Publications by authors named "Behrooz A Akbarnia"

132 Publications

The role of traditional growing rods in the era of magnetically controlled growing rods for the treatment of early-onset scoliosis.

Spine Deform 2021 Apr 19. Epub 2021 Apr 19.

Division of Orthopedics and Scoliosis, Rady Children's Hospital, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA.

Purpose: To describe the clinical and radiographic profile of early-onset scoliosis (EOS) patients treated with traditional growing rods (TGR) during the magnetically-controlled growing rod (MCGR) era.

Methods: A US multicenter EOS database was reviewed to identify (1) patients who underwent TGR after MCGR surgery was introduced at their institution, (2) patients who underwent MCGR during the same time period. Of 19 centers, 8 met criteria with all EOS etiologies represented. Clinical notes were reviewed to determine the indication for TGR. Patient demographics and pre-operative radiographs were compared between groups.

Results: A total of 25 TGR and 127 MCGR patients were identified. The TGR patients were grouped by indication into the sagittal plane profile (n = 11), trunk height (n = 6), co-morbidities/need for MRI (n = 4), and other (ex: behavioral issues, remaining growth). Four patients had a combination of sagittal profile and short stature with sagittal profile listed as primary factor. The TGR short trunk group had a mean T1-S1 length of 192 mm vs 273 mm for the MCGR group (p = 0.0002). The TGR sagittal profile group, had a mean maximal kyphosis of 61° vs 55° for the MCGR group (p = 0.09).

Conclusion: TGR continues to have a role in the MCGR era. In this study, the most commonly reported indications for TGR were sagittal plane profile and trunk height. These results suggest that TGR is indicated in patients of short stature with stiff hyperkyphotic curves. As further experience is gained with MCGR, the indications for TGR will likely be refined.
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http://dx.doi.org/10.1007/s43390-021-00332-4DOI Listing
April 2021

An initial effort to define an early onset scoliosis "graduate"-The Pediatric Spine Study Group experience.

Spine Deform 2021 May 30;9(3):679-683. Epub 2020 Nov 30.

San Diego Spine Foundation, San Diego, CA, USA.

Purpose: Increasingly, patients with early onset scoliosis (EOS) are completing a growth friendly surgical program followed by observation, removal of implants or a definitive spinal fusion. These patients are colloquially referred to as "graduates". A standardized definition of a graduate is needed for research and comparing the outcomes, family counseling, and a better understanding of the population.

Methods: A 15-question electronic survey was completed by 39 experienced pediatric spine surgeons to identify factors salient to the definition of a graduate of EOS surgical programs. A Delphi/Nominal group technique session with nine questions was then performed face-to-face with 21 members of the Pediatric Spine Study Group to discuss and refine the definition. A follow-up electronic survey was then distributed to these same 21 members to gain consensus on the final definition.

Results: From the initial survey, it was identified that a graduate did not require definitive spinal fusion after a growing program. From the Delphi session, it was determined that skeletal maturity was the most important factor in defining a graduate. A strictly defined minimum length of follow-up was not felt to be a prerequisite for qualification of graduation. After the final electronic version was distributed, > 80% of respondents agreed upon the final definition, thereby achieving consensus.

Conclusion: The Pediatric Spine Study Group recommends adoption of the following definition: a "graduate" is a patient who has undergone any surgical program to treat early onset scoliosis, and has reached skeletal maturity and does not have a planned surgical intervention for EOS in the future.

Level Of Evidence: V.
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http://dx.doi.org/10.1007/s43390-020-00255-6DOI Listing
May 2021

Effect of race, age, and gender on lumbar muscle volume and fat infiltration in the degenerative spine.

J Orthop Sci 2021 Jan 29;26(1):69-74. Epub 2020 Oct 29.

San Diego Spine Foundation, San Diego, CA, USA; Department of Orthopaedic Surgery, University of California, San Diego, CA, USA.

Background: The quantity and quality of spinal muscles in patients with degenerative spinal diseases and various backgrounds such as age, gender, or race is unclear. We quantitatively evaluated the cross-sectional area (CSA) and fatty degeneration of the muscles around the spine, using magnetic resonance imaging (MRI) in patients with degenerative spinal disease, and studied the effects of age, gender, and race in multicenter retrospective study.

Methods: The subjects were Caucasian and Asian patients with degenerative lumbar disease who underwent L4-5 single level spinal fusion surgery at centers in the United States and Japan. Using preoperative axial T2 MRI at the L4-5 disc level, the cross-sectional areas of the psoas and paraspinal muscles were measured. Fat infiltration was measured using the threshold method, and percent fat area (%FA) was calculated for each muscle. The muscle/disc area ratio (MDAR) was used to control for size differences per patient. T-test, Pearson's correlation coefficient, partial correlation, and multiple linear regression were used for statistical analysis.

Results: In total, 140 patients (53 men; 87 women; mean age, 69.2 years) were analyzed. Age was similar in Caucasians (n = 64) and Asians (n = 76). MDARs were larger in Caucasians for paraspinal and psoas muscles (p < 0.005). Percent FA of psoas was similar in Caucasians and Asians, but greater in the paraspinal muscles of Asians (p < 0.05). After controlling for race and gender, age was correlated negatively with MDAR (p < 0.001) and positively with %FA (p < 0.001). In the multiple linear regression analysis, age, gender, and race were independently affected by MDAR and %FA.

Conclusions: Lumbar muscle mass and quality were affected by age, gender, and race, independently, in patients with degenerative lumbar disease.
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http://dx.doi.org/10.1016/j.jos.2019.09.006DOI Listing
January 2021

Complications in the treatment of EOS: Is there a difference between rib vs. spine-based proximal anchors?

Spine Deform 2021 Jan 21;9(1):247-253. Epub 2020 Sep 21.

Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY, 10032, USA.

Introduction: Currently, there is significant equipoise regarding the selection and placement of growing spinal instrumentation when treating patients with early-onset scoliosis (EOS). The primary purpose of this study was to compare complications following surgery in patients receiving rib-based versus spine-based proximal anchors as a part of posterior growing instrumentation in the management of EOS.

Methods: Retrospective cohort study. Inclusion criteria required: age 3-10 years old, diagnosis of EOS, treatment with a growing construct that utilized rib- or spine-based proximal anchors, and a major coronal curve larger than 40 degrees. The primary outcome analyzed was postoperative complications. Secondary outcomes included coronal major curve correction and patient reported outcomes measured by the Early-Onset Scoliosis 24-item Questionnaire (EOSQ-24). Subjects were categorized into rib- or spine-based proximal fixation groups for comparison.

Results: Of 104 patients included in the study, 76 (73.1%) were treated with rib-based constructs and 28 (26.9%) were treated with spine-based constructs. 24 (31.6%) patients with rib-based constructs and 9 (32.1%) patients with spine-based constructs experienced at least one implant related complication (p = 0.956). Rod fracture was observed more often in spine-based groups than rib-based groups for both patients with congenital/idiopathic EOS (rib: 0 (0%) vs. spine: 3 (13.6%), p = 0.009) and neuromuscular/syndromic EOS (rib: 0 (0%) vs. spine: 2 (33.3%), p = 0.002). Furthermore, surgical site infection was found to be more frequent in rib-based than spine-based groups for neuromuscular/syndromic patients (rib: (13) 27.15 vs. spine: (1) 4.5%, p = 0.029). The most commonly reported complication was device migration. In patients with rib-based constructs, 2 (12.5%) patients with ≥ 5 anchors and 13 (21.7%) patients with < 5 anchors experienced device migration (p = 0.413). In patients with spine-based constructs, 1 (11.1%) patient with ≥ 5 anchors and 4 (21.1%) patients with < 5 anchors experienced device migration (p = 0.064). Spine-based anchors had significantly higher% correction (42.0%) compared to rib-based anchors (20.6%) (p = 0.003) at the most recent follow-up. There were no significant differences in the change of patient reported outcomes as measured by the EOSQ-24 between patients who received rib or spine-based anchors.

