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Objective: This pilot study was undertaken to evaluate the safety, performance, and usability of the Xvision-Spine (XVS) System (Augmedics, Arlington Heights, IL) during open spinal fixation procedures in patients requiring pedicle screw placement in the lumbosacral spine., Methods: The XVS System is an augmented reality head-mounted display (HMD) based on a computer navigation system designed to assist surgeons in accurately placing pedicle screws. It uses an HMD-mounted tracking camera to provide optical tracking technology, and provides the surgeon a translucent direct near-eye display of the navigated surgical instrument's location relative to the computed tomographic image. We report the preliminary results of a prospective series of all consecutive patients who underwent augmented reality-assisted pedicle screw placement in the lumbosacral vertebrae at 3 institutions. Clinical accuracy for each pedicle screw was graded with Gertzbein-Robbins scores by 2 independent and blinded neuroradiologists., Results: The 19 study participants included 8 men and 11 women with a mean age of 59.13 ± 12.09 and 59.91 ± 12.89 years, respectively. Seventeen procedures were successfully completed via the XVS System. Two procedures were not completed due to technical issues with the system's intraoperative scanner. A total of 86 screws were inserted. The accuracy of the XVS System was 97.7%., Conclusions: The XVS System's performance in accurate placement of pedicle screws in the lumbosacral vertebrae had an overall accuracy of 97.7%. These preliminary results were comparable to the accuracy of other manual computer-assisted navigation systems reported in the literature., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The purpose of the study was to identify preoperative parameters which are associated with height gain after corrective surgery for adolescent idiopathic scoliosis (AIS) and their use to preoperatively quantify the potential for height gain after AIS correction., Methods: Our study included 87 consecutive patients with AIS who underwent posterior fusion. Patients' height was measured the day before surgery and before their discharge. Demographic and radiologic variables were analyzed for predictability of height gain., Results: The mean height gain was 3.85 cm. We have found a statistically significant correlation between height gain and the following measures: preoperative thoracic curve, preoperative thoracolumbar curve, preoperative thoracic kyphosis, flexibility of the main thoracic and thoracolumbar curves, and number of fused levels (all P<0.05). Patients with Lenke type 1 and 2 had statistically less height gain compared with patients with Lenke type 3, 4, 6., Conclusion: Most of the scoliosis patients with Lenke type 1 and 2 will gain up to 3 cm after surgery while most of the patients with Lenke type 3, 4, 6 will gain more than 3 cm. Most patients with Lenke type 3, 4, 6 with a major curve of less than 60 degrees will gain up to 4 cm, while most of those with a major curve of more than 60 degrees will gain more than 4 cm. Patient with a positive thoracic sagittal modifier tend to have more height gain after surgery., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: A case report., Objective: Presentation of a patient diagnosed with perforation of the aorta by pedicle screws at levels T6 and T9 2 years after spinal fusion, who was advised no intervention. Review of other reported cases that did not undergo excision of the penetrating screws., Summary of Background Data: More than 30 cases of aortic penetration by pedicle screws were described. Gradual penetration of the screws into the aorta rarely causes symptoms other than backache. However, only two cases were treated conservatively., Methods: A 65-year-old female patient underwent spinal decompression and T5-T10 posterior fusion following a spinal abscess. Two years and 8 months postoperatively, she underwent a computed tomography scan for suspicion of spinal hardware infection, which showed T6 and T10 screws penetrating the thoracic aorta., Results: Due to high morbidity, the patient was not offered an operation for screw excision., Conclusion: This case report adds to the only two previous reports of patients who did not undergo revision of pedicle screws penetrating thoracic aorta., Level of Evidence: 5.

Purpose: To show the radiological results of adolescent idiopathic scoliosis (AIS) patients treated with posterior fusion using all-pedicle-screw construct with correction carried out using a convex rod reduction technique., Methods: Between October 2004 and June 2007, 42 AIS patients were treated with posterior fusion using all-pedicle-screw construct with correction done through the convex side. Two patients were lost to follow-up and were not included in the study. Forty patients had a minimum follow-up of 2 years. Patients were evaluated for the deformity correction in coronal and sagittal planes and for spinal balance., Results: The mean preoperative Cobb angle of the major curve and secondary minor curves was 60° and 41°, respectively. Immediate postoperative mean Cobb angle of the major curve and secondary minor curves was 17° and 13°, respectively. Postoperative 2-year average major curve loss of correction was 7 %. Postoperative 2-year average minor curve loss of correction was 5 %. Preoperative thoracic kyphosis of 28° was changed to 22° in 2-years follow-up. The loss of thoracic kyphosis was most noted in hyperkyphotic patients., Conclusions: The correction of AIS by convex-sided pedicular screws yields a coronal correction comparable to what is described in the literature for segmental concave-sided screws.

