Letter to the editor: "Effect of electrical stimulation on the fusion rate after spinal surgery: a systematic review and meta-analysis".

This letter provides feedback on the article Effect of electrical stimulation on the fusion rate after spinal surgery: a systematic review and meta-analysis. The study highlights the clinical efficacy of electrical stimulation (ES) in enhancing fusion rates post-surgery. Future research should focus on identifying optimal ES parameters, long-term safety profiles, and its personalized application based on genetic and metabolic factors. Additionally, exploring the combination of ES with other regenerative therapies and evaluating its cost-effectiveness could further improve clinical outcomes.

L4-L5 anatomy classification system for lateral lumbar interbody fusion.

Lateral lumbar interbody fusion (LLIF), developed by Dr. Luiz Pimenta in 2006, allows access to the spinal column through the psoas major muscle. The technique has many advantages, such as reduced bone and muscular tissue damage, indirect decompression, larger implants, and lordosis correction capabilities. However, this technique also has drawbacks, with the most notorious being the risk of spinal pathologies due to indirect injury of the lumbar plexus, but with low rates of persistent injuries. Therefore, several groups have proposed classifications to help identify patients at a greater risk of presenting with neurological deficits. The present work proposes a classification system that relies on simple observation of easily identifiable key structures to guide lateral L4-L5 LLIF decision-making. Patients aged > 18 years who underwent preoperative magnetic resonance imaging (MRI) between 2022 and 2023 were included until 50 high-quality images were acquired. And excluded as follow Anatomical changes in the vertebral body or major psoas muscles prevent the identification of key structures or poor-quality MRIs. Each anatomy was classified as type I, type II, or type III according to the consensus among the three observers. Fifty anatomical sites were included in this study. 70% of the L4-L5 anatomy were type I, 18% were type II, and 12% were type III. None of the type 3 L4-L5 anatomies were approached using a lateral technique. The proposed classification is an easy and simple method for evaluating the feasibility of a lateral approach to-L4-L5.

Evaluation of the use of tranexamic acid in the postoperative period in patients with scoliosis undergoing posterior fusion.

Scoliosis is the most prevalent type of spinal deformity, with a 2-3% prevalence in the general population. Moreover, surgery for scoliotic deformity may result in severe blood loss and, consequently, the need for blood transfusions, thereby increasing surgical morbidity and the rate of complications. Several antifibrinolytic drugs, such as tranexamic acid, have been regarded as safe and effective options for reducing blood loss. Therefore, the present study aimed to analyse the effectiveness of this drug for controlling bleeding when used intraoperatively and in the first 48 h after surgery. A prospective randomized study of a cohort of patients included in a mass event for scoliosis treatment using PSF was performed. Twenty-eight patients were analysed and divided into two groups: 14 patients were selected for intraoperative and postoperative use of tranexamic acid (TXA), and the other 14 were selected only during the intraoperative period. The drainage bleeding rate, length of hospital stay, number of transfused blood units, and rate of adverse clinical effects were compared. All the patients involved had similar numbers of fusion levels addressed and similar scoliosis profiles. The postoperative bleeding rate through the drain did not significantly differ between the two groups (p > 0.05). There was no significant difference in the number of transfused blood units between the groups (p = 0.473); however, in absolute numbers, patients in the control group received more transfusions. The length of hospital stay was fairly similar between the groups, with no statistically significant difference. Furthermore, the groups had similar adverse effects (p = 0.440), with the exception of nausea and vomiting, which were twice as common in the TXA group postoperatively than in the control group. No significant differences were found in the use of TXA during the first 48 postoperative hours or in postoperative outcomes.

Survey of major complications after prone transpsoas surgery: an analysis of early adopters' practice.

INTRODUCTION: The prone transpsoas technique (PTP) is a modification of the traditional lateral lumbar interbody fusion approach, which was first published in the literature in 2020. The technique provides several advantages, such as lordosis correction and redistribution, single-position surgery framework, and ease of performing posterior techniques when needed. However, the prone position also leads to the movement of some retroperitoneal, vascular, and neurological structures, which could impact the complication profile. Therefore, this study aimed to investigate the occurrence of major complications in the practice of early adopters of the PTP approach. METHODS: A questionnaire containing 8 questions was sent to 50 participants and events involving early adopters of the prone transpsoas technique. Of the 50 surgeons, 32 completed the questionnaire, which totaled 1963 cases of PTP surgeries. RESULTS: Nine of the 32 surgeons experienced a major complication (28%), with persistent neurological deficit being the most frequent (7/9). Of the total number of cases, the occurrence of permanent neurological deficits was approximately 0,6%, and the rate of vascular and visceral injuries were both 0,05% (1/1963 for each case). CONCLUSION: Based on the analysis of the questionnaire responses, it can be concluded that PTP is a safe technique with a very low rate of serious complications. However, future studies with a more heterogeneous group of surgeons and a more rigorous linkage between answers and patient data are needed to support the findings of this study.