Discussion: The number of patients with at least one implant related complication was similar between the rib- and spine-based groups. Having 5 or more proximal anchors appeared protective against proximal device migration; however, this result was not statistically significant. Spine-based anchors had better overall correction than rib-based anchors. There were no differences in the change in patient reported outcomes between spine- and rib-based cohorts.
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http://dx.doi.org/10.1007/s43390-020-00200-7DOI Listing
January 2021

Comparing health-related quality of life and burden of care between early-onset scoliosis patients treated with magnetically controlled growing rods and traditional growing rods: a multicenter study.

Spine Deform 2021 Jan 26;9(1):239-245. Epub 2020 Aug 26.

Columbia University Medical Center, New York, NY, USA.

Study Design: Multicenter retrospective cohort study.

Objectives: To compare pre-operative and post-operative EOSQ-24 scores in magnetically controlled growing rods (MCGR) and traditional growing rod (TGR) patients. Since the introduction of MCGR, early-onset scoliosis patients have been afforded a reduction in the number of surgeries compared to the TGR technique. However, little is known about (health-related quality of life) and burden of care outcomes between these surgical techniques.

Methods: This is a retrospective cohort study using a multicenter registry on patients with EOS undergoing MCGR or TGR between 2008 and 2017. The EOSQ-24 was administered at preoperative and postoperative 2-year assessments. The EOSQ-24 scores were compared between MCGR and TGR as well as preoperatively and postoperatively within each procedure.

Results: 110 patients were analyzed in this study (TGR, N = 32; MCGR, N = 78). There were no significant differences in preoperative age, gender, etiology, main coronal curve or maximum kyphosis between TGR and MCGR groups. Patients with TGR had averaged 3.9 surgical lengthenings and MCGR had averaged 7.7 non-invasive lengthenings by the 2-year follow-up. When changes in preoperative to postoperative scores were compared, MCGR had more improvements in pain, emotion, child satisfaction and parent satisfaction than TGR although there were no statistical significance. When analyzed separately, MCGR cohort had improvement in scores for all four domains and four sub-domains; while, TGR cohort only had improvement in financial burden domain and pulmonary function sub-domain.

Conclusion: Although there was no statistical significance, the improvement in pain, emotion and satisfaction scores was larger in MCGR than TGR. Since these areas can be influenced more by mental well-being than other sub-domains, the results may prove our hypothesis that compared to TGR, MCGR with reduced number of surgeries have better psychosocial effects.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s43390-020-00173-7DOI Listing
January 2021

Characterizing Use of Growth-friendly Implants for Early-onset Scoliosis: A 10-Year Update.

J Pediatr Orthop 2020 Sep;40(8):e740-e746

Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.

Background: Growth-friendly treatment of early-onset scoliosis (EOS) has changed with the development and evolution of multiple devices. This study was designed to characterize changes in the use of growth-friendly implants for EOS from 2007 to 2017.

Methods: We queried the Pediatric Spine Study Group database for patients who underwent index surgery with growth-friendly implants from July 2007 to June 2017. In 1298 patients, we assessed causes of EOS; preoperative curve magnitude; age at first surgery; patient sex; construct type; lengthening interval; incidence of "final" fusion for definitive treatment; and age at definitive treatment. α=0.05.

Results: From 2007 to 2017, the annual proportion of patients with idiopathic EOS increased from 12% to 33% (R=0.58, P=0.006). Neuromuscular EOS was the most common type at all time points (range, 33% to 44%). By year, mean preoperative curve magnitude ranged from 67 to 77 degrees, with no significant temporal changes. Mean (±SD) age at first surgery increased from 6.1±2.9 years in 2007 to 7.8±2.5 years in 2017 (R=0.78, P<0.001). As a proportion of new implants, magnetically controlled growing rods increased from <5% during the first 2 years to 83% in the last 2 years of the study. Vertically expandable prosthetic titanium ribs decreased from a peak of 48% to 6%; growth-guidance devices decreased from 10% to 3%. No change was seen in mean surgical lengthening intervals (range, 6 to 9 mo) for the 614 patients with recorded lengthenings. Final fusion was performed in 88% of patients who had undergone definitive treatment, occurring at a mean age of 13.4±2.4 years.

Conclusions: From 2007 to 2017, neuromuscular EOS was the most common diagnosis for patients treated with growth-friendly implants. Patient age at first surgery and the use of magnetically controlled growing rods increased during this time. Preoperative curve magnitude, traditional growing rod lengthening intervals, and rates of final fusion did not change.

Level Of Evidence: Level II.
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http://dx.doi.org/10.1097/BPO.0000000000001594DOI Listing
September 2020

Growth-preserving instrumentation in early-onset scoliosis patients with multi-level congenital anomalies.

Spine Deform 2020 10 25;8(5):1117-1130. Epub 2020 May 25.

University of California, San Diego, CA, USA.

Study Design: Retrospective.

Objectives: To assess final outcomes in patients with early-onset scoliosis (EOS) who underwent growth-preserving instrumentation (GPI). Various types of growth-preserving instrumentation (GPI) are frequently employed, but until recently had not been utilized long enough to assess final outcomes.

Methods: GPI "graduates" with multi-level congenital curves were identified. Graduation was defined as a final fusion or 5 years of follow-up without planned future surgeries. Outcomes included radiographic parameters and complications.

Results: 26 patients were included. 11 had associated diagnoses; eight had fused ribs. 17 were treated with traditional growing rods, seven with vertically expandable prosthetic ribs, and two with Shilla procedures. The mean GPI spanned 12.3 levels including 10.7 motion segments, age at index surgery was 5.5 years, treatment spanned 7.5 years, and follow-up was 9.2 years. 24 patients underwent final fusion. Mean major curve decreased from 73° to 49° with index surgery (p < 0.01) and remained unchanged through a final follow-up. Final major curve was < 40° in 9 patients (35%), 40°-60° in 11 patients (42%), and > 60° in 6 patients (23%). None worsened throughout treatment. Mean T1-T12 height increased 2.4 cm with index surgery (p = 0.02) and 5.4 cm total (p < 0.01). T1-T12 height increased in all patients and was ultimately < 18 cm in 10 patients (38%), 18-22 cm in 10 patients (38%), and > 22 cm in 6 patients (23%). On average, there were 2.6 complications per patient, including 1.7 implant failures. 12 patients (46%) experienced ≥ 3 complications; four patients (15%) experienced none.

Conclusion: We observed successful prevention of deformity progression but substantial residual deformity among GPI graduates with multi-level congenital EOS. Most coronal curve correction was attained during GPI implantation; thoracic height improved throughout treatment. While some favorable results were found, treatment strategies allowing improved deformity correction would be valuable for this challenging population.