We carried out a retrospective analysis to investigate the prevalence of superior mesentery artery syndrome (SMAS) in children who underwent scoliosis surgical repair at our hospital between 1998 and 2006 and to reassess the syndrome's pathogenesis. Among 133 consecutive pediatric patients, two cases were identified, both 13-year-old girls with idiopathic scoliosis, undergoing surgery using third-generation instrumentation systems. Conservative management achieved resolution of the symptoms without recurrence. SMAS prevalence in our series was 1.6%. SMAS might occur after derotation and translation forces application, and even with nonextreme corrections. Low BMI and significant weight loss at presentation are not mandatory.

Objectives: To evaluate long-term treatment outcome of patients with infected posterior lumbar interbody fusion (PLIF) managed with surgical debridement and or prolonged antiobiotic treatment without removal of the interbody cages., Methods: Between 1996 and 1999, 8 out of 111 patients who underwent PLIF were diagnosed with deep wound infection (7.2%). All infected patients were clinically followed for at least 2 years after completion of the antibiotic treatment. Longer follow-up of at least 6 years duration was performed by a telephone interview., Results: Six patients were managed with surgical debridement, wound irrigation, and primary closure of the wound. None of the patients required removal of the instrumentation. In 2 patients, the PLIF cages were repositioned in the face of infection. All 8 patients received 4 to 6 weeks of intravenous antibiotic therapy followed by another 6 to 9 weeks of oral antibiotic administration. At 2-year follow-up, no clinical or laboratory signs of recurrent infection were evident. Four of the 8 patients reported improved clinical status compared with their prefusion status. At 6-year follow-up, 3 patients had minimal disability according to the Oswestry Disability Index and 2 patients had moderate disability with residual leg pain., Conclusions: In cases of postoperative deep wound infection after PLIF with cages, removal of the interbody implants is not necessary. Treatment is composed of prolonged antibiotic therapy guided by antimicrobial susceptibility of the isolated bacteria and supplemented with extensive surgical debridement if needed.

To determine the effect of adding pedicle screws at the level of a burst fracture (intermediate screws) on the stiffness of a short segment pedicle fixation, an in vitro biomechanical study was carried out. Six fresh-frozen pig lumbar spine specimens were used. The flexibility of the intact specimens was examined in flexion, extension, lateral bending, and torsion. An unstable burst fracture model was created by the dropped-mass technique. The unstable spine specimens were instrumented with pedicle screws. The flexibility was tested again with and without intermediate screws. The addition of intermediate screws provided a smaller range of motion in flexion-extension (P<0.001), torsion (P<0.001), and lateral bending (P=0.014). The slopes of the load displacement curves increased in flexion (P<0.001), extension (P=0.003), lateral bending (P=0.003), and torsion (P=0.006), signifying a decrease in flexibility. The addition of intermediate screws at the level of a burst fracture significantly increases the stiffness of a short segment pedicular fixation.

Study Design: A retrospective evaluation of anterior instrumentation of the vertebral bodies in the thoracolumbar spine., Objective: To evaluate the possibility of preserving the segmental vessels following anterior instrumentation., Summary of Background Data: Occlusion of the segmental vessels, routinely performed during anterior spine instrumentation, might cause neurologic injury secondary to cord ischemia., Methods: The medical data of 29 patients following anterior instrumentation of the vertebral bodies at the thoracolumbar spine were reviewed. All underwent surgery recently when we decided to preserve the segmental vessels whenever possible. We sought the reasons that enabled us to do so regarding age, gender, underlying pathology, surgical technique, operation duration, instrumentation type and size, and location in the vertebral body., Results: In only 7 patients, fused between T10 and L5, were we able to preserve the segmental vessels. All were instrumented with one 6.25-7-mm wide screw in each vertebral body connected by one rod, approximately half the screws above and half below the segmental vessels. In 22 patients, we were unable to preserve the vessels due to the need to insert 2 screws or a large threaded wide vertebral cage into each vertebra., Conclusions: There is adequate space anteriorly in the vertebral body, above and below the segmental vessels, for the insertion of one screw, even with staples.

