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Purpose: Surgical treatment of adolescent idiopathic scoliosis (AIS) requires a careful choice of fusion levels. The usual recommendation for the selection of the lowest instrumented vertebra (LIV) for double major or thoracolumbar/lumbar (TL/L) curves falls on L3 or L4. The aim of the present study is to assess if the spinal fusion with LIV selection of L3 or L4 in AIS patients has a clinical or radiological impact in terms of degenerative disc disease (DDD) in distal unfused segments at long-term follow-up. Methods: A systematic search of electronic databases from eligible articles was conducted. Only studies regarding long-term follow-up of AIS patients treated with spinal fusion were included. Clinical and radiographic outcomes were extracted and summarized. Meta-analysis on long-term follow-up MRI studies was performed. pvalue < 0.05 was considered significant. Results: Fourteen studies were included, for a total of 1264 patients. Clinical assessment of included patients showed a slight tendency to have worse clinical outcomes if spinal fusion is extended to L4 rather than L3. Despite that, meta-analysis could not be performed on clinical parameters because of heterogeneity of evaluated PROMs in included studies. Magnetic resonance imaging (MRI) evaluation at long-term follow-up showed no significant difference in terms of disc degeneration rate at overall meta-analysis (p= 0.916) between patients fused to L3 and L4. Conclusion: The LIV selection of L3 rather than L4, according to current literature, does not prevent disc degeneration in distal unfused segments over the long term. Long-term studies of patients treated with contemporary spinal instrumentation are needed.

Study design: Retrospective cohort study. Purpose: to assess the efficacy and safety of Hi-PoAD technique in patients with a major thoracic curve > 90°, < 25% of flexibility and deformity spread over more than five vertebral levels. Methods: retrospective review of AIS patients with a major thoracic curve (Lenke 1–2–3) > 90°, with < 25% of flexibility and deformity spread over more than five vertebral levels. All were treated via the Hi-PoAD technique. Radiographic and clinical score data were collected pre-operatively, operatively, at 1 year, 2 years and at last follow-up (2 years minimum). Results: 19 patients were enrolled. A 65.0% correction rate of the main curve was achieved, from 101.9° to 35.7° (p< 0.001). The AVR reduced from 3.3 to 1.3. The C7PL/CSVL reduced from 1.5 to 0.9 cm (p= 0.013). Trunk Height increased from 31.1 to 37.0 cm (p< 0.001). At the final follow-up no significant changes, except from an improvement in C7PL/CSVL (from 0.9 cm to 0.6 cm; p= 0.017). SRS-22 increased in all patients, from 2.1 to 3.9 at 1 year of follow-up (p< 0.001). 3 patients had a transient drop of MEP and SEP during maneuver and were managed with temporary rods and a second surgery after 5 days. 2 of these 3 cases (66.7%) had a Total-Deformity Angular Ratio (T-DAR) > 25; conversely, among patients who had a one-stage procedure, only 1 (6.2%) had a T-DAR > 25 (p= 0.008). Conclusions: The Hi-PoAD technique proved to be a valid alternative for the treatment of severe, rigid AIS involving more than 5 vertebral bodies. Study design: Retrospective comparative cohort study. Level of evidence: III.

Purpose: To retrospectively evaluate a cohort of athletically active patients who underwent surgery for adolescent idiopathic scoliosis (AIS), and to determine which clinical, surgical and anthropometric variables influenced their return to sport after surgery. Methods: 112 adolescents who underwent high-density posterior fusion for AIS by a single surgeon were analyzed for clinical, surgical and demographic predictors of return to presurgical physical activity levels. Data were retrospectively collected by charts and X-rays analysis and patients interviews. Results: Preoperative main curve Cobb was 64.4 ± 14.12° and obtained correction was 70.0 ± 12.5%. Included patients played many different sports (Table 4), most of all ballet (44/112, 39.2%), swimming (40/112, 35.7%) and gymnastics (32/112, 28.6%). At an average of 50.3 months follow-up, 76 (67.8%) patients returned to sports (RTS) at an equal or higher level than preoperatively. Younger age, lower Lenke curve type and lower main curve Cobb were significantly associated with RTS. As for RTS timing, patients who returned within the first 6 months were younger, with a higher Lenke and a less severe main curve, a more distal UIV and a more proximal LIV. No complications related to RTS were registered. Conclusion: In conclusion, patients with adolescent idiopathic scoliosis safely returned to physical activity after surgery. Younger age, higher Lenke type and lower main curve severity predicted a quicker return to sport. However, prospective studies are needed to confirm these findings.