Results of the Surgical Approach of Idiopathic Scoliosis in Adolescents and Postoperative Quality of Life: Systematic Literature Review / Resultados da abordagem cirúrgica da escoliose idiopática em adolescentes e qualidade de vida pós-operatória: Revisão sistemática de literatura

Abstract Adolescent idiopathic scoliosis is considered the most severe and common spinal deformity, affecting children and adolescents still in the neuropsychomotor development phase before they reach skeletal maturity. This study aimed to evaluate the surgical approach to adolescent idiopathic scoliosis (AIS), considering the results associated with the reduction of pathological curvature, pulmonary function, and repercussions on the quality of life of adolescents undergoing such treatment. Systematic literature review, with a quantitative and qualitative approach to the data collected, structured according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), carried out in the databases linked to the Medical Literature Analysis and Retrieval System Online (MEDLINE) and Latin American and Caribbean Health Sciences Literature (LILACS). The total sample of the studies was 638 adolescents with AIS, with a mean age of 14.93 years ± 1.24. The mean correction of the main pathological curvature in the studies was 55.06% ± 12.24. In all of the selected studies using posterior spinal fusion to correct AIS, there was a significant reduction in pathological curvatures (> 49%), and the recurrence of curvature in none of the studies exceeded a pathological gain of more than 5%. As for lung function, the studies showed significant increases in forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) in patients with severe AIS, and no pulmonary function losses were reported after surgery to correct AIS.

Resumo A escoliose idiopática do adolescente (EIA) é considerada a deformidade vertebral de maior gravidade e ocorrência, que acomete crianças e adolescentes ainda na fase de desenvolvimento neuropsicomotor, antes de atingirem a maturidade esquelética. Este estudo teve como objetivo avaliar a abordagem cirúrgica da EIA, considerando resultados associados à redução de curvatura patológica, função pulmonar e repercussões na qualidade de vida dos adolescentes submetidos a tal tratamento. Revisão Sistemática de literatura, com abordagem quanti-qualitativa dos dados coletados, cuja estruturação se deu conforme as orientações de Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) realizada nas bases de dados vinculadas à Medical Literature Analysis and Retrieval System Online (MEDLINE) e Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS). A amostra total dos estudos foi de 638 adolescentes com EIA, com uma idade média de 14,93 anos ± 1,24. A correção média da curvatura patológica principal nos estudos foi de 55,06% ± 12,24. Em todos os estudos selecionados com fusão espinhal posterior para correção da EIA verificou-se redução significativa das curvaturas patológicas (> 49%), sendo que a reincidência de curvatura em nenhum dos estudos superou um ganho patológico superior a 5%. Quanto à função pulmonar, os estudos apontaram ganhos significativos de volume expiratório forçado em 1 segundo (VEF1) e capacidade vital forçada (CVF) em pacientes com EIA grave. Além disso, não foram relatados prejuízos de função pulmonar após intervenção cirúrgica para correção da EIA.

Navigated Anterior Full-Endoscopic Transcervical Approach Odontoidectomy for Traumatic Posterior Atlantoaxial Dislocation Without Odontoid Fracture.

BACKGROUND AND IMPORTANCE: Complete posterior atlantoaxial dislocation (PAAD) with an unfractured odontoid process is a rare condition where a dislocated but intact odontoid process is positioned ventrally to the anterior arch of C1. This lesion is related to transverse and alar ligament rupture secondary to hyperextension and rotatory traumatic injury and is often associated with neurological deficit. The treatment strategy remains controversial, and in many cases, odontoidectomy is required. Traditional approaches for odontoidectomy (transnasal and transoral) are technically demanding and are related to several complications. This article describes a 360° reduction and stabilization technique through a navigated anterior full-endoscopic transcervical approach (nAFETA) as a novel technique for odontoidectomy and C1-C2 anterior transarticular fixation supplemented with posterior fusion. CLINICAL PRESENTATION: A 21-year-old man presented to the emergency room by ambulance after a motorcycle accident. On evaluation, incomplete ASIA B spinal cord injury was documented. Imaging revealed a complete PAAD. We performed a two-staged procedure, a nAFETA odontoidectomy plus C1-C2 anterior transarticular fixation followed by posterior C1-C2 wired fusion. At a 2-year follow-up, the patient had a 10-point Oswestry Disability Index score and neurological improvement to ASIA E. CONCLUSION: PAAD can be successfully treated through minimally invasive nAFETA. Noteworthy, the risks of the transoral and endonasal routes were avoided through this approach. In addition, nAFETA allows anterior transarticular fixation during the same procedure providing spinal stability. Further studies are required to expand the use of nAFETA in this field.

Comparison of perioperative outcomes in obese and non-obese patients subjected to open lumbar spine surgery.

