Search

Pierce D Nunley,1 Vikas V Patel,2 Douglas G Orndorff,3 William F Lavelle,4 Jon E Block,5 Fred H Geisler6 1Spine Institute of Louisiana, Shreveport, LA, 2The Spine Center, University of Colorado Hospital, Denver, CO, 3Spine Colorado, Mercy Regional Hospital, Durango, CO, 4Upstate Bone and Joint Center, East Syracuse, NY, 5Independent Consultant, San Francisco, CA, 6Independent Consultant, Chicago, IL, USA Background: Lumbar spinal stenosis is the most common indication for spine surgery in older adults. Interspinous process decompression (IPD) using a stand-alone spacer that functions as an extension blocker offers a minimally invasive treatment option for intermittent neurogenic claudication associated with spinal stenosis.Methods: This study evaluated the 5-year clinical outcomes for IPD (Superion®) from a randomized controlled US Food and Drug Administration (FDA) noninferiority trial. Outcomes included Zurich Claudication Questionnaire (ZCQ) symptom severity (ss), physical function (pf), and patient satisfaction (ps) subdomains, leg and back pain visual analog scale (VAS), and Oswestry Disability Index (ODI).Results: At 5 years, 84% of patients (74 of 88) demonstrated clinical success on at least two of three ZCQ domains. Individual ZCQ domain success rates were 75% (66 of 88), 81% (71 of 88), and 90% (79 of 88) for ZCQss, ZCQpf, and ZCQps, respectively. Leg and back pain success rates were 80% (68 of 85) and 65% (55 of 85), respectively, and the success rate for ODI was 65% (57 of 88). Percentage improvements over baseline were 42%, 39%, 75%, 66%, and 58% for ZCQss, ZCQpf, leg and back pain VAS, and ODI, respectively (all P1.0; all P

Background: The aging spine often presents multifaceted surgical challenges for the surgeon because it can directly and indirectly impact a patient's spinal alignment and quality of life. Elderly and osteoporotic patients are predisposed to progressive spinal deformities and potential neurologic compromise and surgical management can be difficult because these patients often present with greater frailty., Methods: This was a literature review of spinal alignment changes, preoperative considerations, and spinal alignment considerations for surgical strategies., Results: Many factors impact spinal alignment as we age including lumbar lordosis flexibility, hip flexion, deformity, and osteoporosis. Preoperative considerations are required to assess the patient's overall health, bone mineral density, and osteoporosis medications. Careful radiographic assessment of the spinopelvic parameters using various classification/scoring systems provide the surgeon with goals for surgical treatment. An individualized surgical strategy can be planned for the patient including extent of surgery, surgical approach, extent of the constructs, fixation techniques, vertebral augmentation, ligamentous augmentation, and staging surgery., Conclusions: Surgical treatment should only be considered after a thorough assessment of the patient's health, deformity, bone quality and corresponding age matched alignment goals. An individualized treatment approach is often required to tackle the deformity and minimize the risk of hardware related complications and pseudarthrosis. Anabolic agents offer a promising benefit in this patient population by directly addressing and improving their bone quality and mineral density preoperatively and postoperatively., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Competing Interests: Declaration of Conflicting Interests : William Lavelle has stock ownership in Curiteva Spine, a sponsor of this special issue.

Introduction: Anterior cervical decompression and fusion (ACDF) is the standard surgical procedure for cervical radiculopathy and myelopathy, although ACDF includes risks of adjacent segment disease (ASD) and subsequent revision procedures. Various interbody cage, plate, and screw options can be utilized. Stand-alone devices were designed to overcome undesired complications of hardware prominence and associated dysphagia, soft tissue violation, and adjacent level encroachment. Implants include biomechanical structural support (cage) composed of various materials (polyetheretherketone (PEEK)/titanium) and integral fixation (screws/blades). The purpose was to compare intraoperative, short- and long-term outcomes of revision ACDF using a stand-alone implant (ACDF-ZP group) versus traditional interbody PEEK cage, titanium plate, and screw instrumentation (ACDF-CP group)., Methods: This was a retrospective, cohort study reviewing charts of patients who underwent revision ACDF. The primary outcome measure was the incidence of postoperative dysphagia. Secondary outcomes included intraoperative, short-term, and long-term outcomes and complications., Results: Sixty-one patients were included (ACDF-ZP group = 50; ACDF-CP group = 11). In-hospital incidence of dysphagia was significantly less in the ACDF-CP group (P = 0.041). Thrity-one (62.0%) of the ACDF-ZP group reported dysphagia postoperatively, half resolved by 6 weeks, and two persisted for more than 6 months. Five (45.5%) of the ACDF-CP group reported dysphagia with most resolving within 6 weeks. There were no statistically significant differences between groups in short- or long-term complications, dysphonia, or reoperation rates. No statistical significance was seen in blood loss, operative time, hospital stay, local and global alignment, or cage subsidence., Conclusion: Rates of dysphagia were comparable between groups at short and long-term follow-up, despite a greater incidence of postoperative dysphagia in the ACDF-ZP group. All complications and occurrences of cage subsidence were observed in the ACDF-ZP group, which may be attributed to the larger sample size. Given these findings, zero-profile stand-alone implants and traditional interbody PEEK cage, titanium plate, and screw instrumentation appear to be both safe and effective options for revision ACDF., Competing Interests: The authors have declared financial relationships, which are detailed in the next section., (Copyright © 2023, Alhammoud et al.)

Purpose: Evaluate the ability of pre-contoured rods to induce thoracic kyphosis (TK) in human cadaveric spines and determine the effectiveness of sequential surgical adolescent idiopathic scoliosis (AIS) release procedures., Methods: Six thoracolumbar (T3-L2) spine specimens were instrumented with pedicle screws bilaterally (T4-T12). Over correction using pre-contoured rods was performed for intact condition and Cobb angle was measured. Rod radius of curvature (RoC) was measured pre- and post-reduction. The process was repeated following sequential release procedures of (1) interspinous and supraspinous ligaments (ISL); (2) ligamentum flavum; (3) Ponte osteotomy; (4) posterior longitudinal ligament (PLL); and (5) transforaminal discectomy. Cobb measurements determined the effective contribution of release on TK and RoC data displayed effects of reduction to the rods., Results: The intact TK (T4-12) was 38.0° and increased to 51.7° with rod reduction and over correction. Each release resulted in 5°-7°of additional kyphosis; the largest releases were ISL and PLL. All releases resulted in significant increases in kyphosis compared to intact with rod reduction and over correction. Regionally, kyphosis increased ∼2° for each region following successive releases. Comparing RoC before and after reduction showed significant 6° loss in rod curvature independent of release type., Conclusion: Kyphosis increased in the thoracic spine using pre-contoured and over corrected rods. Subsequent posterior releases provided a substantial, meaningful clinical change in the ability to induce additional kyphosis. Regardless of the number of releases, the ability of the rods to induce and over correct kyphosis was reduced following reduction., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Shi, Ordway, Sun, Albanese and Lavelle.)

Purpose: The Morbidity and Mortality (M&M) report of the Scoliosis Research Society (SRS) has been collected since 1965 and since 1968 submission of complications has been required of all members. Since 2009, the SRS has collected information on death, blindness, and neurological deficit, with acute infection being added in 2012 and unintentional return to the operating room (OR) being added in 2017. In this report, we use the most recent data submitted to the SRS M&M database to determine the rate of neurological deficit, blindness, acute infection, unintentional return to the OR, and death, while also comparing this information to previous reports., Methods: The SRS M&M database was queried for all cases from 2013 to 2020. The rates of death, vision loss, neurological deficit, acute infection, and unintentional return to the OR were then calculated and analyzed. The rates were compared to previously published data if available. Differences in complication rates between years were analyzed with Poisson regression with significance set at α = 0.05., Results: The total number of cases submitted per year varied with a maximum of 49,615 in 2018 and a minimum of 40,464 in 2020. The overall reported complication rate from 2013 to 2020 was 2.86%. The overall mortality rate ranged from 0.09% in 2018 to 0.14% in 2015. The number of patients with visual impairment ranged from 4 to 13 between 2013 and 2015 (no data on visual impairment were collected after 2015). The overall infection rate varied from 0.95 in 2020 to 1.30% in 2015. When the infection rate was analyzed based on spinal deformity group, the neuromuscular scoliosis group consistently had the highest infection rate ranging from 3.24 to 3.94%. The overall neurological deficit rate ranged from 0.74 to 0.94%, with the congenital kyphosis and dysplastic spondylolisthesis groups having the highest rates. The rates of unintentional return to the OR ranged from 1.60 to 1.79%. Multiple groups showed a statistically significant decreasing trend for infection, return to the operating room, neurologic deficit, and death., Conclusions: Neuromuscular scoliosis had the highest infection rate among all spinal deformity groups. Congenital kyphosis and dysplastic spondylolisthesis had the highest rate of neurological deficit postoperatively. This is similar to previously published data. Contrary to previous reports, neuromuscular scoliosis did not have the highest annual death rate. Multiple groups showed a statistically significant decreasing trend in complication rates during the reporting period, with only mortality in degenerative spondylolisthesis significantly trending upwards., Level of Evidence: Level III., (© 2022. The Author(s).)