Level Of Evidence: Therapeutic-III.
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http://dx.doi.org/10.1007/s43390-020-00124-2DOI Listing
October 2020

MRI utilization and rates of abnormal pretreatment MRI findings in early-onset scoliosis: review of a global cohort.

Spine Deform 2020 10 24;8(5):1099-1107. Epub 2020 Apr 24.

Department of Orthopaedic Surgery, University of California, San Diego, San Diego, CA, USA.

Study Design: Retrospective review OBJECTIVES: To report the frequency of pretreatment magnetic resonance imaging (MRI) utilization and rates and types of intra-spinal abnormalities identified on MRI in patients with early-onset scoliosis (EOS). MRI can help identify spinal cord abnormalities in patients with EOS.

Methods: We reviewed data from patients enrolled from 1993-2018 in an international EOS registry. Patients with incomplete/unverifiable data and those with spinal deformities secondary to infection or tumor were excluded, leaving 1343 patients for analysis. Demographic characteristics, pretreatment major curve magnitude, treatment type, and MRI findings were analyzed. Patients were categorized by EOS type (congenital, idiopathic, neuromuscular, syndromic), pretreatment MRI utilization, and presence of intra-spinal abnormality on MRI. Univariate testing and multivariate logistic regression were performed to identify demographic, radiographic, and clinical predictors of MRI utilization and abnormal MRI findings.

Results: MRI was used in 836 patients (62%). Pretreatment MRI utilization rates ranged from 42% in neuromuscular EOS to 74% in congenital EOS. Prevalence of abnormal MRI findings was 24% overall, ranging from 13% in patients with idiopathic EOS to 39% in neuromuscular EOS. Compared with white/Caucasian patients, Asian/Asian-American patients had higher odds of MRI utilization and abnormal MRI findings. Treatment type, pretreatment major curve magnitude, age at MRI, and age at treatment were not associated with abnormal MRI findings. Overall, 249 abnormalities were identified in 197 patients. The most common findings were syrinx and tethered cord. Syrinx with Chiari malformation was the most frequent combination of abnormal findings.

Conclusion: In the two-thirds of patients who underwent MRI before EOS treatment, findings were abnormal in 24%. EOS type and race/ethnicity were associated with both MRI utilization and abnormal findings. The most frequent abnormalities were syrinx and tethered cord, and the type of abnormalities appeared to differ by EOS type.

Level Of Evidence: Prognostic, Level III.
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http://dx.doi.org/10.1007/s43390-020-00115-3DOI Listing
October 2020

Anterior Column Realignment: Analysis of Neurological Risk and Radiographic Outcomes.

Neurosurgery 2020 09;87(3):E347-E354

Department of Research, San Diego Spine Foundation, San Diego, California.

Background: Anterior column realignment (ACR) is a less invasive alternative to 3-column osteotomy for the correction of sagittal imbalance. We hypothesized that ACR would correct sagittal imbalance with an acceptable neurological risk.

Objective: To assess long-term neurological and radiographic outcomes after ACR.

Methods: Patients ≥18 yr who underwent ACR from 2005 to 2013 were eligible. Standing scoliosis radiographs were studied at preoperation, postoperation (≤6 wk), and at minimum 2 yr of follow-up. Clinical/radiographic data were collected through a retrospective chart review, with thoracic 1 spino-pelvic inclination (T1SPi) used as the angular surrogate for sagittal vertical axis.

Results: A total of 26 patients had complete data, with a mean follow-up of 2.8 yr (1.8-7.4). Preoperative, sagittal parameters were lumbar lordosis (LL) of -16.1°, pelvic incidence (PI)-LL of 41.7°, T1SPi of 3.6°, and pelvis tilt (PT) of 32.4°. LL improved by 30.6° (P < .001) postoperation. Mean changes in PT (-8.3), sacral slope (8.9), T1SPi (-4.9), and PI-LL (-33.5) were all significant. The motion segment angle improved by 26.6°, from 5.2° to -21.4° (P < .001). Neurological complications occurred in 32% patients postoperation (n = 8; 1 patient with both sensory and motor). New thigh numbness/paresthesia developed in 3 (13%) patients postoperation; only 1 (4%) persisted at latest follow-up. A total of 6 (24%) patients developed a new lower extremity motor deficit postoperation, with 4 (8%) having persistent new weakness at last follow-up. Out of 8 patients with preoperative motor deficit, half saw improvement postoperation and 75% improved by last follow-up.

Conclusion: There was net motor improvement, with 24% of patients improving and 16% having persistent new weakness at latest follow-up; 60% were unchanged. Radiographic results demonstrate that ACR is a useful tool to treat severe sagittal plane deformity.
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http://dx.doi.org/10.1093/neuros/nyaa064DOI Listing
September 2020

Idiopathic Early-onset Scoliosis: Growing Rods Versus Vertically Expandable Prosthetic Titanium Ribs at 5-year Follow-up.

J Pediatr Orthop 2020 Mar;40(3):142-148

Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD.

Background: Distraction-based techniques allow spinal growth until skeletal maturity while preventing curve progression.

Methods: Two multicenter early-onset scoliosis databases were used to identify patients with idiopathic spine abnormalities treated with traditional growing rods (TGR) or vertically expandable titanium ribs (VEPTR). Patients underwent at least 4 lengthenings and had at least 5-year follow-up. Significance was set at P<0.05.

Results: In total, 50 patients treated with TGR and 22 treated with VEPTR were included. Mean (±SD) age at surgery was 5.5 (±2.0) years for the TGR group versus 4.3 (±1.9) years for the VEPTR group (P=0.044); other demographic parameters were similar. VEPTR patients had more procedures (mean 15±4.2) than TGR patients (mean 10±4.0) (P=0.001). Unilateral constructs were present in 18% (4 of 22) of VEPTR and 16% (8 of 50) of TGR patients. Bilateral constructs spanned a mean 2.1 additional surgical levels and exposed patients to 1.6 fewer procedures than unilateral constructs. Curve correction was similar between bilateral and unilateral constructs. TGR patients experienced greater curve correction (50%) than VEPTR patients (27%) (P<0.001) and achieved a greater percentage of thoracic height gain (24%) than VEPTR patients (12%) (P=0.024). At latest follow-up, TGR patients had better maintenance of curve correction, less kyphosis, and 15% greater absolute gain in thoracic height versus VEPTR patients. TGR patients had a lower rate of wound complications (14%) than VEPTR patients (41%) (P=0.011).

Conclusions: In patients with idiopathic early-onset scoliosis, TGRs produced greater initial curve correction, greater thoracic height gains, less kyphosis, and lower incidence of wound complications compared with VEPTR.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BPO.0000000000001202DOI Listing
March 2020

A high degree of variability exists in how "safety and efficacy" is defined and reported in growing rod surgery for early onset scoliosis: a systematic review.

Spine Deform 2020 04 8;8(2):269-283. Epub 2020 Jan 8.

San Diego Spine Foundation, 6190 Cornerstone Ct, Ste 212, San Diego, CA, 92121, USA.

Established criteria for reporting safety and efficacy have not yet been defined in growing rod surgery for early onset scoliosis. A systematic literature review revealed a high degree of variability in how authors stratified complications and patient outcomes as a means to define safety and efficacy for this challenging patient population.