OBJECTIVE: Obesity is a global epidemic affecting developing countries. The relationship between obesity and perioperative outcomes during elective lumbar spine surgery remains controversial, especially in those without morbid disease. MATERIALS AND METHODS: We retrospectively revised the medical records of patients with lumbar spine degeneration subjected to elective surgery. The data retrieved included demographic and clinical characteristics, body mass index (BMI), obesity status (BMI ≥ 30), surgical interventions, estimated blood loss (EBL), operative time, length of stay (LOS), and post-operative complications. Perioperative outcomes were compared between Grade I-II obese and non-obese individuals. RESULTS: We enrolled 53 patients, 18 with Grade I-II obesity. Their median age was 51, with no differences in gender, comorbidities, laboratory parameters, and surgical procedures received between groups. No clinically relevant differences were found between grade I-II obese and non-obese participants in EBL (300 mL vs. 250 mL, p = 0.069), operative time (3.2 h vs. 3.0 h, p = 0.037), and LOS (6 days vs. 5 days, p = 0.3). Furthermore, BMI was not associated with the incidence of significant bleeding and long stay but showed a modest correlation with operative time. CONCLUSION: Grade I-II obesity does not increase surgical complexity nor perioperative complications during open lumbar spine surgery.

OBJETIVO: La obesidad es una epidemia mundial que afecta a países subdesarrollados. Su relación con los resultados de la cirugía de columna lumbar electiva sigue siendo controvertida, especialmente en obesos sin enfermedad mórbida. MÉTODOS: Se revisaron los expedientes de pacientes con degeneración de la columna lumbar sometidos a cirugía. Los datos recuperados incluyeron características demográficas y clínicas, índice de masa corporal (IMC), estado de obesidad (IMC > 30), intervenciones quirúrgicas, sangrado estimado, tiempo operatorio, tiempo de estancia y complicaciones. Los resultados se compararon entre individuos obesos grado I-II y controles. RESULTADOS: Se incluyeron 53 pacientes, 18 con obesidad de grado I-II. La edad media fue de 51 años, sin diferencias en el sexo, las comorbilidades, los parámetros de laboratorio y los procedimientos quirúrgicos recibidos entre grupos. No se encontraron diferencias relevantes entre los participantes obesos y los no obesos en sangrado (300 vs. 250 mL, p = 0.069), tiempo operatorio (3.2 vs. 3.0 horas, p = 0.037) y estancia (6 vs. 5 días, p = 0.3). El IMC no se asoció con hemorragia y larga estancia, pero mostró una correlación modesta con el tiempo operatorio. CONCLUSIONES: La obesidad grado I-II no predispone a complicaciones durante la cirugía de columna lumbar.

Intra-abdominal Content Movement in Prone Versus Lateral Decubitus Position Lateral Lumbar Interbody Fusion (LLIF).

STUDY DESIGN: A prospective, anatomical imaging study of healthy volunteer subjects in accurate surgical positions. OBJECTIVE: To establish if there is a change in the position of the abdominal contents in the lateral decubitus (LD) versus prone position. SUMMARY OF BACKGROUND DATA: Lateral transpsoas lumbar interbody fusion (LLIF) in the LD position has been validated anatomically and for procedural safety, specifically in relation to visceral risks. Recently, LLIF with the patient in the prone position has been suggested as an alternative to LLIF in the LD position. MATERIALS AND METHODS: Subjects underwent magnetic resonance imaging of the lumbosacral region in the right LD position with the hips flexed and the prone position with the legs extended. Anatomical measurements were performed on axial magnetic resonance images at the L4-5 disc space. RESULTS: Thirty-four subjects were included. The distance from the skin to the lateral disc surface was 134.9 mm in prone compared with 118.7 mm in LD ( P <0.0001). The distance between the posterior aspect of the disc and the colon was 20.3 mm in the prone compared with 41.1 mm in LD ( P <0.0001). The colon migrated more posteriorly in relation to the anterior margin of the psoas in the prone compared with LD (21.7  vs . 5.5 mm, respectively; P <0.0001). 100% of subjects had posterior migration of the colon in the prone compared with the LD position, as measured by the distance from the quadratum lumborum to the colon (44.4  vs . 20.5 mm, respectively; P <0.001). CONCLUSION: There were profound changes in the position of visceral structures between the prone and LD patient positions in relation to the LLIF approach corridor. Compared with LD LLIF, the prone position results in a longer surgical corridor with a substantially smaller working window free of the colon, as evidenced by the significant and uniform posterior migration of the colon. Surgeons should be aware of the potential for increased visceral risks when performing LLIF in the prone position. LEVEL OF EVIDENCE: Level II-prospective anatomical cohort study.

Impact of Social Determinants of Health on Adolescent Idiopathic Scoliosis Curve Severity.