Purpose: To compare the operative implications between adolescent idiopathic scoliosis patients (10-18 years) and young adult idiopathic scoliosis (YAdIS) patients (19-30 years)., Methods: This was a retrospective study querying the SRS M&M database for AIS (10-18 years) and YAdIS (19-30 years) cases enrolled between 2009 and 2015. Demographic and surgical parameters (Lenke curve classification, preoperative curve magnitude, approach type, osteotomy type, estimated blood volume (EBV), levels of fusion and ASA scores) were evaluated and compared between groups., Results: N = 690: AIS (n = 607) and YAdIS (n = 83). Lenke curve classification distributions in AIS and YAdIS cases were: main thoracic, 293 vs. 34; double thoracic, 42 vs. 5; double major, 159 vs. 15; triple major, 15 vs. 5; thoracolumbar, 85 vs. 17; and lumbar, 5 vs. 6, respectively. Patients with a coronal curve > 90° were significantly greater in YAdIS vs. AIS patients, p = 0.008. Anterior and combined surgery rates were significantly higher in YAdIS, p = 0.028. Two-staged surgeries were significantly higher for YAdIS cohort, p = 0.01. Osteotomy rate was similar between groups, p = 0.42, but proportion of 3-column osteotomies was significantly higher for YAdIS, p < 0.001. ASA (severe systemic disease and some functional limitation) score 3 patients' rate was higher in YAdIS cohort, p = 0.01. EBV was significantly higher in YAdIS, p = 0.01. Average number of levels of fusions between cohorts was not significant, p = 0.87., Conclusions: The operative implications observed with young adult idiopathic scoliosis patients may potentially result in more complex surgical procedures and operative-associated complications than their adolescent counterparts. Further studies are required and should include a larger number of cases, be prospective in nature and verifiable data., Level of Evidence: II., (© 2022. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background: Proximal junctional fractures (PJFr) can be a catastrophic complication associated with adult spinal deformity surgery. Osteoporosis can be a major risk factor for the cause of PJFr. Recent studies suggest using surrogate computed tomography (CT) scans in place of spinal dual-energy x-ray absorptiometry (DEXA) scores for bone mineral density (BMD). Investigate the feasibility of using preoperative CT based bone mineral density at upper instrumented vertebrae (UIV) and one level proximally (UIV+1) and distally (UIV-1) to predict the possibility of PJFr risk., Methods: Retrospective two-academic center case-controlled study, reviewed consecutive adult spinal deformity surgeries; included constructs encompassing at least five fusion levels and fusions to pelvis. Examined demographic, surgical, and radiographic data preoperatively, postoperatively, and final follow-up. Formed groups based on type of proximal junctional deformity (PJD): Control (no PJD), proximal junctional kyphosis (PJK) and PJFr. Preoperative CT BMD values measured in Hounsfield units (HU) for sagittal and axial planes at UIV, UIV+1, and UIV-1 and compared between groups., Results: N=92 patients. Preoperative CT scan BMD values were significantly lower in PJFr vs. control at: UIV+1 in sagittal (p=0.007), axial (p=0.02) planes; UIV sagittal (p=0.04) and axial (p=0.03) planes; and UIV-1 sagittal (p=0.05) plane. Similarly, lower CT scan BMD values noted in PJFr vs. PJK at: UIV+1 in sagittal (p=0.04) and axial (p=0.03) planes. Trend seen with lower CT scan BMD values at UIV+1 level in PJFr vs. PJK in sagittal (p=0.12) and axial (p=0.10) planes. Preoperative global sagittal imbalance measurements significantly lower in control, but comparable between PJK and PJFr., Conclusions: Higher preoperative global sagittal imbalance with lower preoperative CT BMD values at UIV and UIV+1 vertebral body may increase the risk of proximal junctional fractures after adult spine deformity surgery. Proximal junctional hooks may supplement the pathogenesis. Readers should note the small sample size. Level of Evidence: 3., Competing Interests: This study was performed with the approval of SUNY Upstate Medical University IRB and The Ohio State University Wexner Medical Center IRB and in accordance with the boards’ regulations. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

Purpose: To investigate the impact of intraoperative blood transfusion on outcomes in patients who had major thoracic and lumber posterior spine instrumentation surgery., Methods: Retrospective study included patients who underwent major spine surgery between 2013 and 2017. Patients' demographics, surgical charts, anesthesia charts, discharge charts and follow-up outpatient charts were reviewed. Data collection included: age, gender, BMI, Charlson Co-morbidity Index (CCI) scores, American Society of Anesthesiologists (ASA) scores, amount of estimated blood loss [% estimated blood volume (%EBV)], amount of blood transfused during surgery and post-surgery before discharge, number of fusion levels, pre- and postoperative hemoglobin (Hb) levels, and length of hospital stay. Also collected in-hospital postoperative complications (cardiovascular, pulmonary, infections and deaths). Patients' postoperative intubation status data documented. Reviewed follow-up charts to document any complications., Results: Sample size = 289; No transfusion = 92; transfusion = 197. Transfused patients were significantly older, p < 0.001, higher average BMIs (p < 0.001); ASA scores (p < 0.001); CCI scores (p < 0.001), mean postoperative Hb level (p = 0.004), average intraoperative %EBV loss (p < 0.001), longer hospital stays (p = 0.003). Non-transfusion cohort had significantly higher proportion of patients (p < 0.001) extubated immediately after surgery. Seventeen patients had at least one in-hospital complication, p = 0.05. Complications were not significant among groups., Conclusion: Intraoperative blood transfusions and high volume intraoperative allogeneic blood transfusions did not increase risk for in-hospital complications or surgical site infections. Delayed extubations noticed in patients who received higher volumes of intraoperative allogeneic blood transfusions. High-volume intraoperative blood transfusions increased length of hospital stays. High post-hospital surgical infections associated with high volume intraoperative blood transfusions. Results should be interpreted cautiously due to small sample size., (© 2021. The Author(s), under exclusive licence to Scoliosis Research Society.)

Study Design: The Children Spine Study Group registry was queried for early onset scoliosis (EOS) patients who had final definitive spinal fusion after their scoliosis was managed with either growing rods or VEPTR. The Harms Study Group registry was queried for adolescent idiopathic scoliosis (AIS) patients who had definitive fusion OBJECTIVE: The goal is to assess shoulder alignment in EOS patients after a definitive fusion and how these radiographic outcomes relate to the more familiar situation of post-definitive fusions shoulder alignment in AIS patients., Background: EOS is a challenging pathology to manage. Numerous components are important in the success of spinal surgery for this population. Shoulder balance is a one of the components that is easily seen by the patient. Recently, the importance of its relationship to patient satisfaction has received greater attention., Methods: Sample size: n = 145 (EOS (n = 34) and AIS (n = 111)). Shoulder balance parameters (SBP) of clavicular angle (CA), coracoid height difference (CHD), clavicular tilt angle difference (CTAD), and clavicle-rib cage intersection difference (CRID) measurements were measured from the reviewed radiographs and documented pre-definitive, post-definitive and 2-year follow-up measures. Shoulder balance parameters were compared between EOS and AIS cohorts at documented intervals., Results: EOS mean pre-definitive fusion SBPs (CA, CTAD, CRID, CHD) were significantly higher compared to AIS, p = 0.004, 0.003, < 0.001, < 0.001, respectively. Significant post-definitive fusion corrections were noticed for CTAD (0.01), CHD (0.01), nearly significant CA (0.07), non-significant CRID in EOS patients. In AIS patients, no significant corrections were noticed for CA, CTAD, CHD and but significant for CRID (0.02). At post-definitive and 2-year follow-up, CA, CRID, CHD were not significant between cohorts, but CTAD (< 0.01) was significantly higher in EOS cohort at final follow-up., Conclusion: Post-definitive and 2-year follow-up shoulder balance for EOS patients was not significantly different from AIS patients., Level of Evidence: III., (© 2021. Scoliosis Research Society.)