Introduction: Several publications have reported the safety and efficacy of traditional growing rods (TGR) and magnetically controlled growing rods (MCGR) using various parameters. Radiographic parameters are most commonly used to measure efficacy, while incidence and type of complications are used to assess safety. A systematic review of peer-reviewed articles was performed to identify whether a consensus exists in how safety and efficacy parameters are reported in EOS patients treated with TGR and MCGR.

Hypothesis: There is no consensus on the parameters used for reporting safety and efficacy in growing rod treatment for early onset scoliosis.

Study Design: Systematic literature review.

Methods: Four databases were searched on November 10, 2016 to identify all qualified peer-reviewed articles using specific keyword searches. All peer-reviewed articles published in English language reporting any data related to safety and efficacy of the TGR and/or MCGR surgical technique were included. Articles that met the inclusion criteria were scored by modified Downs and Black scoring system (J Epidemiol Community Health 52(6):377-384, 1998) for non-randomized studies. All reported safety and efficacy data were extracted and analyzed.

Results: Search of the databases resulted in 111 unique citations including: PubMed (50), Embase (68 with 21 duplicates), Web of Science (29 with 15 duplicates), and CINAHL (15; all duplicates). Fifty-six of 111 citations were excluded during the review of the titles and abstracts. In addition, 16 citations were excluded at the time of full manuscript review. The remaining 39 articles included 23 TGR (2007-2016) and 16 MCGR papers (2012-2016). The overall Downs and Black score was 63.9 for TGR papers vs. 64.0 for MCGR papers (p = 0.97). Efficacy measures were not consistently reported among the publications. The only consistently reported efficacy parameter in majority (> 90%) of papers was curve size. Complication reporting was highly variable.

Conclusion: Major curve size was the only consistent parameter to report efficacy in peer-reviewed TGR and MCGR publications. Since complications were not consistently reported, assessing safety of either treatment was infeasible. Establishing standardized safety and efficacy parameters in growing rod surgery for EOS would improve the quality of future studies and makes comparison of different treatment modalities possible. Indeed, other clinically relevant parameters such as health-related quality of life, pulmonary function, nutritional status, and psychiatric and developmental health should also be considered to improve the future safety and efficacy reporting.
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http://dx.doi.org/10.1007/s43390-019-00004-4DOI Listing
April 2020

Results of growth-friendly management of early-onset scoliosis in children with and without skeletal dysplasias: a matched comparison.

Bone Joint J 2019 12;101-B(12):1563-1569

Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA.

Aims: The aim of this study was to compare the surgical and quality-of-life outcomes of children with skeletal dysplasia to those in children with idiopathic early-onset scoliosis (EOS) undergoing growth-friendly management.

Patients And Methods: A retrospective review of two prospective multicentre EOS databases identified 33 children with skeletal dysplasia and EOS (major curve ≥ 30°) who were treated with growth-friendly instrumentation at younger than ten years of age, had a minimum two years of postoperative follow-up, and had undergone three or more lengthening procedures. From the same registries, 33 matched controls with idiopathic EOS were identified. A total of 20 children in both groups were treated with growing rods and 13 children were treated with vertical expandable prosthetic titanium rib (VEPTR) instrumentation.

Results: Mean preoperative major curves were 76° (34° to 115°) in the skeletal dysplasia group and 75° (51° to 113°) in the idiopathic group (p = 0.55), which were corrected at final follow-up to 49° (13° to 113°) and 46° (12° to 112°; p = 0.68), respectively. T1-S1 height increased by a mean of 36 mm (0 to 105) in the skeletal dysplasia group and 38 mm (7 to 104) in the idiopathic group at the index surgery (p = 0.40), and by 21 mm (1 to 68) and 46 mm (7 to 157), respectively, during the distraction period (p = 0.0085). The skeletal dysplasia group had significantly worse scores in the physical function, daily living, financial impact, and parent satisfaction preoperatively, as well as on financial impact and child satisfaction at final follow-up, than the idiopathic group (all p < 0.05). The domains of the 24-Item Early-Onset Scoliosis Questionnaire (EOSQ24) remained at the same level from preoperative to final follow-up in the skeletal dysplasia group (all p > 0.10).

Conclusion: Children with skeletal dysplasia gained significantly less spinal growth during growth-friendly management of their EOS and their health-related quality of life was significantly lower both preoperatively and at final follow-up than in children with idiopathic EOS. Cite this article: 2019;101-B:1563-1569.
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http://dx.doi.org/10.1302/0301-620X.101B12.BJJ-2019-0735.R1DOI Listing
December 2019

Resting Pain Level as a Preoperative Predictor of Success With Indirect Decompression for Lumbar Spinal Stenosis: A Pilot Study.

Global Spine J 2019 Apr 26;9(2):150-154. Epub 2018 Jul 26.

San Diego Spine Foundation, San Diego, CA, USA.

Study Design: Retrospective review of a single institution.

Objective: To determine if resting leg pain level is a predictor of success for indirect decompression in the setting of lumbar spinal stenosis, with lower levels of rest pain correlating with greater likelihood of successful indirect decompression.

Methods: Reviewed anterior or lateral lumbar interbody fusions from T12 to L5-S1 patients with a posterior-based pedicle screw-rod construct. Patients were separated into 2 groups based on a preoperative response to Oswestry Disability Index (ODI) Question 7 regarding level of pain at rest in the supine position. Responses of 0 to 2 (minimal rest pain) were group 1 (n = 54) and responses of 3 to 5 (significant rest pain) were group 2 (n = 16).

Results: Preoperative difference was detected between groups 1 and 2, in ODI (38 vs 63, < .001) and Numeric Rating Scale (NRS) back (6.8 vs 7.9, = .023). Three-month NRS leg and back scores were significantly lower in group 1 (leg, 1.9 vs 4.8, < .001; back, 3.5 vs 6.4, = .001). A significant difference was further noted in the percentage decrease in NRS leg and back scores from pre- to 3 months postoperatively between groups 1 and 2 (leg, 68.4% vs 22.7%, < .001; back, 40.0% vs 7.4%, = .012). Group 1 reached minimal clinically important difference for leg pain more often than group 2 (83.3% vs 43.8%, = .001).

Conclusion: Preoperative assessment of rest pain level in the supine position has a significant association with reduction in NRS leg and back scores in patients undergoing indirect decompression for lumbar spinal stenosis. This tool may successfully indicate which patients will be candidates for indirect decompression with interbody fusion from an anterior or lateral approach.
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http://dx.doi.org/10.1177/2192568218765986DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6448191PMC
April 2019

Early and Late Reoperation Rates With Various MIS Techniques for Adult Spinal Deformity Correction.

Global Spine J 2019 Feb 10;9(1):41-47. Epub 2018 May 10.

University of California, San Francisco, CA, USA.

Study Design: A multicenter retrospective review of an adult spinal deformity database.

Objective: We aimed to characterize reoperation rates and etiologies of adult spinal deformity surgery with circumferential minimally invasive surgery (cMIS) and hybrid (HYB) techniques.

Methods: Inclusion criteria were age ≥18 years, and one of the following: coronal Cobb >20°, sagittal vertical axis >5 cm, pelvic tilt >20°, and pelvic incidence-lumbar lordosis >10°. Patients with either cMIS or HYB surgery, ≥3 spinal levels treated with 2-year minimum follow-up were included.