INTRODUCTION: Social determinants of health have been shown to influence the health and outcomes of pediatric patients. Adolescent idiopathic scoliosis (AIS) may be particularly sensitive to such factors as early diagnosis and treatment can obviate the need for surgical intervention. The purpose of this study was to analyze the effect that social determinants of health have on the severity of AIS at presentation and at the time of surgery. METHODS: A retrospective review was conducted for consecutive patients who underwent posterior spinal fusion for AIS from 2020 to 2022. Demographic data was collected, while insurance status (private vs. public) and childhood opportunity index (COI) categories (LOW vs. HIGH) were used as a proxy for socioeconomic status. Curve magnitude at the initial presentation and at the latest preoperative visit were recorded with a threshold of 25 to 40 degrees considered within the bracing range. Univariate and multivariate analysis was done to compare differences between subgroups as appropriate. RESULTS: A total of 180 patients with mean initial and preoperative major curve angles of 48 and 60 degrees were included. Statistically significant differences in race and insurance types were appreciated, with the LOW COI group having a higher proportion of underrepresented minority and publicly insured patients than the HIGH COI group ( P <0.001). Patients within the LOW COI group presented with an initial curve that was, on average, 6 degrees more severe than those within the HIGH group ( P =0.009) and a preoperative curve that was 4 degrees larger than those within the HIGH group ( P =0.015). Similarly, only 13% of patients within the LOW COI group presented with curves within the bracing threshold, compared with 31% in the HIGH COI group ( P =0.009). CONCLUSION: Socioeconomic status plays a significant role in the severity of AIS. Specifically, patients with lower COI tend to present with curve magnitudes beyond what is responsive to nonsurgical treatment, leading to larger curves at the time of surgery. Future work should focus on addressing social inequalities to optimize the treatment and outcomes of AIS patients. LEVEL OF EVIDENCE: Level III- Retrospective Comparative Study.

Implementation of a Private Payer Bundled Payment Model While Maintaining High-Value Lumbar Spinal Fusion.

STUDY DESIGN: Retrospective single-institution cohort. OBJECTIVE: To evaluate the implementation of a commercial bundled payment model in patients undergoing lumbar spinal fusion. SUMMARY OF BACKGROUND DATA: BPCI-A caused significant losses for many physician practices, prompting private payers to establish their own bundled payment models. The feasibility of these private bundles has yet to be evaluated in spine fusion. METHODS: Patients undergoing lumbar fusion from October to December 2018 in BPCI-A before our institution's departure were included for BPCI-A analysis. Private bundle data was collected from 2018 to 2020. Analysis of the transition was conducted among Medicare-aged beneficiaries. Private bundles were grouped by calendar year (Y1, Y2, Y3). Stepwise multivariate linear regression was performed to measure independent predictors of net deficit. RESULTS: The net surplus was the lowest in Y1 ($2,395, P =0.03) but did not differ between our final year in BPCI-A and subsequent years in private bundles (all, P >0.05). AIR and SNF patient discharges decreased significantly in all private bundle years compared with BPCI. Readmissions fell from 10.7% (N=37) in BPCI-A to 4.4% (N=6) in Y2 and 4.5% (N=3) Y3 of private bundles ( P <0.001). Being in Y2 or Y3 was independently associated with a net surplus in comparison to the Y1 (ß: $11,728, P =0.001; ß: $11,643, P =0.002). Postoperatively, length of stay in days (ß: $-2,982, P <0.001), any readmission (ß: -$18,825, P =0.001), and discharge to AIR (ß: $-61,256, P <0.001) or SNF (ß: $-10,497, P =0.058) were all associated with a net deficit. CONCLUSIONS: Nongovernmental bundled payment models can be successfully implemented in lumbar spinal fusion patients. Constant price adjustment is necessary so bundled payments remain financially beneficial to both parties and systems overcome early losses. Private insurers who have more competition than the government may be more willing to provide mutually beneficial situations where cost is reduced for payers and health systems. LEVEL OF EVIDENCE: 3.

Access to the Lumbosacral Spine: A Current View / Acesso à coluna lombossacral: Visão atual

Abstract The surgical approach to the lumbosacral spine has been the subject of experimental and scientific anatomical studies since the Hippocratic era. However, it was in the 20th century that, with the evolution of asepsis and antibiotic therapy, spine surgery began to evolve at breakneck speed, and the various possibilities of access roads became objects of development and discussion. As a result, pathologies of the lumbosacral spine can be accessed in different ways and positions, from the traditional posterior approach in the prone position to the anterior, oblique, lateral, and endoscopic approaches. The current article brings state-of-the-art access routes to the lumbosacral spine. This article objective is to elucidate the possibilities of accesses the lumbar spine for any purposes, as decompression, fusion, tumour resections, reconstruction or deformity correction, despites type of implants or implants positioning.