Study Design: A retrospective study to detect patients with cement leakage into the disc space following vertebroplasty., Objective: To determine the frequency, causes, and clinical significance of cement leakage into the disc space., Summary of Background Data: Much has been written about cement leakage into the epidural space following vertebroplasty but only little about intradiscal leakage., Methods: A total of 66 patients with 1 cemented osteoporotic, fractured vertebra between T5 and L5 were followed for at least 2 years. Two of the senior authors (Y.M. and A.P.) evaluated independently cement leakage into the disc space, possible causes were investigated, and the clinical results were evaluated according to patient self-assessment., Results: Detected in 27 patients, cement leakage into the disc space did not negatively affect patient satisfaction with the procedure. In 7 of these patients, leakage occurred through an intravertebral vacuum cleft and, in 8, through a perforation of the endplate created by the needle tip. In only 2 patients was cement found to cross the height of the vertebral body and leak into the contralateral disc., Conclusions: Apart from iatrogenic endplate perforation, cement extravasation into the disc space was always found to occur through the fractured endplate or a vacuum cleft. Placing the needle tip far from the fractured endplate and using more solid cement appear to decrease the risk of leakage.

Objectives: To determine the safety of pedicle screw fixation in thoracic spine deformity correction., Methods: One hundred twelve pedicle screws were surgically placed in 25 patients with degenerative, posttraumatic, and Scheuermann kyphosis and idiopathic and neuromuscular scoliosis. Screw position was evaluated using intraoperative and postoperative radiographs and thin-slice computed tomography., Results: Of the total 112 thoracic pedicle screws that were inserted, 98 screws (87.5%) were fully contained within the cortical boundaries of the pedicle. When comparing proximal screws (T1-T8) with distal screws (T9-T12) and convex placed screws with concave ones, a statistically significant difference in screw placement was evident (P < 0.05). More misplaced screws were seen proximally and on the concave side. Of the 14 malpositioned screws, 2 (1.8%) demonstrated aortic abutment. There were no neurologic deficits, vascular injuries, or mechanical failures recorded., Conclusions: Placement of thoracic pedicle screws is both feasible and safe.

Object: The authors retrospectively evaluated the safety and efficacy of a decompression and fixation technique in the treatment of patients with multilevel cervical spondylotic myelopathy (CSM)., Methods: The authors describe the "hybrid decompression fixation" technique, a procedure involving a combination of corpectomies and discectomies to preserve a vertebra intact within the area of the decompression, thus augmenting mechanical stability. The authors retrospectively reviewed outcomes in 25 patients with multilevel CSM in whom the hybrid technique was performed between 1999 and 2003. Twelve patients underwent a single-level corpectomy and three-level discectomies. In 13 patients a two-level corpectomy and adjacent four-level discectomies were conducted, leaving a vertebral bridge the middle. All patients underwent fusion involving placement of disc and vertebral body cages filled with autogenous local bone and supplemental anterior dynamic plate fixation. The mean preoperative Nurick grade was 3 and improvement in status was reflected by a postoperative decrease to 2.6 (p < 0.05). In one patient neurological deterioration was demonstrated. At the end of the follow-up period (mean 29 months) radiography revealed evidence of osseous fusion in 24 patients; fusion status could not be determined in one patient. No evidence of late-onset instrumentation-related failure was observed in any of the 25 patients., Conclusions: The authors found the hybrid technique to be safe and efficient for anterior decompression in patients with multilevel CSM. The use of this technique obviates the need for staged circumferential procedures.

Transforaminal interbody fusion (TLIF) has gained increased popularity over recent decades and is being employed as an established surgical treatment for several lumbar spine pathologies, including degenerative spondylosis, spondylolisthesis, infection, tumor and some cases of recurrent disc herniation. Despite the seemingly acceptable fusion rates after TLIF (up to 94%), the literature is still limited regarding the specific location and quality of fusion inside the fixated segment. In this single-institution, retrospective population-based study, we evaluated all post-operative computed tomography (CT) of patients who underwent TLIF surgery at a medium-sized medical center between 2010 and 2020. All CT studies were performed at a minimum of 1 year following the surgery, with a median of 2 years. Each CT study was evaluated for post-operative fusion, specifically in the posterolateral and intervertebral body areas. The fusion's quality was determined and classified in each area according to Lee's criteria, as follows: (1) definitive fusion: definitive bony trabecular bridging across the graft host interface; (2) probable fusion: no definitive bony trabecular crossing but with no gap at the graft host interface; (3) possible arthrosis: no bony trabecular crossing with identifiable gap at the graft host interface; (4) definite pseudarthrosis: no traversing trabecular bone with definitive gap. A total of 48 patients were included in this study. The median age was 55.6 years (SD ± 15.4). The median time from surgery to post-operative CT was 2 years (range: 1–10). Full definitive fusion in both posterolateral and intervertebral areas was observed in 48% of patients, and 92% showed definitive fusion in at least one area (either posterolateral or intervertebral body area). When comparing the posterolateral and the intervertebral area fusion rates, a significantly higher definitive fusion rate was observed in the posterolateral area as compared to the intervertebral body area in the long term follow-up (92% vs. 52%, p < 0.001). In the multivariable analysis, accounting for several confounding factors, including the number of fixated segments and cage size, the results remained statistically significant (p = 0.048). In conclusion, a significantly higher definitive fusion rate at the posterolateral area compared to the intervertebral body area following TLIF surgery was found. Surgeons are encouraged to employ bone augmentation material in the posterolateral area (as the primary site of fusion) when performing TLIF surgery. [ABSTRACT FROM AUTHOR]