Background: Pelvic fixation improves the stability of spinal instrumentation and can be used in high-grade degenerative disease, trauma, deformity, and destabilizing invasive pathologies, such as infection and tumor. Classic techniques for spinopelvic fixation include traditional iliac screws and S2-Alar-Iliac screws. We present a case series describing the distal ventral iliac pathway (DVIP) for spinopelvic fixation and discuss surgical indications and merits of this technique. We describe the use of the DVIP for spinopelvic fixation in the setting of degenerative and traumatic pathologies, compare this technique with existing approaches, and summarize literature to support this approach., Methods: One hundred twenty-eight cases of DVIP screws were identified at 1 academic medical center, and 3 cases were chosen as representative examples for technique demonstration., Results: Patient ages ranged from 19 to 81 (mean 62) years. Intraoperative and postoperative complications include 12 incidental durotomies, 3 suprafascial infections, and 2 compressive hematomas. There were 22 instances of hardware failure and 8 instances of pseudoarthrosis. Overall, 26 patients underwent revision surgery. Mean estimated blood loss, operative time, and time under fluoroscopy were 1959 mL, 386 minutes, and 3.19 minutes, respectively., Conclusions: The DVIP is both safe and effective as a treatment for patients with degenerative and traumatic lumbosacral pathology. Spinopelvic fixation provides improved soft tissue coverage and fewer hardware complications at minimum of 1 year follow up. This case series demonstrates a novel surgical technique for spinopelvic fixation in the setting of numerous spinal pathologies., Level of Evidence: 4., Clinical Relevance: This surgical technique is less technically challenging than current approaches, minimizes radiation exposure, and obviates the need for horizontal connector rods. In addition, in highly destabilizing pathologies, this technique also allows for multiple screw placement within the ilium, while maintaining the ability to connect to a single rod construct. This technique is safe, technically approachable, and broadly applicable to an array of spinopelvic pathologies., (This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2021 ISASS.)

Background Context: Cervical disc arthroplasty (CDA) has been advocated as an alternative to anterior cervical discectomy and fusion (ACDF) with the added potential to reduce the risk of adjacent level disc degeneration and segmental instability. However, the long-term adverse events of arthroplasty have yet to be fully reported., Purpose: To investigate the 10-year follow-up adverse events rates between CDA and ACDF., Study Design/setting: The study was a randomized, prospective, multicenter Investigational Device Exemption (IDE) trial and its continued follow-up as a postapproval study (PAS). Single level surgeries were performed for cervical disc pathologies between May 2002 and October 2004., Patient Sample: n=463 patients., Outcome Measures: Adverse events comparison of CDA and ACDF from self-reported and physiologic measures., Methods: At each evaluation time point, subjects were queried for adverse events since their last visit; and all adverse events were documented, regardless of whether or not they appeared related to the surgery or device. Adverse events were recorded, categorized, and assessed for severity and relationship to the study device and/or surgical procedure. The 10-year cumulative rates for each type of adverse events were summarized using a life-table method for the time-to-event analysis. A log-rank test was used to compare the two treatment groups., Results: A total of 242 patients received CDA and 221 patients received ACDF. At 10-year follow-up, 54% (130/242) of CDA patients and 47% (104/221) of the ACDF subjects were evaluated. At up to 10-year follow-up, 231 patients in the CDA group (cumulative rate 98.4%) and 199 patients in the ACDF group (cumulative rate 98.7%) had at least one adverse event. Overall, the difference in the cumulative rate of all adverse events over 10 years was not statistically different (p=0.166). The cumulative rates of the following adverse events were not different between the two groups for cancer, cardiovascular, death, dysphonia/dysphagia, gastrointestinal, infection, urogenital, respiratory, implant displacement/loosening, implant malposition, neck and arm pain, neurological, other pain, spinal events, and intraoperative vascular injury. However, there were more adverse events in the CDA group resulting from trauma (p=.012) and more spinal events at the index level (p=.006). The ACDF group had significantly more nonunion events (p=.019), and nonunion outcome pending (p=.034), adjacent level spinal events (p=.033), and events that fell into the "other" category (p=.015)., Conclusions: The cumulative rates of patients who had any adverse events were not different between the artificial cervical disc and the anterior cervical arthrodesis groups. In addition, the cumulative rates were not different between the two groups for the majority of categories as well., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Study Design: An analysis of employment status data up to 10 years following the Federal Drug Administration (FDA) Investigational Device Exemption (IDE) randomized trial and extension as post-approval study comparing BRYAN cervical disc (Medtronic, Minneapolis, MN) arthroplasty (CDA) versus single-level anterior cervical discectomy and fusion (ACDF) was performed., Objective: Ten-year experience with the BRYAN disc arthroplasty trial provides opportunity to report patient employment data., Summary of Background Data: The long-term consequences of arthroplasty remain incomplete, including the occurrence of occupational compromise., Methods: Patients' employment status were measured at regular intervals in both groups up to 10 years., Results: The preoperative employment status proportion was comparable between investigational (BRYAN CDA) and control (ACDF) groups. In the investigational group, 49.2% returned to work at 6 weeks compared with 39.4% of the control group (P = 0.046). At 6 months and 2 years postoperatively, there was a similar likelihood of active employment in both groups. After 2 years at all time points, 10% drop-off seen in control group employment, but not in investigational group. At 10 years, 76.2% CDA patients were employed to 64.1% ACDF patients (P = 0.057). Preoperative variables influencing work status at 10 years following CDA included: preoperative work status, age, and SF-36 Mental Component Score (SF-36 MCS); whereas, no significant preoperative factor identified with ACDF. Time to return to work was influenced in both groups by preoperative work status; and in the ACDF group: reaching age 65 at 10-year visit, preoperative arm pain and NDI score had significant influences., Conclusion: More patients returned to work at 6 weeks after CDA compared with ACDF, although there was no difference by 6 months. After 2 years, a nonsignificant trend toward higher employment rates in the arthroplasty group was evident, but this difference could not be validated due to the very high rate of loss of patients to the follow-up., Level of Evidence: 2.

Background: Many studies report benefits using negative pressure wound therapy (NPWT) in surgical site infections (SSIs). We measured and compared efficacy and complications associated with NPWT for traditional versus suprafascial vacuum-assisted closures (VACs)., Methods: This is a retrospective chart review of consecutive SSIs managed with negative wound therapy after spinal procedures between 2012 and 2015 from a single, academic center. Patients were collected through International Classification of Diseases, Ninth Revision, procedure codes. Inclusion criteria were patients with spine SSIs managed by irrigation and debridement with a VAC device; infection occurring after spinal surgeries; and age over 18. A total of 23 consecutive patients met the criteria. We reviewed demographic data, surgical data, infectious disease data, discharge summaries, and postoperative follow-up charts. We compared and analyzed demographics, duration of VAC therapy, and reoperation rates between VAC groups. Statistical analysis was completed using analysis of variance and χ 2 tests; P ≤ 0.05 was considered statistically significant., Results: A total of 7 patients had traditional VACs (Group 1), and 16 patients had suprafascial VACs (Group 2). Average blood loss and number of levels involved during index surgery were not statistically significant between groups. Locations of infection occurrence were cervical spine = 3, thoracic spine = 1, and lumbar spine = 19. Reoperation rate after initial wound VAC placement was 34%, with rates significantly higher for Group 1 (71%) than Group 2 (16%), P = 0.02. Average duration of wound therapy was longer in Group 1 (77 days) than Group 2 (33 days), P = 0.08. Average number of operating room visits after initial wound VAC implantation were 0.7 for Group 1 and 0.3 for Group 2, P = 0.26, before obtaining a clean wound closure., Conclusions: Small sample size and retrospective nature were limitations. Negative pressure wound therapy may be useful for managing spinal infections, and suprafascial VAC had less time duration, lower risk of sponge fragment retainment, and fewer procedures to ultimately achieve wound closure., Level of Evidence: 3., (This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2020 ISASS.)