Results: A total of 133 patients met inclusion for this study (65 HYB and 68 cMIS). Junctional failure (13.8%) was the most common reason for reoperation in the HYB group, while fixation failure was the most common reason in the cMIS group (14.7%). There was a higher incidence of proximal junctional failure (PJF) than distal junctional failure (DJF) within HYB (12.3% vs 3.1%), but no significant differences in PJF or DJF rates when compared to cMIS. Early (<30 days) reoperations were less common (cMIS = 1.5%; HYB = 6.1%) than late (>30 days) reoperations (cMIS = 26.5%; HYB = 27.7%), but early reoperations were more common in the HYB group after propensity matching, largely due to infection rates (10.8% vs 0%, = .04).

Conclusions: Adult spinal deformity correction with cMIS and HYB techniques result in overall reoperation rates of 27.9% and 33.8%, respectively, at minimum 2-year follow-up. Junctional failures are more common after HYB approaches, while pseudarthrosis/fixation failures happen more often with cMIS techniques. Early reoperations were less common than later returns to the operating room in both groups, but cMIS demonstrated less risk of infection and early reoperation when compared with the HYB group.
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http://dx.doi.org/10.1177/2192568218761032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6362559PMC
February 2019

Growth-Friendly Spine Surgery in Escobar Syndrome.

J Pediatr Orthop 2019 Aug;39(7):e506-e513

Department of Orthopaedic Surgery, University of California-San Diego, San Diego, CA.

Background: The aims of this study were to characterize the spinal deformity of patients with Escobar syndrome, describe results of growth-friendly treatments, and compare these results with those of an idiopathic early-onset scoliosis (EOS) cohort to determine whether the axial stiffness in Escobar syndrome limited correction.

Methods: We used 2 multicenter databases to review the records of 8 patients with EOS associated with Escobar syndrome who had at least 2-year follow-up after initiation of growth-friendly treatment from 1990 to 2016. An idiopathic EOS cohort of 16 patients matched for age at surgery (±1 y), postoperative follow-up (±1 y), and initial curve magnitude (±10 degrees) was identified. A randomized 1:2 matching algorithm was applied (α=0.05).

Results: In the Escobar group, spinal deformity involved 7 to 13 vertebrae and ranged from no vertebral anomalies in 3 patients to multiple segmentation defects in 6 patients. Mean age at first surgery was 5 years (range, 1.4 to 7.8 y) with a mean follow-up of 7.5 years (range, 4.0 to 10 y). Mean major curve improved from 76 degrees at initial presentation, to 43 degrees at first instrumentation, to 37 degrees at final follow-up (both P<0.001). Mean pelvic obliquity improved from 16 degrees (range, 5 to 31 degrees) preoperatively to 4 degrees (range, 0 to 8 degrees) at final follow-up (P=0.005). There were no differences in the mean percentage of major curve correction between the idiopathic EOS and Escobar groups at the immediate postoperative visit (P=0.743) or final follow-up (P=0.511). There were no differences between the cohorts in T1-S1 height at initial presentation (P=0.129) or in growth per month (P=0.211).

Conclusions: Multiple congenital fusions and spinal curve deformity are common in Escobar syndrome. Despite large areas of congenital fusion, growth-friendly constructs facilitate spinal growth and improve curve correction. These results are comparable to those in idiopathic EOS.

Level Of Evidence: Level III-case-control study.
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http://dx.doi.org/10.1097/BPO.0000000000001315DOI Listing
August 2019

Surgical and Health-related Quality-of-Life Outcomes of Growing Rod "Graduates" With Severe versus Moderate Early-onset Scoliosis.

Spine (Phila Pa 1976) 2019 May;44(10):698-706

Department of Orthopaedic Surgery, University of California-San Diego, San Diego, CA.

Study Design: A retrospective review of a prospective, multicenter database.

Objective: The aim of this study was to compare surgical and quality-of-life outcomes at the end of growing rod treatment in patients with severe versus moderate early-onset scoliosis (EOS).

Summary Of Background Data: Knowledge of the outcomes of severe EOS after growth-friendly treatment is limited because this condition is uncommon.

Methods: We identified 40 children with severe EOS (major curve ≥90°) treated with growing rods before age 10 with minimum 2-year follow-up after last lengthening or final fusion. From the same registry, we matched 40 patients with moderate EOS (major curve < 90°). Twenty-seven patients in the severe group and 12 in the moderate group underwent final fusion (P < 0.001).

Results: Mean preoperative curves were 102° (range, 90°-139°) in the severe group and 63° (range, 33°-88°) in the moderate group (P < 0.001). At final follow-up, mean curves were 56° (range, 10°-91°) and 36° (range, 12°-89°), respectively (P < 0.001). Fourteen (35%) children in the severe group and 32 (80%) in the moderate group had scoliosis of < 45° at final follow-up [risk ratio (RR), 0.44; 95% confidence interval (95% CI), 0.20-0.57]. At final follow-up, 30 (75%) children in the severe group and 35 (88%) in the moderate group had achieved T1-T12 length of ≥18 cm (RR, 0.86; 95% CI, 0.70-1.09). Thirty-five children in the severe group and 26 in the moderate group had at least one complication (RR, 1.35; 95% CI, 1.05-1.73). Mean 24-Item Early-Onset Scoliosis Questionnaire scores were similar between groups at final follow-up.

Conclusion: Delaying surgery until the major curve has progressed beyond 90° is associated with larger residual deformity and more complications than treating at a lesser curve magnitude. Quality-of-life outcomes were similar between those with severe and moderate EOS.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000002922DOI Listing
May 2019

Preservation of Spine Motion in the Surgical Treatment of Adolescent Idiopathic Scoliosis Using an Innovative Apical Fusion Technique: A 2-Year Follow-Up Pilot Study.

Int J Spine Surg 2018 Aug 31;12(4):441-452. Epub 2018 Aug 31.

San Diego Spine Foundation, San Diego, California.

Background: This trial reports the 2-year and immediate postremoval clinical outcomes of a novel posterior apical short-segment (PASS) correction technique allowing for correction and stabilization of adolescent idiopathic scoliosis (AIS) with limited fusion.

Methods: Twenty-one consecutive female AIS patients were treated at 4 institutions with this novel technique. Arthrodesis was limited to the short apical curve after correction with translational and derotational forces applied to upper and lower instrumented levels. Instrumentation spanned fused and unfused segments with motion and flexibility of unfused segments maintained. The long concave rods were removed at maturity. Radiographic data collected included preoperative and postoperative data for up to 2 years as well as after long rod removal.

Results: All 21 patients are beyond 2 years postsurgery. Average age at surgery was 14.2 years (11-17 years). A mean of 10.5 ± 1 levels per patient were stabilized and 5.0 ± 0.5 levels (48%) were fused. Cobb angle improved from 56.1° ± 8.0° to 20.8° ± 7.8° (62.2% improvement) at 1 year and 20.9° ± 8.4°, (62.0% improvement) at 2 years postsurgery. In levels instrumented but not fused, motion was 26° ± 6° preoperatively compared to 10° ± 4° at 1 year postsurgery, demonstrating 38% maintenance of mobility in nonfused segments. There was no report of implant-related complications.