Background: Adolescent idiopathic scoliosis (AIS) is a frequent disorder. Since patients with AIS are typically as active as age-matched controls and post-operative reduction in physical activity has detrimental effects on their well-being, return to sport (RTS) is an important perioperative concern. Aim of the present study is to review the literature concerning return to sport after spinal fusion for AIS. Methods: This work was carried out in accordance with Preferential Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The search was carried out in December 2020. Only peer-reviewed randomized controlled trials (RCTs), retrospective studies (RS), retrospective case series (RCS) and perspective cohort studies (PCS) were considered for inclusion. Results: Six studies were included; only one of them was prospective. All the authors reported a time to RTS ranging between 6 and 18 months. Between 28 and 36.6% of all patients changed sport, choosing lower impact activities, mostly due to loss of flexibility of the spine. No complications due to return to play were noted. Conclusion: According to current evidence, patients who received spinal arthrodesis for AIS can safely return to any sport, even those that require extreme levels of spinal and pelvic movements such as gymnastics and golf. As there is little evidence, however, of the spinal loading that occurs during such movements, there is a lack of scientific evidence-based recommendations or guidelines surgeons and other health care providers can follow. Prospective comparative studies are needed to investigate these biomechanical and clinical issues. Level of evidence: Level III.

Study Design Metanalysis.Objective Surgical site infections (SSI) is one of the commonest postoperative adverse events after spine surgery. Frailty has been described as a valuable summary risk indicator for SSI in spine surgery. The aim of this metanalysis is to evaluate the influence of frailty on postoperative SSI in this cohort and provide hints on which index can predict the risk of SSI.Methods Papers describing the postoperative SSI rate in adult degenerative spine disease or adult spine deformity patients with varying degrees of frailty were included in the analysis. The SSI rate in different grades of frailty was considered for outcome measure. Meta-analysis was performed on studies in whom data regarding patients with different levels of frailty and occurrence of postoperative SSI could be pooled. P< .05 was considered significant.Results 16 studies were included. The frailty prevalence measured using mFI-11 ranged from 3% to 17.9%, these values were inferior to those measured with mFI-5. Significant difference was found between frail and non-frail patients in postoperative SSI rate at metanalysis (z = 5.9547, P< .0001 for mFI-5 and z = 3.8334, P= .0001 for mFI-11).Conclusion This is the first meta-analysis to specifically investigate the impact of frailty, on occurrence of SSI. We found a relevant statistical difference between frail and non-frail patients in SSI occurrence rate. This is a relevant finding, as the ageing of population increases alongside with spine surgery procedures, a better understanding of risk factors may advance our ability to treat patients while minimizing the occurrence of SSI.

Study Design Retrospective cohort study.Objectives To assess if pedicle dysplasia is present in proximal thoracic (PT), both structural and nonstructural, compared to main thoracic (MT) curves; and to assess if it is predictive of radiographic outcomes at minimum 2 years of follow-up.Methods A retrospective review of surgically-treated Adolescent Idiopathic Scoliosis (AIS) patients with Lenke 1-2-3-4 curves was performed. On preoperative CT-scan, at the apical vertebra, pedicle width on the concavity (PWc) and on the convexity (PWv) and Pedicle Dysplasia Index (PDI, defined as PWc/PWv) were measured. Preoperative and last follow-up (at least 2 years) x-rays were reviewed.Results 104 patients meeting the inclusion criteria were divided into Structural-PT (S-PT) and Nonstructural-PT (NS-PT) groups based on Lenke criteria. PWc (P< .001). And PDI (P< .001 for S-PT, P= .004 for NS-PT) were significantly smaller in the PT than in MT curves for both groups. PT-PWc significantly correlated with follow-up PT Cobb for both groups (P< .001 and P= .015 respectively). PT-PDI significantly correlated with follow-up PT-Cobb (P< .001), CA (P< .040) and T1 tilt (P< .002), only for NS-PT group. NS-PT patients with PWc PT <1 mm had higher RSHD (P= .021) and T1 tilt (P= .025) at follow-up. NS-PT patients with PDI PT <.3 had higher RSHD (P< .001), CA (P= .002) and T1 tilt (P= .003) at follow-up.Conclusion S-PT and NS-PT curves show significant pedicle dysplasia on the concavity. Pedicle dysplasia significantly correlated with shoulder balance at follow-up, for NS-PT patterns. Patients with a PWc <1 mm or PDI <.30 are at particular risk of postoperative shoulder imbalance.