Study Design: A multicenter retrospective IRB exempt case series analyzing clinical and radiographical data of patients treated by three surgeons over the past two decades was conducted., Objective: To examine the factors involved in the development of quadriparesis in patients who underwent posterior spinal fusion for scoliosis. Delayed spinal cord infarcts usually present at the region of instrumentation according to reports from the Scoliosis Research Society. Nonetheless, there is a lack of data regarding factors associated with delayed quadriparesis following posterior spinal fusion METHODS: Evaluated variables were age, Cobb angle, blood loss, and curve correction percentage. Postoperative imaging was also evaluated to determine factors indicative of the etiology of the quadriparesis., Results: Eight patients presented delayed postoperative quadriparesis. All patients had a postoperative examination equal to that of baseline. The first patient deteriorated at 6 h postoperatively and the most delayed patient presented 4 days postoperatively. Six patients had neuromuscular disorders and 2 had adolescent idiopathic scoliosis. Mean age was 13.7, mean curve magnitude was 78.7°, mean percent curve correction was 71% and the mean estimated blood loss was 1185 cc. Seven of eight patients had documented peri- or postoperative hypotension., Conclusions: Cervical infarction is the likely cause of delayed quadriparesis after posterior spinal fusion. Even though the underlying etiology continues to be unclear, postoperative hypotension, curve magnitude, percent curve correction, and the presence of cervical kyphosis/stenosis may be contributory and need to be closely evaluated., Level of Evidence: IV, Case Series.

Background: With the COVID-19 pandemic disrupting many facets of our society, physicians and patients have begun using telemedicine as a platform for the delivery of health care. One of the challenges in implementing telemedicine for the spine care provider is completing a comprehensive spinal examination. Currently, there is no standardized methodology to complete a full spinal examination through telemedicine., Methods: We propose a novel, remote spinal examination methodology that is easily implemented through telemedicine, where the patient is an active participant in the successful completion of his or her examination. This type of examination has been validated in a neurology setting. To facilitate the telemedicine visit, we propose that video instruction be shared with the patient prior to the telemedicine visit to increase the efficacy of the examination., Results: Since the issuance of stay-at-home order across the states, many spine practices around the country have rapidly adopted and increased their telemedicine program to continue provide care for patients during COVID-19 pandemic. At a tertiary academic center in a busy metropolitan area, nearly 700 telemedicine visits were successfully conducted during a 4-week period. There were no remote visits being done prior to the shutdown., Conclusions: Implementation of our proposed remote spinal examination has the potential to serve as a guideline for the spine care provider to efficiently assess patients with spine disease using telemedicine. Because these are only suggestions, providers should tailor examination to each individual patient's needs., Level of Evidence: V., Clinical Relevance: It is likely that physicians will incorporate telemedicine into health care delivery services even after the COVID-19 pandemic subsides because of telemedicine's efficiency in meeting patient needs. Using the standard maneuvers provided in our study, spine care providers can perform a nearly comprehensive spine examination through telemedicine. Further studies will be needed to validate the reproducibility and reliability of our methodology., Competing Interests: Disclosures and COI: The authors declare no conflicts of interests with this manuscript. This research received no specific grant from any funding agency in public, commercial, or not-for-profit sectors., (©International Society for the Advancement of Spine Surgery 2020.)

There is a growing impetus to treat aging as a disease in the quest to significantly extend the human life span through cellular regeneration methods. This approach, while promising, overlooks the fact that the evolutionary adaptation to bipedalism puts the human body in a distinctively vulnerable biomechanical and functional position. Orthograde human posture places unusually-high axial compressive loads on the weight-bearing joints of the skeleton, resulting in arthritic deterioration with aging. The effects are particularly robust in the lumbar spine were age-related degeneration, most commonly lumbar spinal stenosis (LSS), is ubiquitous among the elderly. It is postulated that re-establishing a favorable mechanical environment via interventions that unload the affected spinal joint complex may mitigate and potentially reverse the structural damage that is the cardinal pathoanatomical feature of this disease. The hypothesis of this paper is that a minimally-invasive surgical procedure, interspinous process decompression (IPD), which utilizes a stand-alone intervertebral spacer, effectively unloads the diseased spinal motion segment providing a healthy micro-environment to reverse and repair age-related and genetic deterioration of the spinal motion segment. Several lines of supporting evidence are provided from long-term follow-up results of a randomized controlled trial of IPD safety and effectiveness of the Superion® device including clinical outcomes, reoperation rates, opioid analgesic usage and advanced imaging utilization. All of these outcomes show uniquely-favorable trends with time that imply that the benefits of IPD are structural. The compendium of evidence suggests that IPD offers both a durable palliative effect due to direct blocking of back extension and a disease-modifying effect due to unloading of the spinal joint complex., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objective: Prevertebral soft tissue swelling (PSTS) is a known complication of anterior cervical fusion (ACF). Prior studies have shown that perioperative steroids may reduce PSTS after ACF. We retrospectively evaluated the role of perioperative intravenous (IV) corticosteroid administration in minimizing radiographic PSTS measurements in patients undergoing ACF for degenerative disease., Methods: Records of 100 consecutive patients undergoing ACF for degenerative disease (Current Procedural Terminology code 63075) from January 2010 through December 2012 by 2 orthopedic spine fellowship-trained surgeons at a single institution were retrospectively reviewed. Patients were included on the basis of specific criteria. They were then separated into comparison and IV steroid groups. Demographic and surgical data were collected. Last, measurements of PSTS, which included PSTS ratio and PSTS index (PSTSI), were obtained from plain radiographs preoperatively and at 3 postoperative time points., Results: Eighty patients were included; 26 received IV steroids at the surgeon's discretion (12 intraoperatively, 11 postoperatively and 3 at both time periods). With the exception of a history of prior anterior cervical spine surgery (3.70% comparison vs. 23.08% IV steroid, P = 0.01), there was no statistically significant demographic characteristic. Furthermore, there was no statistically significant surgical characteristic. Last, there was no statistically significant difference between groups at any time point for either PSTS ratio at any level or PSTSI., Conclusions: There does not appear to be a role for perioperative IV steroid administration in minimizing radiographic PSTS in patients undergoing ACF for degenerative disease. The relationship between perioperative IV steroid administration and PSTS requires further investigation., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Study Design: A prospective, randomized multicenter IDE trial between May 2002 and October 2004., Objective: The aim of this study was to report on the 10-year safety and efficacy of BRYAN cervical disc arthroplasty (CDA)., Summary of Background Data: Cervical disc arthroplasty (CDA) is a potential alternative for anterior cervical decompression and fusion (ACDF) with the hope that maintenance of motion may decrease the likelihood of adjacent segment disease., Methods: This is an analysis of a US Food and Drug Administration (FDA) investigation comparing CDA with ACDF for single-level patients. Eligible patients were ≥ 21 years of age with symptomatic cervical disc disease who had failed conservative care. Patients were followed at regular intervals with the current data set at > 10 years. Protocol for overall success: ≥ 15-point improvement in NDI scores, maintenance or improvement in neurologic status, no serious adverse events related to implant or implant/surgical procedure, and no subsequent surgery or intervention classified as "failure.", Results: At 10-year follow-up, 128 (CDA) and 104 (ACDF) patients were available for evaluation. Overall success rate was significantly higher for CDA group (81.3% vs. 66.3%; P = 0.005). The rate of second surgeries at adjacent levels was lower for CDA group (9.7% vs. 15.8%; P = 0.146). NDI scores improved significantly in CDA group (Δ38.3 vs. Δ31.1; P = 0.010). Visual Analog Scale (VAS) neck and arm improved in the CDA group (Δ54.3 vs. Δ49.2; P = 0.119), (Δ58.1 vs. Δ51.6; P = 0.0.60) respectively. About 4.1% of CDA patients and 4.9% of ACDF patients had serious adverse events related to study device. Mean angular motions at index level for BRYAN disc and ACDF were 8.69° and 0.60°, respectively., Conclusion: CDA can preserve and maintain motion in the long term compared with ACDF. There was a trend toward fewer adjacent segment surgeries for BRYAN disc that did not reach significance. Significant improvement in CDA NDI scores may suggest better long-term success for CDA as compared to fusion., Level of Evidence: 2.

Introduction: Cervical disc arthroplasty (CDA) has become an acceptable alternative for anterior cervical discectomy and fusion (ACDF) for a significant patient population with cervical radiculopathy and/or myelopathy secondary to degenerative changes in the cervical spine. There are sufficient mid- and long-term data supporting performance and safety of one-level CDA. With the success of single-level cervical CDA, considerable interest exists about CDA use for multilevel cervical degenerative disc disease (DDD). This review analyzes the safety and efficacy of two-level CDA for treatment of symptomatic cervical DDD with focus on the Mobi-C® Cervical Disc., Areas Covered: This review summarizes previously published articles in a literature search using keywords: 'two-level-anterior cervical arthrodesis; two-level anterior cervical decompression and fusion (ACDF); two-level cervical disc arthroplasty (CDA); two-level cervical total disc replacement; two-level symptomatic degenerative disc disease (DDD); Mobi-C® disc'., Expert Opinion: Two-level CDA with the Mobi-C® device demonstrated equivalent, and in certain aspects, favorable outcomes compared to ACDF for treatment of symptomatic cervical 2-level degenerative disc disease (DDD) indicating a satisfactory safety and efficacy profile.