Conclusions: PASS correction technique corrected the deformity profile in AIS patients with a lower implant density while sparing 52% of the instrumented levels from fusion through the 2-year follow-up.
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http://dx.doi.org/10.14444/5053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6159724PMC
August 2018

Construct Levels to Anchored Levels Ratio and Rod Diameter Are Associated With Implant-Related Complications in Traditional Growing Rods.

Spine Deform 2018 May - Jun;6(3):320-326

Growing Spine Foundation, 555 E Wells St, Milwaukee, WI 53202, USA.

Introduction: In addition to patient characteristics, consideration of length of construct to number of anchored levels ratio and rod diameter should be a part of preoperative planning to minimize implant-related complications (IRCs). IRCs including rod breakage, anchor dislodgement, and pullout are among the most common adverse events in traditional growing rods (TGRs). The current study hypothesized that anchor type and configuration are associated with IRC.

Methods: Patients with (1) age ≤10 years at surgery; (2) spine-based dual TGR; (3) minimum 2-year follow-up; and (4) available imaging. Cephalad and caudal foundations were grouped based on the number of instrumented levels and anchor type. All radiographs were reviewed. Based on the results, a "construct levels / anchored levels" (CL/AL) ratio was calculated, which is the number of levels spanned by instrumentation divided by the number of levels with bone-anchor fixation. Receiver operating characteristic curve was used to define the CL/AL threshold.

Results: 274 patients divided into patients with complications (IRC+, n = 140) and without complications (IRC-, n = 134) groups. Mean follow-up was 6.3 years (2.1-18.0 years). No significant differences in age, gender, body mass index, ambulatory status, etiology, primary curve size, T1-S1 height, coronal and sagittal balance, and rod material were observed between the two groups. Comparative analysis showed that connector type, presence and location of crosslinks, number of levels instrumented, number and type of anchors, presence of pelvic fixation, and mirroring of cephalad and caudal foundations were not different. However, maximum kyphosis and rod diameter were significantly different. The CL/AL ratio threshold was 3.5. Multivariate analysis of kyphosis, rod diameter, and CL/AL ratio showed a significant association with IRC (p < .05).

Discussion And Conclusion: Although patient characteristics like kyphosis have been proven to be associated with instrumentation failure, it is a combination of characteristics that include rod diameter and CL/AL ratio that showed significant correlation with IRC. Validation of the CL/AL ratio is recommended.
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http://dx.doi.org/10.1016/j.jspd.2017.11.004DOI Listing
January 2019

Expert Consensus and Equipoise: Planning a Randomized Controlled Trial of Magnetically Controlled Growing Rods.

Spine Deform 2018 May - Jun;6(3):303-307

Columbia University Medical Center, 3959 Broadway, 8 North, New York, NY 10032, USA.

Study Design: Expert consensus building using combined Delphi method and Nominal group technique.

Objectives: To identify the current state of equipoise surrounding the use of magnetically controlled growing rods (MCGRs) and to determine consensus for planning a randomized controlled trial (RCT) with MCGRs.

Background: The use of MCGRs for the treatment of early-onset scoliosis (EOS) is a new technology. Optimal use has not been thoroughly investigated and much uncertainty exists. Areas of uncertainty include construct architecture, timing of lengthenings, and amount of distraction per lengthening. Expert discussion and consensus is useful at this early juncture and necessary when designing an RCT.

Methods: Two rounds of surveys were administered to a group of experienced pediatric spine surgeons, followed by a 2-hour, face-to-face meeting in November 2015 and a 1-hour, face-to-face meeting in February 2016. The first survey used example cases to establish agreement around the proper use of MCGRs and identified areas of equipoise and disagreement. The second survey again used example cases-this time selected for their equipoise status-to solicit trial arms for a potential RCT of MCGRs and identified important open questions in the use of MCGRs. Lastly, the face-to-face meetings employed iterative voting to preliminarily plan an RCT of MCGRs.

Results: Following the Delphi survey rounds and the two Nominal face-to-face meetings, the group of experts decided on an MCGR RCT design that standardized all patients to bidirectional constructs, and randomized to a lengthening interval of 6 versus 16 weeks with a standardized equation for calculating the total yearly lengthening that approximates normal spine growth.

Conclusion: This endeavor indicates expert support for the use of MCGR in children older than 6 years, with curves greater than 60°. The uncertainty surrounding frequency of lengthening justifies an RCT of MCGRs.

Level Of Evidence: Level V.
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http://dx.doi.org/10.1016/j.jspd.2017.11.002DOI Listing
January 2019

Peak Timing for Complications After Adult Spinal Deformity Surgery.

World Neurosurg 2018 Jul 22;115:e509-e515. Epub 2018 Apr 22.

Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA.

Background: Overall complication rates for adult spinal deformity (ASD) surgery have been reported; however, little data exist on the peak timing associated with specific complications. This study quantifies the peak timing for multiple complication types in an ASD cohort at minimum 2-year follow-up.

Methods: Multicenter, prospective analysis of all complications after ASD surgery in a consecutively enrolled cohort was performed. Inclusion criteria were ASD, age ≥18 years, spinal fusion ≥4 levels, and minimum 2-year follow-up. Complications included major and minor and specific complication types. Peak timing of specific complications was identified and described. Regression analysis was performed to assess correlation between patient/surgical factors and complication timing.

Results: There were 280 patients who met the inclusion criteria. Mean follow-up time was 2.9 years (range, 2-5 years). Of the patients, 209 (74.6%) had at least 1 complication, accounting for 529 total complications (258 minor and 271 major). Both major and minor complications peaked at <3 months. Infection and neurologic complications peaked at <3 months. Proximal junctional kyphosis had bimodal peaks at <3 and >24 months. Implant failure peaked at 12-24 and >24 months. There was a significant positive correlation between preoperative sagittal vertical axis and total complications at 6-12 months, major complications at 24 months, and reoperation. Body mass index was associated with total complications and implant failure at 12-24 and >24 months.

Conclusions: The peak timing of specific complications after ASD surgery is identifiable. Understanding when these complications are likely to occur may improve patient counseling, early diagnosis, and prophylactic interventions and may help inform future reimbursement models.
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http://dx.doi.org/10.1016/j.wneu.2018.04.084DOI Listing
July 2018

Preliminary results of anterior lumbar interbody fusion, anterior column realignment for the treatment of sagittal malalignment.

Neurosurg Focus 2017 Dec;43(6):E6

San Diego Spine Foundation, San Diego.