Surgery in adolescent idiopathic scoliosis (AIS) is a major operative intervention where 10-12 vertebrae are instrumented and fused. A smaller motion preserving surgery would be more desirable for these otherwise healthy adolescents. The ApiFix® system is a novel less invasive short segment pedicle screw based instrumentation inserted around the apex of the main curve. The system has a ratchet mechanism that enables gradual postoperative device elongation and curve correction. The ratchet is activated by performing specific spinal exercises. The unique features of the device allow curve correction without fusion. The system which has a CE approval was employed in adolescents with main thoracic curves. More than a dozen of ApiFix surgeries have been performed so far. The preoperative Cobb angle was 45° ± 8, and 25° ± 8 at final follow up. The following is a report on three adolescent females aged 13-16 years with curves between 43°-53° and Risser sign of 1-4 who underwent surgery with ApiFix®. Two pedicle screws were inserted around the curve apex and the ratchet based device with polyaxial ring connectors was attached to the screws. No fusion attempt was made. Operative time was around one hour. Two weeks after surgery the patients were instructed to perform Schroth like daily exercises with the aim of rod elongation and gradual curve correction. Patients were followed between 6 months to 2 years. Curves were reduced and maintained between 22- 33°. Patients were pain free and were able to perform their spinal exercises. Postoperative gradual elongation of the device was observed. No screw loosening or rod breakage were observed. No adding on or curve progression was seen. Three factors may contribute to the ApiFix® success: polyaxial connections that prevent mechanical failure, gradual curve correction by spinal motion and spinal growth modulation. The ApiFix® system allows managing moderate AIS with a simple and minor surgical intervention. Recovery is rapid with negligible motion loss. It allows gradual and safe curve correction with high patient satisfaction. It may also serve as an internal brace for AIS. [ABSTRACT FROM AUTHOR]

Background It is common practice for patients to be admitted to the intensive care unit following scoliosis surgery, because of the prolonged anesthesia, the need for efficient pain control and the known immediate postoperative complications. However, this may be unnecessary in many patients. Purpose We aimed to establish possible associations between pre- and perioperative parameters and early postoperative complication rates, in particular the need for prolonged mechanical ventilation (>1 day), and the presence of major complications in children undergoing primary spinal fusion by thoracolumbar spine instrumentation. Methods We conducted a retrospective review of children undergoing primary scoliosis surgery at a university-affiliated general hospital from 1998 to 2008. Results Surgical approaches were as follows: anterior spinal fusion, posterior spinal fusion, and combined anterior and posterior fusion. Prior to mid-2005, anesthesia included morphine; thereafter, remifentanil was used. Major complications correlated significantly with neuromuscular scoliosis ( NMS) ( OR, 4.94; 95% CI, 1.02-24.05), comorbidity conditions ( OR, 3.47; 95% CI, 1.16-10.42), and anterior or combined fusion ( OR, 7.81; 95% CI, 2.12-28.57). Late extubation correlated significantly with NMS ( OR, 31.25; 95% CI, 1.06-100.00) and morphine use during anesthesia ( OR, 17.91; 95% CI, 1.44-222.9). Conclusions Relatively young, healthy idiopathic scoliosis children receiving intraoperative remifentanil sedation and undergoing posterior fusion can be successfully managed in regular wards in the immediate postoperative period. However, intensive care unit admission should be considered in NMS patients, patients with comorbidity conditions, those undergoing anterior or combined spinal fusion, and patients whose anesthesia involves long-acting opioids. [ABSTRACT FROM AUTHOR]