Background Context: Early-onset scoliosis is a challenging problem that is defined as a curvature of the spine of more than 10 degrees identified in a child less than 10 years. Early-onset idiopathic scoliosis (EOIS) can cause substantial morbidity and may require surgical intervention., Purpose: The aim of the present study was to identify the trends of EOIS type of surgeries, length of hospital stay, in-hospital complications, and total inpatient admission charges over a 15-year study period in the United States from 1997 to 2012., Study Design/setting: This retrospective study used the ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes from the Healthcare Cost and Utilization Project (HCUP) Kids Inpatient's Database (KID) for a 15-year period (1997-2012)., Patient Sample: We identified a total of 897 patients with EOIS over the 15-year study period., Outcome Measures: The present study determines the current trends for EOIS surgeries., Methods: The present study had no funding sources or any potential conflicts of interest associated biases. Idiopathic scoliosis patients with ages between 0 and <10 years were identified from the Kids' Inpatient Database with ICD-9-CM code 737.30. Posterior, anterior, and combined spinal surgeries were identified in EOIS through the procedure codes. Patients' gender, discharge diagnosis (comorbidities), hospital length of stay (LOS), mortality rates, hospital charges, and in-hospital complication rate data were collected between 1997 and 2012. The primary grouping variable of the study was the type of surgery (posterior, anterior, and combined). The trends of each variable (female gender, mortality rates, in-hospital complications rates, discharge diagnosis, LOS, and total hospital charges) were assessed for each surgical group separately. Cost inflation of hospital charges was adjusted for the year 2012. An analysis of variance test was used to analyze continuous variables and a chi-square test was used for categorical variables. A linear regression test was used to assess the trend of changes. p≤.05 was considered statistically significant., Results: The study identified 897 patients, with 546 (61%) of them requiring surgery. Spine deformity surgery rates significantly decreased in patients with EOIS over time from 75% in 1997 to 47% in 2012, p=.019. In the surgery cohort, the male to female distribution was 37% and 63%, respectively. The overall mortality rate was 0.1%. The average length of hospital stay was 8 days and the average number of discharge diagnosis was 5.3. Aggregated complications were seen in 6% of the patients. The total mean hospital charge (per 2012 US dollars) was $119,613, which increased significantly for all types of surgeries. Over the 15-year study period, 62% (n=342) of the patients had posterior surgeries, 13% (n=71) of the patients had anterior surgeries, and 24% (n=133) of the patients had combined (anterior and posterior) surgeries. Posterior surgeries increased significantly from 33% in 1997 to 91% in 2012 (p<.004). Combined surgeries saw a significant decline from 50% to 4.3% (0<0.001). Anterior surgeries also decreased from 17% to 4.3% (p<.126), but this did not reach statistical significance., Conclusions: From 1997 to 2012 (15 years) study period of patients with EOIS, posterior-based surgeries significantly increased. The overall surgery rate has significantly decreased for these patients. A significant increase in hospital charges were noticed in posterior, anterior, and combined surgeries., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Ten-year follow-up data from the US Food and Drug Administration investigational device exemption trial comparing BRYAN® Cervical Disc (Medtronic, Dublin, Ireland) arthroplasty to anterior cervical discectomy and fusion (ACDF) demonstrated that disc arthroplasty maintained range of motion and improvements in overall success and neck disability., Objective: To compare the 10-yr rates of symptomatic adjacent level disease requiring surgery (SALDRS)., Methods: Prospective randomized trial data were analyzed comparing BRYAN® Cervical Disc arthroplasty to ACDF for single-level cervical disc disease with concordant radiculopathy or myelopathy with clinicoradiographic analysis at 10 yr. Secondarily, 84-mo data were pooled with PRESTIGE® Cervical Disc arthroplasty (Medtronic) study data to provide overall rates of SALDRS., Results: Significantly greater overall success was maintained at every postoperative interval with an overall success rate of 81.3% with BRYAN® disc and 66.3% with ACDF (P = .005) without loss of motion preservation (8.69° vs 0.60°). Reoperation at adjacent levels up to the 120-mo visit was 9.7% in the arthroplasty group and 15.8% in the ACDF group (P = .146). The combined data from BRYAN® and Prestige ST demonstrate that BRYAN® and Prestige disc groups had a lower rate of second surgeries at the adjacent levels, up to the 84-mo visit, compared to the combined ACDF groups (6.9% vs 11.7%; P = .023)., Conclusion: Compared with ACDF, fewer patients with the BRYAN® disc required surgery for symptomatic adjacent level degeneration, but this did not achieve statistical significance. Analysis of combined study data using Bryan and Prestige discs shows significant differences in SADLRS as early as 7 yr.

Study Design: After placing a thoracic three-vertebra segment saw bones model on a standardized turntable, a series of anteroposterior (AP) radiographs were obtained and then set in increments to 90° rotation. Then the specimen was instrumented with 35-mm pedicle screws bilaterally and the rotation process and image acquisition were repeated., Objective: Assess reliability and accuracy of spine surgeons evaluating apical vertebral rotation (AVR) through surgeon's visual x-ray estimation, Nash-Moe system, Upasani trigonometric method, and Upasani grading system., Background Context: Accurate assessment of AVR is one measure surgeons can evaluate the success of intervention and potential loss of correction in scoliotic deformities., Methods: Eighty-four representative images of uninstrumented and instrumented vertebral segments were blinded. AVR was estimated by five experienced spinal deformity surgeons using the four techniques. The surgeons' grading, estimates, and errors compared to actual rotation were calculated. Inter- and intraobserver reliability were calculated using interclass correlation (ICC)., Results: Each surgeon's error for simple visual estimation for uninstrumented segments was 8.7° to 17.4° (average error = 12.4°), and for instrumented segments it was 7.7° to 11.3° (average error = 9.5°). Error for the Upasani trigonometric method was -6.7° to 11.6° (average error = 0.9°). There was relatively poor accuracy for Nash-Moe system (38.2%-53.9%) compared with the Upasani grading system (76.74%-80.23%). Interobserver reliability using the Nash-Moe method was good (0.844), with intraobserver reliability from fair to excellent (0.684-0.949). Interobserver reliability for the Upasani grading method was good (0.829), with intraobserver reliability from fair to good (0.751-0.869). We found excellent interobserver reliability for Upasani trigonometric classification (0.935) with fair to excellent intraobserver reliability (0.775-0.991). The interobserver reliability of surgeons' visual estimates was good (0.898) and the intraobserver reliability from good to excellent (0.866-0.99) without pedicle screws, and interobserver reliability was excellent (0.948) and intraobserver reliability also excellent (0.959-0.986) with pedicle screws., Conclusions: We confirm that both techniques described by Upasani have good reliability and accuracy, appearing more accurate than surgeon's visual estimates or Nash-Moe system., Level of Evidence: Level III., (Copyright © 2018 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

OBJECTIVEUse of surgical site drains following posterior cervical spine surgery is variable, and its impact on outcomes remains controversial. Studies of drain use in the lumbar spine have suggested that drains are not associated with reduction of reoperations for wound infection or hematoma. There is a paucity of studies examining this relationship in the cervical spine, where hematomas and infections can have severe consequences. This study aims to examine the relationship between surgical site drains and reoperation for wound-related complications following posterior cervical spine surgery.METHODSThis study is a multicenter retrospective review of 1799 consecutive patients who underwent posterior cervical decompression with instrumentation at 4 tertiary care centers between 2004 and 2016. Demographic and perioperative data were analyzed for associations with drain placement and return to the operating room.RESULTSOf 1799 patients, 1180 (65.6%) had a drain placed. Multivariate logistic regression analysis identified history of diabetes (OR 1.37, p = 0.03) and total number of levels operated (OR 1.32, p < 0.001) as independent predictors of drain placement. Rates of reoperation for any surgical site complication were not different between the drain and no-drain groups (4.07% vs 3.88%, p = 0.85). Similarly, rates of reoperation for surgical site infection (1.61% vs 2.58%, p = 0.16) and hematoma (0.68% vs 0.48%, p = 0.62) were not different between the drain and no-drain groups. However, after adjusting for history of diabetes and the number of operative levels, patients with drains had significantly lower odds of returning to the operating room for surgical site infection (OR 0.48, p = 0.04) but not for hematoma (OR 1.22, p = 0.77).CONCLUSIONSThis large study characterizes current practice patterns in the utilization of surgical site drains during posterior cervical decompression and instrumentation. Patients with drains placed did not have lower odds of returning to the operating room for postoperative hematoma. However, the authors' data suggest that patients with drains may be less likely to return to the operating room for surgical site infection, although the absolute number of infections in the entire population was small, limiting the analysis.