OBJECTIVE Sagittal malalignment decreases patients' quality of life and may require surgical correction to achieve realignment goals. High-risk posterior-based osteotomy techniques are the current standard treatment for addressing sagittal malalignment. More recently, anterior lumbar interbody fusion, anterior column realignment (ALIF ACR) has been introduced as an alternative for correction of sagittal deformity. The objective of this paper was to report clinical and radiographic results for patients treated using the ALIF-ACR technique. METHODS A retrospective study of 39 patients treated with ALIF ACR was performed. Patient demographics, operative details, radiographic parameters, neurological assessments, outcome measures, and preoperative, postoperative, and mean 1-year follow-up complications were studied. RESULTS The patient population comprised 39 patients (27 females and 12 males) with a mean follow-up of 13.3 ± 4.7 months, mean age of 66.1 ± 11.6 years, and mean body mass index of 27.3 ± 6.2 kg/m. The mean number of ALIF levels treated was 1.5 ± 0.5. Thirty-three (84.6%) of 39 patients underwent posterior spinal fixation and 33 (84.6%) of 39 underwent posterior column osteotomy, of which 20 (60.6%) of 33 procedures were performed at the level of the ALIF ACR. Pelvic tilt, sacral slope, and pelvic incidence were not statistically significantly different between the preoperative and postoperative periods and between the preoperative and 1-year follow-up periods (except for PT between the preoperative and 1-year follow-up, p = 0.018). Sagittal vertical axis, T-1 spinopelvic inclination, lumbar lordosis, pelvic incidence-lumbar lordosis mismatch, intradiscal angle, and motion segment angle all improved from the preoperative to postoperative period and the preoperative to 1-year follow-up (p < 0.05). The changes in motion segment angle and intradiscal angle achieved in the ALIF-ACR group without osteotomy compared with the ALIF-ACR group with osteotomy at the level of ACR were not statistically significant. Total visual analog score, Oswestry Disability Index, and Scoliosis Research Society-22 scores all improved from preoperative to postoperative and preoperative to 1-year follow-up. Fourteen patients (35.9%) experienced 26 complications (15 major and 11 minor). Eleven patients required reoperation. The most common complication was proximal junctional kyphosis (6/26 complications, 23%) followed by vertebral body/endplate fracture (3/26, 12%). CONCLUSIONS This study showed satisfactory radiographic and clinical outcomes at the 1-year follow-up. Proximal junctional kyphosis was the most common complication followed by fracture, complications that are commonly associated with sagittal realignment surgery and may not be mitigated by the anterior approach.
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http://dx.doi.org/10.3171/2017.8.FOCUS17423DOI Listing
December 2017

Is There a Patient Profile That Characterizes a Patient With Adult Spinal Deformity as a Candidate for Minimally Invasive Surgery?

Global Spine J 2017 Oct 28;7(7):703-708. Epub 2017 Jul 28.

University of California, San Francisco, CA, USA.

Study Design: Retrospective review.

Objectives: The goal of this study was to evaluate the baseline characteristics of patients chosen to undergo traditional open versus minimally invasive surgery (MIS) for adult spinal deformity (ASD).

Methods: A multicenter review of 2 databases including ASD patients treated with surgery. Inclusion criteria were age >45 years, Cobb angle minimum of 20°, and minimum 2-year follow-up. Preoperative radiographic parameters and disability outcome measures were reviewed.

Results: A total of 350 patients were identified: 173 OPEN patients and 177 MIS. OPEN patients were significantly younger than MIS patients (61.5 years vs 63.74 years, = .013). The OPEN group had significantly more females (87% vs 76%, = .006), but both groups had similar body mass index. Preoperative lumbar Cobb was significantly higher for the OPEN group (34.2°) than for the MIS group (26.0°, < .001). The mean preoperative Oswestry Disability Index was significantly higher in the MIS group (44.8 in OPEN patients and 49.8 in MIS patients, < .011). The preoperative Numerical Rating Scale value for back pain was 7.2 in the OPEN group and 6.8 in the MIS group preoperatively, = .100.

Conclusions: Patients chosen for MIS for ASD are slightly older and have smaller coronal deformities than those chosen for open techniques, but they did not have a substantially lesser degree of sagittal malalignment. MIS surgery was most frequently utilized for patients with an sagittal vertical axis under 6 cm and a baseline pelvic incidence and lumbar lordosis mismatch under 30°.
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http://dx.doi.org/10.1177/2192568217716151DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5624382PMC
October 2017

Unplanned Reoperations in Magnetically Controlled Growing Rod Surgery for Early Onset Scoliosis With a Minimum of Two-Year Follow-Up.

Spine (Phila Pa 1976) 2017 Dec;42(24):E1410-E1414

Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong.

Study Design: A retrospective review of prospectively collected clinical and radiologic data of patients with magnetically controlled growing rods (MCGRs) from a multi-centered study with a minimum of 2-year follow-up.

Objective: The aim of this study was to describe the incidence and causes of unplanned reoperations and to report the outcomes of patients treated with MCGR for early-onset scoliosis (EOS).

Summary Of Background Data: Published clinical studies have demonstrated that MCGR is safe and effective for curvature control of EOS, and can avoid repeated surgeries for distractions. However, there have been no reports on the unplanned reoperations and complications of MCGR for EOS with a large series of patients.

Methods: Between 2009 and 2012, 30 patients with EOS underwent MCGR implantation in six institutions. A retrospective review of prospectively collected clinical and radiologic data with a minimum of 2-year follow-up was conducted. Demographic data, radiologic measurements, unplanned reoperations, and other complications were noted. Risk factors for unplanned reoperations were analyzed.

Results: Patients underwent MCGR implantation at the mean age of 7.2 years. The mean follow-up period was 37 months. Fourteen patients (46.7%) underwent an unplanned reoperation within the follow-up period, with a mean time to reoperation of 23 months after initial surgery (range, 5-48 months). Causes of unplanned reoperation were failure of rod distractions, proximal foundation failure, rod breakage, and infection. More frequent distractions (between 1 week and 2 months) were associated with a higher rate of reoperation than distraction frequencies between 3 and 6 months (71% vs. 25%).

Conclusion: This is the largest series with the longest follow-up to date that examines the need for additional unplanned surgery after the initial procedure. It highlights that MCGR surgery can be associated with unplanned reoperations, and more frequent distractions may be a risk factor. Long-term comparative studies with traditional growing rod are required to evaluate the effectiveness of this implant.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000002297DOI Listing
December 2017

A Critical Analysis of Sagittal Plane Deformity Correction With Minimally Invasive Adult Spinal Deformity Surgery: A 2-Year Follow-Up Study.

Spine Deform 2017 07;5(4):265-271

International Spine Study Group Foundation, 15480 Iola St., Brighton, CO 80602, USA.

Introduction: Sagittal plane realignment is important to achieve desirable clinical outcomes after adult spinal deformity (ASD) surgery. This study evaluates the impact of minimally invasive (MIS) techniques on sagittal plane alignment and clinical outcomes in ASD patients.

Methods: A retrospective, multi-center review of ASD patients (age ≥18 years, and with one of the following: coronal Cobb ≥20°, sagittal vertical axis [SVA] >5 cm, and/or pelvic tilt >25°), MIS surgery, and four or more levels instrumented. Patients were stratified by baseline SRS-Schwab global alignment modifier (GAM) into three groups: 0 (SVA <4 cm), + (SVA 4-9.5 cm), or ++ (SVA >9.5 cm). Radiographic and clinical outcomes measures were analyzed with a minimum of 2-year follow-up.