Resumo A abordagem cirúrgica da coluna lombossacral tem sido objeto de estudos anatômicos experimentais e científicos desde a era hipocrática. Contudo, foi no século XX que, com a evolução da assepsia e da antibioticoterapia, a cirurgia da coluna começou a evoluir em velocidade vertiginosa e as diversas possibilidades de vias de acesso tornaram-se objetos de desenvolvimento e discussão. Desta forma, as doenças da coluna lombossacral podem ser acessadas de diferentes maneiras e posições, desde a abordagem posterior tradicional em decúbito ventral até as abordagens anterior, oblíqua, lateral e endoscópica. O presente artigo traz vias de acesso de última geração para a coluna lombossacral. O objetivo deste artigo é elucidar as possibilidades de acesso à coluna lombar para quaisquer finalidades, como descompressão, fusão, ressecções tumorais, reconstrução ou correção de deformidades, independentemente do tipo de implante ou seu posicionamento.

Modificación del corredor aorto-psoas para el acceso oblicuo lumbar intervertebral según los cambios posturales y la composición corporal. Estudio multicéntrico observacional mediante resonancia magnética / Modification of the safe corridor for oblique lumbar interbody fusion based on postural changes and body composition. An observational, multicenter study using MRI

Introducción: La cirugía mínimamente invasiva de columna se ha vuelto cada vez más popular en los últimos años. Se han desarrollado técnicas nuevas y menos invasivas que se han convertido en procedimientos de elección para determinadas enfermedades. El tamaño del corredor aorto-psoas es un factor determinante al elegir la técnica oblicua de fusión intersomática. Objetivos: Describir las modificaciones en el tamaño del corredor aorto-psoas en decúbito lateral derecho y decúbito supino mediante resonancia magnética y su asociación con el índice de masa corporal. materiales y métodos: Se realizó una resonancia magnética de los espacios discales de L1-L2 a L4-L5 a 13 voluntarios en decúbito supino y decúbito lateral derecho. Se midió el corredor y se comparó el tamaño en cada nivel. Resultados: El tamaño del corredor aorto-psoas y de la distancia arteria-disco tuvo un aumento estadísticamente significativo al posicionar al paciente en decúbito lateral derecho. Conclusiones: La resonancia magnética es de suma importancia en la planificación prequirúrgica, pues deja en evidencia la movilidad de las estructuras abdominales. Se producen cambios significativos en el corredor aorto-psoas y la distancia arteria-disco al ubicar al paciente en decúbito lateral derecho. Sin embargo, estos cambios no tienen una relación significativa con el índice de masa corporal. Nivel de Evidencia: IV

Introduction: Minimally invasive spine surgery (MISS) has gained popularity in recent years. New and less invasive techniques have emerged as the preferred procedures for certain pathologies. The size of the aorta-psoas corridor is decisive when choosing the oblique interbody fusion technique. Objectives: To describe the changes in the size of the aorta-psoas corridor in the right lateral decubitus and supine decubitus positions by magnetic resonance imaging and their association with body mass index. materials and methods: 13 volunteers underwent MRI of the disc spaces from L1-L2 to L4-L5 in the supine and right lateral decubitus positions. The corridor was measured, and the sizes at each level were compared. Results: A statistically significant increase in the size of the aorta-psoas corridor and the artery-disc distance was obtained when positioning the patient in the right lateral decubitus position. However, these have no significant relationship with BMI. Conclusions: The use of MRI in pre-surgical planning is extremely important. This study reveals the mobility of the abdominal structures. We can conclude that, as stated in the objective of the study, significant changes occur in the aorta-psoas corridor and the artery-disc distance when the patient is positioned in the right lateral decubitus position. Level of Evidence: IV

Complicaciones asociadas a la artrodesis intersomática lumbar por vía lateral. Revisión narrativa de la bibliografía / Complications of lateral lumbar interbody fusion (XLIF). Narrative literature review

Introducción: El abordaje lateral de la columna lumbar en la artrodesis intersomática está descrito para tratar varias enfermedades. Si bien es un procedimiento seguro, a medida que la técnica ha ganado popularidad, se han publicado diversas complicaciones asociadas. El objetivo de este artículo es presentar una revisión narrativa de la bibliografía para proveer al lector de un resumen organizado de las complicaciones comunicadas más frecuentes relacionadas con esta técnica. Materiales y métodos: Se llevó a cabo una revisión narrativa de la bibliografía obtenida en las bases de datos PubMed, Web of Science, Scopus y LILACS para identificar artículos que detallen complicaciones relacionadas con el abordaje lateral de la columna lumbar. Resultados: Luego del análisis de los resultados de la búsqueda bibliográfica, se seleccionaron 18 artículos para esta revisión. Conclusiones: Las complicaciones más frecuentes directamente relacionadas con este abordaje son la cruralgia y el déficit motor para la flexión de la cadera o la extensión de la pierna que, en su gran mayoría, son transitorias y reversibles. Hay escasos reportes de lesiones vasculares severas o fatales. Nivel de Evidencia: III