Background: Vertebral compression fractures (VCFs) are common comorbidities encountered in the elderly, and they are on the rise. Kyphoplasty may be superior in VCF management compared with conservative management. A comprehensive review of literature was conducted, focusing on the effect of kyphoplasty on mortality and overall survivorship in patients with a diagnosis of symptomatic VCFs., Methods: A comprehensive literature search was conducted to find recently published literature on kyphoplasty effects on mortality using the following keywords: "kyphoplasty," "mortality," "morbidity," "vertebral compression fractures," and "survivorship." We only included articles that listed one of their primary or secondary outcomes as morbidity and mortality after a kyphoplasty procedure in VCF patients., Results: Of 27 articles, only 6 articles met the inclusion criteria. Studies have reported that surgical procedures have decreased the mortality rate in symptomatic VCF patients. Four studies concluded that the mortality rate was lower after kyphoplasty compared with vertebroplasty and nonoperative treatments. One study reported there was no significant difference between kyphoplasty and nonoperative management. One study summarized that the mortality rate was not significantly different between kyphoplasty and vertebroplasty., Conclusions: Multicenter prospective and randomized control studies are required to fully evaluate the decreasing trend of mortality rates after a kyphoplasty procedure., Competing Interests: Disclosures and COI: There were no sources of funding from any source for this study. There were no grants for this paper, and no authors have any personal or institutional financial interest in drugs, materials, or devices described in this submission.

Background: Three-column osteotomy is an effective means of correcting fixed sagittal plane deformities. Deformity correction surgeries may be associated with early postoperative neurological deficits often presenting as palsies involving the lumbar roots. The objective was to retrospectively assess a subset of our series of adult deformity correction surgeries and analyze neurological deficits and associated patient and surgical factors., Methods: Hospital records of 17 patients from a single center were examined. Inclusion criterion were adults (>18 years) who underwent a 3-column osteotomy (pedicle subtraction osteotomy) at the lumbar level for fixed sagittal plane deformities including positive sagittal balance, flat back syndrome, and posttraumatic kyphosis. These also included cases with associated degenerative lumbar scoliosis. Patients were divided in 2 groups: Group 1 with lumbar root deficit and Group 2 with no deficits. We examined the surgical details of the osteotomy, complications during surgery, and observed if the magnitude of correction in the sagittal or coronal plane bore any influence on the nerve deficit., Results: All 17 patients had a single-level resection except 1 patient who had 2-level osteotomy; 23.5% (4 of 17) developed nerve deficit. Nerve deficit presented as bilateral foot drop (1); unilateral extensor hallucis longus (EHL) weakness (2); and unilateral quadriceps weakness (1). The patient with quadriceps weakness partially recovered to functional strength. Two patients with EHL weakness fully recovered; however, the patient with bilateral foot drop did not improve. L5-S1 interbody fusion was done in 3 of 4 cases in Group 1 and 4 of 13 cases in Group 2., Conclusions: Nerve deficits after 3-column corrective osteotomies occurred in 23% cases. All but 1 case had significant improvement. Most nerve palsies are neuropraxia and unilateral and tend to recover. L5 weakness appears most common after high lumbar osteotomies. Significant correction of scoliosis at the osteotomy level (>50%) may be a reason for nerve palsy., Competing Interests: Disclosures and COI: There were no sources of funding or grants from any source. This work had institutional review board approval.

Lumbar spinal stenosis has been shown to negatively impact health-related quality of life. Interspinous process decompression (IPD) is a minimally invasive procedure that utilizes a stand-alone spacer to serve as a joint extension blocker to relieve neural compression in patients with spinal stenosis. Using the 5-year results from an FDA randomized controlled trial of IPD, the quality of life in 189 patients treated with the Superion® spacer was evaluated with the SF-12. Physical and mental component summary (PCS, MCS) scores were computed preoperatively and at annual intervals. For the PCS, mean scores improved from 29.4 ± 8.1 preoperatively to 41.2 ± 12.4 at 2 years (40%) and to 43.8 ± 11.6 at 5 years (49%) (p<0.001 for both comparisons). At 2 years, 81% (103 of 128) of subjects demonstrated maintenance or improvement in PCS scores. The mean MCS score improved from 50.0 ± 12.7 preoperatively to 54.4 ± 10.6 and 54.7 ± 8.6 at 2 and 5 years, respectively (p>0.10 for both comparisons). These results demonstrate that the significant impairment in physical well-being found in patients with lumbar spinal stenosis can be ameliorated, in large part, by IPD treatment.

Background Context: Patients with spinal deformity may present with complaints related to either the deformity itself or the manifestations of the coexisting spinal stenosis. There are reports of successful management of lumbar pathology in the absence of global sagittal or coronal imbalance, with limited decompression and fusion, addressing only the symptomatic segment., Purpose: Our study examined the long-term outcomes of transforaminal lumbar interbody fusion (TLIF), a less extensive procedure, based on the experience of the senior author over the past 10 years., Study Design/setting: This was a retrospective study of symptomatic lumbar spinal stenosis and spinal deformity managed by one surgeon at The Cleveland Clinic since 2003., Patient Sample: Forty-one patients were included in the study., Outcome Measures: The present study measures the long-term clinical functional outcomes of these patients through EQ-5D (EuroQol five dimensions questionnaire), PHQ-9 (Patient Health Questionnaire), and PDQ (Pain Disability Questionnaire) forms, along with documented radiographic parameters and Charlson Comorbidity Index (CCI)., Methods: There were no funding or potential conflicts of interest associated biases in the present study. Patients with symptomatic lumbar spinal stenosis with neutral global alignment in the sagittal and coronal planes and symptomatic stenosis at the deformity level were treated by limited fusion and TLIF, and had a follow-up period of at least 5 years. Excluded were patients under 18 years of age, had more than three levels of fusion, and had an active spinal malignancy or recent spinal trauma. The grouping variables were curve magnitude, revision surgeries, and TLIF levels. Clinical outcomes were compared in all the grouping variables. Analysis of variance (ANOVA) and chi-square tests were utilized; p<.05 was considered statistically significant., Results: The average age and follow-up period were 66±10 and 7.5 years, respectively. There was no statistical difference between patients with curves measuring between 10° and 20° and greater than 20° for EQ-5D, PHQ-9, and PDQ. Patients had worse PDQ data with larger curves compared with smaller curves at both 5 years and final follow-up. Although there was no statistical significance between preoperative coronal curve magnitude and revision surgeries, patients with curves greater than 20° had higher rates of revision surgeries (75%; p=.343) in the global lumbar curve deformity group. Although there was no statistical significance for patients who underwent revision surgeries,those patients had low PHQ-9 values at the final follow-up (p=.09). The revision surgery rate was 48% in one-level TLIF and 18% in two-level TLIF. Moderate pain disability scores were noticed for one-level TLIF patients (mean=75) compared with two-level TLIF patients (mean=27) at the final follow-up, and approached statistical significance in this comparison (p=.06)., Conclusion: Although this topic has a limited audience to spinal deformity surgeons, the prevalence of patients who present with adult spinal deformities has been increasing. Short segment fusion, in the setting of modest spinal deformity, is a reasonable and safe option. Further study on the concept of short segment fusions in the growing patient population is required as more comprehensive fusions do have noted complication rates, and a compromise must be reached between the extent of surgery that is enough to provide pain relief and disability and the degree of surgery that is too much to be tolerated in terms of complication rates., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Study Design: Retrospectively reviewed surgeries between 2011 and 2015 of patients who underwent posterior spinal deformity instrumentation with constructs involving fusions to pelvis and encompassing at least five levels., Objective: Measure the radiographic outcomes of coronal malalignment (CM) after use of an intraoperative T square shaped instrument in posterior spinal deformity surgeries with at least five levels of fusion and extension to pelvis., Background: Neuromuscular children found to benefit from intraoperative T square technique to help achieve proper coronal spinal balance with extensive fusions. This intraoperative technique used in our posterior spine deformity instrumentation surgeries with the aforementioned parameters., Methods: There were 50 patients: n = 16 with intraoperative T square and n = 34 no-T square shaped device. Subgroups divided based on greater than 20 mm displacement and greater than 40 mm displacement of the C7 plumb line to the central sacral vertical line on either side in preoperative radiographs. We analyzed the demographics and the pre- and postoperative radiographic parameters of standing films: standing CM (displacement of C7 plumb line to central sacral vertical line), and major coronal Cobb angles in total sample and subgroups and compared T square shaped device with no-T square shaped device use by analysis of variance. A p value ≤.05 is statistically significant., Results: In the total sample, though postoperative CM mean was not statistically different, we observed greater CM corrections in patients where a T square shaped device was used (70%) versus no-T square shaped device used (18%). In >20 mm and >40 mm subgroups, the postoperative mean CM values were statistically lower for the patients where a T square shaped device was used, p = .016 and p = .003, respectively. Cobb corrections were statistically higher for T square shaped device use in both >20 mm and >40 mm subgroups, 68%, respectively., Conclusion: The intraoperative T square shaped device technique had a positive effect on the amount of spine coronal malalignment correction after its use and for lumbar and thoracic coronal Cobb angles., Level of Evidence: Level III., (Copyright © 2017 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Introduction: Cervical disc arthroplasty (CDA) was developed as an alternative for anterior cervical discectomy and fusion (ACDF) for nerve root decompression. The rationale behind CDA was to help prevent adjacent segment degeneration which potentially may lead to additional surgery. Multiple randomized controlled trials have evaluated a myriad of disc arthroplasty devices over the past 10 years and provided data regarding clinical benefits and safety. Their long-term data, reporting results at 5-10 years, presents the opportunity to comment on the overall efficacy, safety and reported complications of these devices. This report reviews results of the Prestige, proDisc-C, Mobi-C Disc and various other arthroplasty devices and provides an overall report of the longest term available data and comparisons between devices., Areas Covered: This review summarizes previously published articles in a literature search using keywords: 'cervical disc arthroplasty', 'cervical total disc replacement', 'anterior cervical decompression and fusion', 'anterior cervical arthrodesis', 'symptomatic degenerative disc disease' and commercial names of devices., Expert Commentary: CDA, with the devices reviewed, resulted in favorable outcomes in comparison to ACDF for the treatment of symptomatic cervical degenerative disc disease (DDD) taking in to account the long-term functional recovery, adverse events, development of adjacent segment degeneration and subsequent surgical interventions.