Results: A total of 96 ASD patients were identified, and 63 met the study's inclusion criteria of circumferential MIS or posterior MIS only, with four or more levels instrumented (n: Group 0 = 37, Group + = 15, and Group ++ = 11). Group 0 was younger than ++ (56.8 vs. 69.6 years), with a higher proportion of females than Group + or ++ (83.8% vs. 66.7% and 54.5%, respectively). Baseline HRQoL was similar. Postoperatively, Groups 0 and + had improved Oswestry Disability Index (ODI) and numeric rating scale (NRS) back and leg scores. Group ++ only had improvement in NRS scores. At the latest follow-up, Groups 0 and ++ had similar sagittal measurements except for PT (21.6 vs. 23.6, p = .009). The + group had improvement in PI-LL (24.2 to 17; p = .015) and LL (30.9 to 38.3; p = .013). Eight of 27 (21.6%) Group 0 patients deteriorated (4 to Group +, 4 to Group ++). Three of 15 (20.0%) Group + patients deteriorated to Group ++, and 3 improved to Group 0. Six of 11 (54.5%) Group ++ patients improved (3 to Group + and 3 to Group 0).

Conclusions: MIS techniques successfully stabilized ASD patients with Group 0 and + deformities and improved HRQoL. This study suggests that severe sagittal imbalance is not adequately treated with MIS approaches.
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http://dx.doi.org/10.1016/j.jspd.2017.01.010DOI Listing
July 2017

Anterior Column Realignment has Similar Results to Pedicle Subtraction Osteotomy in Treating Adults with Sagittal Plane Deformity.

World Neurosurg 2017 Sep 27;105:249-256. Epub 2017 May 27.

Department of Research, San Diego Spine Foundation, San Diego, California, USA.

Objective: Anterior column realignment (ACR) is a minimally invasive surgical technique used for the correction of adult sagittal plane deformity. ACR is performed via a minimally invasive lateral transpsoas approach with anterior longitudinal ligament release and hyperlordotic cage placement. The objective of this study was to compare radiographic outcomes and complications in patients treated by ACR or Pedicle subtraction osteotomy (PSO).

Methods: Patients who underwent ACR were matched with patients from a retrospective PSO dataset, by pelvic incidence, lumbar lordosis, and thoracic kyphosis. Inclusion criteria included pelvic incidence and lumbar lordosis mismatch > 10°, pelvic tilt > 25°, and/or C7 sagittal vertical axis >5 cm, and minimum 1-year follow-up.

Results: All (n = 17) patients who underwent ACR underwent second-stage open posterior instrumented fusion. There were no differences in baseline demographic or radiographic parameters. Both groups were found to have significant improvement from preoperative to final follow-up for lumbar lordosis, T1 spinopelvic inclination, and T1 pelvic angle. Pelvic tilt did not improve with PSO (31° to 28°) at final follow-up but did improve in ACR group (34° to 25°). No differences were identified at 3-month or final follow-up for lumbar lordosis (51° vs. 47°), pelvic tilt (25° vs. 28°), and T1 pelvic angle (23° vs. 24°). The group undergoing PSO achieved greater T1 spinopelvic inclination correction (8° vs. 1.9°). Patients who underwent ACR had significantly less estimated blood loss than patients who underwent PSO (1.6 vs. 3.6 L, respectively), but no difference in the overall major complication rates was found (35.3% vs. 41.2%, respectively).

Conclusions: ACR achieved similar radiographic results as PSO in a matched cohort with significantly less estimated blood loss and similar overall complication rate.
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http://dx.doi.org/10.1016/j.wneu.2017.05.122DOI Listing
September 2017

Re-operation After Long-Segment Fusions for Adult Spinal Deformity: The Impact of Extending the Construct Below the Lumbar Spine.

Neurosurgery 2018 02;82(2):211-219

San Diego Spine Foundation, San Diego, California.

Background: Deciding where to end a long-segment fusion for adult spinal deformity (ASD) may be a challenge, particularly in the absence of an abnormality at L5/S1. Some suggest prophylactic extension of the construct to the sacrum and/or ilium (S/I) to protect against distal junctional failure, while others support terminating in the lower lumbar spine to preserve motion.

Objective: To compare the risk of re-operation after long-segment fusions for ASD that ends at L4 or L5 (L4/5) vs S/I.

Methods: A multicenter database of patients treated for ASD by circumferential minimally invasive surgery or hybrid surgical technique was screened for individuals with long fusions (≥4 vertebral levels) ending at L4 or below and with at least 2 yr of follow-up. Multivariate regression modeling was used to compare surgical morbidity between the L4/5 and S/I groups, and Cox proportional hazard modeling was used to compare risk of re-operation.

Results: There were 45 subjects with fusion to L4/5 and 71 to S/I. Over a 32-mo median follow-up, 41 re-operations were performed; 6 were for distal junctional failure. In those with normal or mild degeneration at L5/S1, fusion to S/I afforded no significant change in re-operative risk (hazard ratio = 1.18 [95% confidence interval: 0.53-2.62], P = .682). In those undergoing circumferential minimally invasive surgery correction, fusion to S/I was associated with significantly greater blood loss (499.6 cc, P < .001) and surgical time (97.5 min, P = .04).

Conclusion: In the setting of a normal or mildly degenerated L5/S1 disc space, fusion to the sacrum/ilium did not significantly change the risk of requiring a re-operation after a long-segment fusion for ASD.
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http://dx.doi.org/10.1093/neuros/nyx163DOI Listing
February 2018

Retrieval and clinical analysis of distraction-based dual growing rod constructs for early-onset scoliosis.

Spine J 2017 10 26;17(10):1506-1518. Epub 2017 Apr 26.

US Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD 20993, USA; Fischell Department of Bioengineering, University of Maryland, Room 2330, Jeong H. Kim Engineering Building, Bldg #225, College Park, MD 20742, USA.

Background Context: Growing rod constructs are an important contribution for treating patients with early-onset scoliosis. These devices experience high failure rates, including rod fractures.

Purpose: The objective of this study was to identify the failure mechanism of retrieved growing rods, and to identify differences between patients with failed and intact constructs.

Study Design/setting: Growing rod patients who had implant removal and were previously enrolled in a multicenter registry were eligible for this study.

Patient Sample: Forty dual-rod constructs were retrieved from 36 patients across four centers, and 34 of those constructs met the inclusion criteria. Eighteen constructs failed due to rod fracture. Sixteen intact constructs were removed due to final fusion (n=7), implant exchange (n=5), infection (n=2), or implant prominence (n=2).

Outcome Measures: Analyses of clinical registry data, radiographs, and retrievals were the outcome measures.

Methods: Retrievals were analyzed with microscopic imaging (optical and scanning electron microscopy) for areas of mechanical failure, damage, and corrosion. Failure analyses were conducted on the fracture surfaces to identify failure mechanism(s). Statistical analyses were performed to determine significant differences between the failed and intact groups.

Results: The failed rods fractured due to bending fatigue under flexion motion. Construct configuration and loading dictate high bending stresses at three distinct locations along the construct: (1) mid-construct, (2) adjacent to the tandem connector, or (3) adjacent to the distal anchor foundation. In addition, high torques used to insert set screws may create an initiation point for fatigue. Syndromic scoliosis, prior rod fractures, increase in patient weight, and rigid constructs consisting of tandem connectors and multiple crosslinks were associated with failure.

Conclusion: This is the first study to examine retrieved, failed growing rod implants across multiple centers. Our analysis found that rod fractures are due to bending fatigue, and that stress concentrations play an important role in rod fractures. Recommendations are made on surgical techniques, such as the use of torque-limiting wrenches or not exceeding the prescribed torques. Additional recommendations include frequent rod replacement in select patients during scheduled surgeries.
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http://dx.doi.org/10.1016/j.spinee.2017.04.020DOI Listing
October 2017