Introduction: The lateral approach for lumbar interbody fusion has been described for the treatment of diverse pathologies. Although it is a safe procedure, its popularity has led to an increase in reports of complications associated with it. The objective of this work is to conduct a narrative review of the literature on the most frequently reported complications associated with this surgical approach. Materials and methods: We performed a narrative review of the literature based on the publications obtained from the following databases: PubMed.gov, Web of Science, Scopus and Lilacs to identify published articles that detail complications related to the lateral approach to the lumbar spine. Results: After analyzing the results of the bibliographic search, 18 articles were selected to carry out this review. Conclusions: The most frequent complications directly related to this approach are thigh pain and motor deficit for hip flexion and/or leg extension, which are mostly temporary and reversible. Severe or fatal vascular injuries have rarely been reported. Level of Evidence: III

[Comparison of cervical fusion with autografting of fibula vs titanium cage]. / Comparación de artrodesis cervical mediante autoinjerto de peroné frente a caja de titanio.

Background: The anterior cervical discectomy and fusion (ACDF) is the gold standard in the treatment of cervical compression pathology and the titanium cage for fusion represents the most used procedure at an institutional level. A technique using fibular autograft has been described, with good results, lower morbidity and lower cost. Objective: To compare the rate of fusion, subsidence and functional clinical results after discectomy with titanium cage and fibular autograft. Material and methods: A clinical trial with follow-up at 3 and 6 months was carried out in patients diagnosed with cervical spondylosis, candidates for ACDF. 2 groups were formed: fibular autograft and titanium cage. Pre and post functional evaluation using the cervical disability score was made, as well as radiographic fusion and subsidence evaluation. Descriptive statistics, Fisher's exact test, t-test and ANOVA were obtained, establishing p < 0.05. Results: A sample of 20 patients with an average age of 56 years was obtained, finding a fusion rate of 90% for fibular autograft and 30% for titanium (p = 0.02) at 3 months. 10% of patients with fibular autograft presented subsidence and 70% with titanium cage at 3 and 6 months (p = 0.02). In the functional results was not found difference between both procedures (p = 0.874). Conclusions: The use of autologous fibular graft offers a better rate of fusion and subsidence compared to the titanium cage, as well as similar functional results at 3 months of follow-up. It represents an excellent treatment option for cervical spondylosis.

Introducción: la disectomía cervical anterior y fusión (ACDF) es el estándar de oro en el tratamiento de la patología compresiva cervical. La caja de titanio para artrodesis es el procedimiento más usado a nivel institucional. Se ha descrito una técnica con autoinjerto de peroné, con buenos resultados, menor morbilidad y menor costo. Objetivo: comparar la tasa de fusión, subsidencia y resultados clínicos funcionales posteriores a disectomía con caja de titanio y autoinjerto de peroné. Material y métodos: ensayo clínico con seguimiento a tres y seis meses en pacientes con diagnóstico de espondilosis cervical, candidatos a ACDF. Se formaron dos grupos: autoinjerto de peroné y caja de titanio. Se hizo evaluación funcional antes y después mediante la escala de discapacidad cervical, y evaluación de fusión y subsidencia radiográficas. Se usó estadística descriptiva, prueba exacta de Fisher, prueba t y ANOVA, estableciendo una p < 0.05. Resultados: se obtuvo una muestra de 20 pacientes con promedio de 56 años; hubo una tasa de fusión del 90% para autoinjerto de peroné y 30% para titanio (p = 0.02) a los tres meses. De los pacientes con autoinjerto de peroné, 10% presentaron subsidencia y un 70% con caja de titanio a los tres y seis meses (p = 0.02). No se encontró diferencia en los resultados funcionales a tres y seis meses de ambos procedimientos. Conclusiones: el uso de injerto autólogo de peroné ofrece mejor tasa de fusión y subsidencia en comparación con la caja de titanio, así como resultados funcionales similares a los tres meses. Es una excelente opción para tratar la espondilosis cervical.

Postsurgical Pyoderma Gangrenosum After Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Case Report.

CASE: A 61-year-old woman with lower back and radicular leg pain underwent minimally invasive spinal fusion at L5-S1. By postoperative day 6, she exhibited erythema, wound dehiscence, and necrotic changes. Although a necrotizing infection was initially suspected, multiple debridements and antibiotic therapy failed to improve her condition. The patient was eventually diagnosed with pyoderma gangrenosum (PG) and was managed with immunosuppressants and extended wound care. CONCLUSION: PG is a rare dermatosis that is often misdiagnosed, leading to inappropriate treatment, debridements, and additional complications. Prompt identification and multidisciplinary collaboration are key to preventing unnecessary interventions and achieving the best outcomes.