Background: Treating surgeon's visual assessment of axial MRI images to ascertain the degree of stenosis has a critical impact on surgical decision-making. The purpose of this study was to prospectively analyze the impact of surgeon experience on inter-observer and intra-observer reliability of assessing severity of spinal stenosis on MRIs by spine surgeons directly involved in surgical decision-making., Methods: Seven fellowship trained spine surgeons reviewed MRI studies of 30 symptomatic patients with lumbar stenosis and graded the stenosis in the central canal, the lateral recess and the foramen at T12-L1 to L5-S1 as none, mild, moderate or severe. No specific instructions were provided to what constituted mild, moderate, or severe stenosis. Two surgeons were "senior" (>fifteen years of practice experience); two were "intermediate" (>four years of practice experience), and three "junior" (< one year of practice experience). The concordance correlation coefficient (CCC) was calculated to assess inter-observer reliability. Seven MRI studies were duplicated and randomly re-read to evaluate inter-observer reliability., Results: Surgeon experience was found to be a strong predictor of inter-observer reliability. Senior inter-observer reliability was significantly higher assessing central(p<0.001), foraminal p=0.005 and lateral p=0.001 than "junior" group.Senior group also showed significantly higher inter-observer reliability that intermediate group assessing foraminal stenosis (p=0.036). In intra-observer reliability the results were contrary to that found in inter-observer reliability., Conclusion: Inter-observer reliability of assessing stenosis on MRIs increases with surgeon experience. Lower intra-observer reliability values among the senior group, although not clearly explained, may be due to the small number of MRIs evaluated and quality of MRI images.Level of evidence: Level 3.

Background: The aim of surgical treatment of scoliosis is to obtain fusion of the spinal column, balanced in the coronal and sagittal planes. Great success has been attained with coronal correction; however, the sagittal profile has received less attention, resulting in little correction of sagittal plane alignment. The purpose of this study was to compare uniplanar and fixed pedicle screws in the correction of the thoracic sagittal alignment in the treatment of adolescent idiopathic scoliosis (AIS)., Methods: The sagittal profile of 2 groups of patients undergoing posterior spinal fusion (PSF) for AIS was compared. One group had uniplanar screws (n=16) as bone anchors, and the second group had fixed screws (n=20). Consecutive patients with AIS treated by PSF during 2004 to 2006 with fixed screws; and those treated in 2008 with uniplanar screws were included in the study. Data included: patient demographics, medical conditions, curve type, Risser stage, coronal and sagittal curve magnitude, curve flexibility, osteotomies, fusion levels, type and location of instrumentation, curve magnitude at the initial postoperative visit and at final follow-up. ANOVA and χ testing was completed. A P<0.05 was considered significant., Results: Both groups were comparable demographically, medically, in relation to the curve characteristics and the surgical treatment. Immediate postcorrection sagittal curvature measurements were greater using the uniplanar than fixed screws, 36 versus 26 degrees and was also statistically significant at final follow-up (P=0.006). There was no difference between groups with respect to coronal thoracic deformity. In the Lenke 1 and Lenke 2 curve population, similar results were found., Conclusions: In patients undergoing PSF for AIS, uniplanar screws achieved superior correction of the sagittal thoracic alignment than fixed screws. This advantage was maintained in the postoperative follow-up period. The ability of the uniplanar screws to adapt to variable sagittal orientation appears to contribute to better radiographic outcomes., Level of Evidence: This is a level III respective review study conducted at a single center from a single, pediatric spine surgeon.

Rod reduction to pedicle screws is used for a variety of spinal fixation procedures; however, it can alter the integrity of the screw-bone interface. The authors investigated the effect of pedicle fill (ratio of pedicle screw diameter to pedicle diameter) on the strength of the screw-bone interface after simulated rod reduction on 17 vertebrae (3 thoracolumbar spine specimens). Pedicle diameter was measured with standard clinical computed tomography scan protocols. The authors determined the minimum pedicle diameter for each level. Polyaxial pedicle screws were surgically placed bilaterally with a freehand technique with standard clinical anatomic landmarks. The pedicle pairs were instrumented with pedicle screws of predetermined diameter, 1 with greater than 80% fill and 1 with less than 80% fill. A simulated reduction maneuver was performed with a 5-mm gap followed by an axial pullout test to assess screw interface strength. Comparison of insertion torque between less than 80% fill and greater than 80% fill did not show significant increases. A significant difference in pullout load (P=.043) occurred with greater than 80% fill (791±637 N) compared with less than 80% fill (636±492 N). No significant difference in stiffness was noted (P=.154) with pedicle fill of greater than 80% (427±134 N/mm) compared with less than 80% (376±178 N/mm). The current findings support the use of greater than 80% pedicle fill for optimal screw anchoring in pedicle screw-based constructs involving rod reduction. Surgeons should consider placing screws that can safely fill vertebral pedicles, especially at the apex of the curve and the proximal and distal levels of constructs, where excessive forces are imparted to the screws. [Orthopedics. 2017; 40(6):e990-e995.]., (Copyright 2017, SLACK Incorporated.)

