobile biconcave design.

PURPOSE: A safety study was conducted on a cohort of 25 patients who underwent lateral unicompartmental arthroplasty with a biconcave mobile-bearing insert. METHODS: The first 25 lateral mobile-bearing unicompartmental knee replacements, performed in a general hospital by one surgeon, were prospectively reviewed, with a minimum follow-up of 1 year. RESULTS: One bearing dislocation occurred 4 months postsurgery. The Oxford knee score improved in all patients from a preoperative mean of 23.3 (range 8-40, SD 8.4) to a postoperative mean of 42.1 (range 23-48, SD 6.7). General patient satisfaction at a mean follow-up of 20 months was excellent in 84 %, good in 12 % and fair in 4 %. The mechanical axis as a measure on full-leg standing radiographs improved from 5.7° valgus (range 1°-16°, SD 4.1°) to 1.7° valgus (7° to -3°, SD 2.1°). Mechanical alignment correction averaged 4.0° (range -1° to 15°, SD 3.9°). CONCLUSION: The mobile biconcave insert design in the lateral unicompartmental knee replacement seems appropriate as a innovative, anatomy imitating solution, resulting in a good clinical outcome. Still, bearing dislocation remains a concern, especially in extended indication.