[Early-onset scoliosis: pathophysiology, diagnosis and treatment]. / Escoliosis de inicio temprano: fisiopatología, diagnóstico y tratamiento.

Early-onset scoliosis corresponds to a group of heterogeneous spinal conditions that present before 10 years of age with a curvature in the coronal plane of 10° or more. Regardless of the etiology, adequate control of the deformity is required to avoid cardiopulmonary deterioration and preserve quality and life expectancy. Diagnosis can be difficult and is usually incidental at a young age. To choose the best treatment, it is important to consider the patient's age, etiology, and rate of progression. Among the non-operative treatments, the most effective are the use of serial casts or brace, whose main objective is to stop the progression of the deformity and thus delay surgical treatment. Among the surgical treatments the distraction based systems and definitive arthrodesis have proven to be most effective. Early surgery leads to multiple complications, which is why, if feasible, non surgical management should be sought and fusion postponed till skeletal maturity. Due to the life-threatening risks associated with the deformity and treatment, it is important to educate the patient and family members about the importance of treatment adherence and follow-up.

La escoliosis de inicio temprano corresponde a un grupo heterogéneo de padecimientos de la columna, la cual se presenta antes de los 10 años de edad con una curvatura en el plano coronal de 10° o más. Independientemente de la etiología requiere un adecuado control de la deformidad para evitar deterioro cardiopulmonar, disminución en la calidad y expectativa de vida. El diagnóstico puede ser difícil y habitualmente se da de forma incidental. Para el tratamiento, es importante considerar la edad del paciente, la etiología y la velocidad de progresión. Dentro de los tratamientos conservadores, se encuentra el uso de yesos seriados o el corsé, cuyo objetivo principal es detener la progresión de la deformidad y con ello retrasar la cirugía a una edad mayor. Dentro de los tratamientos quirúrgicos se encuentran el uso de barras de crecimiento tradicionales, las barras de crecimiento magnéticas y la artrodesis definitiva. Se ha observado que realizarlos de forma temprana condiciona múltiples complicaciones por lo cual, de ser posible, debe optarse por el manejo no quirúrgico y postergar el tratamiento definitivo. Debido a los riesgos potencialmente mortales que conlleva la deformidad y el tratamiento, es de importancia educar al paciente y sus familiares sobre la importancia del apego y el seguimiento.

Comparative Analysis Between Isolated Posterior and Anteroposterior Approaches for Severe Scoliosis Treatment / Análise comparativa entre as abordagens cirúrgicas por via posterior isolada e por via anteroposterior para tratamento de escoliose severa

Abstract Objective To comparatively analyze isolated posterior and double surgical approaches for the treatment of severe scoliosis. Methods We retrospectively analyzed medical records of 32 patients with scoliosis angular value > 70° submitted to surgical treatment in a tertiary hospital between 2009 and 2019. These patients were divided into two groups: PV group with 17 patients submitted to arthrodesis by isolated posterior route (PV) and APV group with 15 patients approached anteriorly and posteriorly (APV). In the PV group, there were 16 female patients and 1 male, with a mean age of 16.86 years old. In the APV group, there were 10 female patients and 5 males, with a mean age of 17.71 years old. Cobb angles were measured by a single spinal surgeon manually on panoramic radiographs, orthostasis before and after surgery. Weight, pre- and postoperative height, and duration of the procedure were also evaluated. Results In the PV group, preoperative and postoperative Cobb angles, verified in the main curve, were 96.06 ± 8.45° and 52.27 ± 15.18°, with an average correction rate of 0.54 ± 0.16, respectively. In the APV group, these values were 83.12 ± 11.60° for preoperative Cobb angle, and 48.53 ± 10.76° postoperatively, with correction rate of the main curve of 0.58 ± 0.11. Conclusion The two forms of surgical approach for the treatment of severe scoliosis were astowed as to the rate of correction of the deformity. Therefore, isolated posterior access has an advantage over the double approach, based on shorter surgical time, shorter hospital stay, and less risk of complications