Objective: To determine 4-year clinical outcomes in patients with moderate lumbar spinal stenosis treated with minimally invasive stand-alone interspinous process decompression using the Superion device., Methods: The 4-year Superion data were extracted from a randomized, controlled Food and Drug Administration investigational device exemption trial. Patients with intermittent neurogenic claudication relieved with back flexion who failed at least 6 months of nonsurgical management were enrolled. Outcomes included Zurich Claudication Questionnaire (ZCQ) symptom severity (ss), physical function (pf) and patient satisfaction (ps) subdomains, leg and back pain visual analog scale (VAS), and Oswestry Disability Index (ODI). At 4-year follow-up, 89 of the 122 patients (73%) provided complete clinical outcome evaluations., Results: At 4 years after index procedure, 75 of 89 patients with Superion (84.3%) demonstrated clinical success on at least 2 of 3 ZCQ domains. Individual component responder rates were 83% (74/89), 79% (70/89), and 87% (77/89) for ZCQss, ZCQpf, and ZCQps; 78% (67/86) and 66% (57/86) for leg and back pain VAS; and 62% (55/89) for ODI. Patients with Superion also demonstrated percentage improvements over baseline of 41%, 40%, 73%, 69%, and 61% for ZCQss, ZCQpf, leg pain VAS, back pain VAS, and ODI. Within-group effect sizes all were classified as very large (>1.0): 1.49, 1.65, 1.42, 1.12, and 1.46 for ZCQss, ZCQpf, leg pain VAS, back pain VAS, and ODI., Conclusions: Minimally invasive implantation of the Superion device provides long-term, durable relief of symptoms of intermittent neurogenic claudication for patients with moderate lumbar spinal stenosis., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The standard for evaluating scoliosis is PA radiographs using Cobb angle to measure curve magnitude. Newer PACS systems allow easier Cobb angle calculations, but have not improved inter/intra observer precision of measurement. Cobb angle and its progression are important to determine treatment; therefore, angle variability is not optimal. This study seeks to demonstrate that a performance equivalent to that achieved in the manual method is possible using a novel computer algorithm with limited user input. The authors compared Cobb angles from predetermined spinal levels in the average attending score versus the computer assisted approach., Methods: Retrospective analysis of PA radiographs from 58 patients previously evaluated for scoliosis was collected. Predesignated spinal levels (e.g., T2-T10) were assigned for different curves and calculated by Cobb method. Four spine surgeons evaluated these Cobb angles. Their average scores were measured and compared to formulated values using the novel computer-based algorithm. Literature reports inter-observer reliability is 6.3-7.2degrees. Limits of accuracy were set at 5 degrees of average orthopedic surgeons' score., Results: The computer-based algorithm calculated Cobb angles within 5 degrees of orthopedic surgeons' average with a standard deviation of 3.2 degrees. This result was based on a 95% confidence interval with p values <0.001. The computer algorithm was plotted against average angle determined by the surgeons, with individual determinations and linear regression (r 2 =0.90). The average difference between surgeons' measures and computer algorithm was 0.4 degrees(SD= 3.2degrees, n=79). There was a tendency for the computer algorithm program to overestimate the angle at larger angles, but difference was small with r 2 = 0.09., Conclusions: Our study showed the novel computer based algorithm was an efficient and reliable method to assess scoliotic curvature in the coronal plane with the possibility of expediting clinic visits, ensuring reliability of calculation and decreasing patient exposure to radiation. Level of Evidence: III.

Background: Correction of fixed spinal imbalance in a sagittal and/or coronal plane frequently needs a tricolumnar wedge resection when the deformity is rigid. Complications associated with deformity correction surgery are pseudoarthrosis and implant failure located along the construct. The purposes of this study were to assess comparative rates of pseudoarthrosis (implant failure) at weaker points along lumbosacral junction and level of osteotomy, estimate overall incidence of implant failure, and comparatively analyze failures at different points along the construct., Methods: This was an IRB approved, single center study retrospective analysis. Twenty-six patients who underwent three column osteotomies were grouped according to procedure: pedicle subtraction osteotomy (PSO, ( n  = 18)); vertebral column resection (VCR, ( n  = 4)); hemivertebra excision (HE, ( n  = 2)); and extracavitary corpectomy (EC, ( n  = 2)). Follow-up data is presented on all of the study patients. Number of levels of fusion, anchors, percent saturation of fixation levels, type of bone graft and graft substitutes, and rod material and diameter were recorded. Radiographical data was reviewed preoperatively and postoperatively at 2 weeks and 3, 6, and 12 months and annually to determine sagittal and coronal balance, lumbopelvic parameters, presence or absence of interbody structural support, laterality or rod failure, and time to implant failure., Results: Twenty-seven percent (7/26) patients demonstrated rod breakage either unilaterally ( N  = 2) or bilaterally ( N  = 5) during follow-up. Seventy-one percent had increasing back pain or worsening sagittal balance, while remaining failures found incidentally. No failures in children were seen., Conclusion: Tricolumnar osteotomy by posterior approach is a valuable tool. Rod failures found approximately 1 year from surgery, with 86% located at level of osteotomy and 14% at lumbosacral junction. Possible reasons are increased stress in the rod at this point and relatively deficient bone stock secondary to wide laminectomy. The low rate of rod breakage at lumbosacral junction may be related to adoption of structural interbody graft and stronger iliac screws. Additional biomechanical studies needed to assess the importance of these factors. This was a level IV study.

Background: C1-C2 rotatory subluxation can result from a variety or etiologies. Pediatric patients are particularly susceptible to C1-C2 rotatory subluxation. If left untreated the condition is termed an atlantoaxial rotatory fixation (AARF) and chronic neck pain and deformity can result. Patients failing conservative treatment or those with recurrent or chronic rotatory subluxation may require halo treatment or surgical intervention. This illustrative case report is about a patient with chronic C1-C2 AARF who was treated with C1 lateral mass screws and C2 translaminar screws, a treatment that has not been addressed by this technique in a pediatric population., Methods: This is a retrospective case review., Results: After an unsuccessful attempt at reduction, an 11-year-old girl underwent surgery to treat her C1-C2 AARF. Through an all posterior approach, screws were placed bilaterally into the C1 lateral masses followed by the placement of C2 translaminar screws bilaterally. A small amount of distraction was applied through the screw construct to open up the C1-C2 articulation and the AARF was open reduced and fused. A detailed postoperative computed tomographic scan focused on the occiput C1-C2 joint confirmed the anatomical reduction of the joint complex., Conclusions: The patient had cosmetically pleasing relief of her torticollis and was doing well at 60 months after surgery., Level of Evidence: Level IV.

Introduction: Early onset scoliosis can be both a disfiguring as well as a life threatening condition. When more conservative treatments fail, pediatric spinal surgeons are forced to consider operative interventions. Traditionally, these interventions have involved the insertion of a variety of implants into the patient with a limited number of anchor points controlling the spine. In the past, these pediatric patients have had multiple surgeries for elective lengthening of these devices to facilitate their growth while attempting to control the scoliosis. These patients often experience a physical and emotional toll from their multiple repeated surgeries. Growing spine techniques have also had a noted high complication rate due to implant dislodgement and infections. Recently, the development of non-invasively, self-lengthening growing rods has occurred. These devices have the potential to allow for the devices to be lengthened magnetically in a conscious patient in the surgeon's office. Areas covered: This review summarized previously published articles in the English literature using a key word search in PubMed for: 'magnetically controlled growing rods', 'Magec rods', 'magnetic growing rods' and 'growing rods'. Expert commentary: Magnetically controlled growing rods have an advantage over growing rods in lengthening the growing spine in the absence of repetitive surgeries.

Objective: To determine the relationship between the severity of stenosis graded using both surgeons' visual assessment of spinal stenosis as well as measurement of dural cross-sectional area on magnetic resonance imaging (MRI), with the patient's disability., Methods: Seven fellowship-trained spine surgeons reviewed MRI studies retrospectively of 30 symptomatic consecutive patients with lumbar stenosis and graded stenosis in the central canal, the lateral recess, and the foramen at T12-L1 to L5-S1 as none, mild, moderate, or severe. Dural cross-sectional area was measured at each level from T12-L1 to L5-S1. All patients completed the questionnaires for Oswestry Disability Index (ODI), Short Form 36 (SF-36), and recorded Visual Analog Scale scores for leg and back pain, and symptom severity scale of the Zurich claudication questionnaire., Results: There was positive correlation between the right leg pain Visual Analog Scale score and the mean surgeon grades for central and lateral recess stenosis at L4-L5 and lateral recess stenosis at L5-S1. Except for a positive correlation between role physical score and surgeon grade for lateral recess stenosis at L5-S1, we found no correlation between the surgeons' grading of stenosis at any level with the ODI or SF-36. We found no correlation between the dural cross-sectional area with the ODI or SF-36. We did not find any correlation between the Zurich symptom severity scale and surgeons' grading of stenosis at any level., Conclusions: Although surgeons rely on visual assessment of the severity of stenosis while making surgical decisions, we found that objective and subjective imaging parameters to grade severity of stenosis did not consistently indicate the patient's disability level., (Copyright © 2016 Elsevier Inc. All rights reserved.)