Resumo Objetivo Analisar comparativamente as abordagens cirúrgicas por via posterior isolada e dupla abordagem para tratamento da escoliose severa. Métodos Analisou-se retrospectivamente prontuários de 32 pacientes com escoliose de valor angular > 70° submetidos a tratamento cirúrgico em hospital terciário entre 2009 e 2019. Dividiu-se estes pacientes em dois grupos: Grupo VP com 17 pacientes submetidos a artrodese por via posterior isolada (VP) e Grupo VAP com 15 pacientes abordados por via anterior e posterior (VAP). O Grupo VP apresentou 16 pacientes do sexo feminino e 1 do masculino, com idade média de 16,86 anos. No grupo VAP, 10 pacientes do sexo feminino e 5 do masculino, com idade média de 17,71 anos. Os ângulos de Cobb foram mensurados por único cirurgião de coluna, manualmente, em radiografias panorâmicas, em ortostase no pré- e pós-operatório. Foram avaliados também peso, altura pré- e pós-operatória e duração do procedimento. Resultados No Grupo VP, o ângulo de Cobb pré-operatório e pós-operatório, verificados na curva principal, foram respectivamente 96,06° ± 8,45° e 52,27 ± 15,18°, apresentando taxa média de correção de 0,54 ± 0,16. No grupo VAP, esses valores foram de 83,12° ± 11,60° para o ângulo de Cobb pré-operatório, 48,53 ± 10,76, pós-operatório, com a taxa de correção da curva principal de 0,58 ± 0,11. Conclusão As duas formas de abordagem cirúrgica para tratamento de escoliose severa se equiparam quanto à taxa de correção da deformidade. Portanto, o acesso posterior isolado apresenta vantagem em relação a dupla via, baseado no menor tempo cirúrgico, menor tempo de internação e menos risco de complicações

Pain After Anterior Vertebral Body Tethering: Incidence, Risk Factors, and Timing.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To examine the incidence and risk factors for postoperative pain following anterior vertebral body tethering (AVBT) for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Up to 78% of patients with AIS report preoperative pain; it is the greatest patient concern surrounding surgery. Pain significantly decreases following posterior spinal fusion, but pain following AVBT is poorly understood. MATERIALS AND METHODS: We retrospectively reviewed 279 patients with a two-year follow-up after AVBT for AIS. We collected demographic, radiographic, and clinical data pertinent to postoperative pain at each time interval of preoperative and postoperative visits (6 wk, 6 mo, 1 y, and annually thereafter). RESULTS: Within our cohort, 68.1% of patients reported preoperative pain. Older age ( P =0.014) and greater proximal thoracic ( P =0.013) and main thoracic ( P =0.002) coronal curve magnitudes were associated with preoperative pain. Pain at any time point > 6 weeks postoperatively was reported in 41.6% of patients; it was associated with the female sex ( P =0.032), need for revision surgery ( P =0.019), and greater lateral displacement of the apical lumbar vertebrae ( P =0.028). The association between preoperative and postoperative pain trended toward significance ( P =0.07). At 6 months postoperatively, 91.8% had pain resolution; the same number remained pain-free at the time of last follow-up. The presence of a postoperative complication was associated with new-onset postoperative pain that resolved ( P =0.009). Only 8.2% had persistent pain, although no risk factors were found to be associated with persistent pain. CONCLUSION: In our cohort of 279 patients with a minimum 2-year follow-up after AVBT, 68.1% reported preoperative pain. Nearly 42% reported postoperative pain at any time point, but only 8.2% had persistent pain. Postoperative pain after AVBT was associated with female sex, revision surgery, and Lenke lumbar modifier. AVBT is associated with a significant reduction in pain, and few patients report long-term postoperative pain.

Are Clinical or Surgical Outcomes Different Based on Whether the Same Surgeon or Hospital System Performs the Spine Revision?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine the effects of discontinuity in care by changing surgeons, health systems, or increased time to revision surgery on revision spine fusion surgical outcomes and patient-reported outcomes. SUMMARY OF BACKGROUND INFORMATION: Patients undergoing revision spine fusion experience worse outcomes than those undergoing primary lumbar surgery. Those requiring complex revisions are often transferred to tertiary or quaternary referral centers under the assumption that those institutions may be more accustomed at performing those procedures. However, there remains a paucity of literature assessing the impact of discontinuity of care in revision spinal fusions. METHODS: Patients who underwent revision 1-3 level lumbar spine fusion 2011-2021 were grouped based on (1) revision performed by the index surgeon versus a different surgeon, (2) revision performed within the same versus different hospital system as the index procedure, and (3) length of time from index procedure. Multivariate regression for outcomes controlled for confounding differences. RESULTS: A total of 776 revision surgeries were included. An increased time interval between the index procedure and the revision surgery was predictive of a lower risk for subsequent revision procedure (odds ratio: 0.57, P =0.022). Revision surgeries performed by the same surgeon predicted a reduced length of hospital stay (ß: -0.14, P =0.001). Neither time to revision nor undergoing by the same surgeon or same practice predicted 90-day readmission rates. Patients are less likely to report meaningful improvement in Mental Component Score-12 or Physical Component Score-12 if revision surgery was performed at a different hospital system. CONCLUSIONS: Patients who have revision lumbar fusions have similar clinical outcomes regardless of whether their surgeon performed the index procedure. However, continuity of care with the same surgeon may reduce hospital length of stay and associated health care costs. The length of time between primary and revision surgery does not significantly impact patient-reported outcomes. LEVEL OF EVIDENCE: Level III.