Advances in Scoliosis, Spinal Deformity and Other Spinal Disorders

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Orthopedics".

Deadline for manuscript submissions: 12 June 2024 | Viewed by 6529

Special Issue Editors

Department of Neurological Surgery, Mayo Clinic, Rochester, MN 55902, USA
Interests: spinal deformity; spinal oncology; spine tumor; bone health optimization; machine learning in spine surgery
1. Department of Neurosurgery, Northwell Health Chair of Neurosurgery at North Shore University Hospital and Long Island Jewish Medical Center, Manhasset, NY 11030, USA
2. Institute for Neurology and Neurosurgery, Northwell Health and Chair of Neurosciences, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY 11030, USA
Interests: spinal oncology; chordoma; predictive calculators and machine learning; perioperative optimization; adult spinal deformity; machine learning in spine
Department of Neurosurgery, Orthopedics and Biomedical Engineering, Mayo Clinic School of Medicine, 200 1st St. SW, Rochester, MN 55905, USA
Interests: bone health optimization; spinopelvic biomechanics; adult spinal deformity; normal-pressure hydrocephalus
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Special Issue Information

Dear Colleagues,

Spinal disorders are the leading cause of disability worldwide, with the World Health Organization (WHO) documenting lumbar pathology to account for 7.4% of all years lived with disability. While much of this pathology is nonoperative myofascial pain, with the progressive aging of the global population, there is a growing number of persons with adult spinal deformities, currently estimated to affect 6% of all adults 50 years and older. There is, therefore, a growing need to better understand which of these patients would benefit from surgical intervention, how potential surgical candidates can be best optimized preoperatively and how operative morbidity can be lowered given the frailty of many of these patients. In the present Special Issue for the Journal of Clinical Medicine, we aim to highlight current research focused on the management of adult spinal deformities. Specific areas of focus include the following: 1) the application of predictive analytics to patients with adult spinal deformities, focusing on preoperative risk stratification and the development of clinical tools that can assist with preoperative counseling; 2) musculoskeletal health optimization, including pre/postoperative bone health optimization and the incorporation of bone and musculoligamentous integrity into construct selection and mechanical complication prevention; and 3) the utilization of novel technologies and techniques, such as minimally invasive approaches (e.g., anterior column reconstruction) and individualized/patient-specific hardware, to improve outcomes.

Dr. Zach Pennington
Prof. Dr. Daniel M. Sciubba
Dr. Benjamin D. Elder
Guest Editors

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Keywords

  • adult spinal deformity
  • scoliosis
  • spinal biomechanics
  • predictive calculators
  • bone health optimization
  • minimally invasive spine surgery
  • mechanical complication prevention
  • frailty

Published Papers (9 papers)

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Research

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17 pages, 2763 KiB  
Article
Differences in Pubertal Curve Progression among Females with Adolescent Idiopathic Scoliosis Using Pregnenolone Therapy: A Retrospective Case-Controlled Series
J. Clin. Med. 2024, 13(3), 788; https://doi.org/10.3390/jcm13030788 - 30 Jan 2024
Viewed by 952
Abstract
Background: Differences in hormone metabolism have been observed in children with adolescent idiopathic scoliosis. These differences have been offered as underlying reasons for rapid curve progression during puberty. This study retrospectively compared two groups of females with a history of adolescent idiopathic [...] Read more.
Background: Differences in hormone metabolism have been observed in children with adolescent idiopathic scoliosis. These differences have been offered as underlying reasons for rapid curve progression during puberty. This study retrospectively compared two groups of females with a history of adolescent idiopathic scoliosis. They were seen for initial presentation prior to menarche, or within 2 months after menarche, and they were followed up 1 year after first menarche. Methods: All patients in both groups underwent baseline salivary hormone testing to identify any hormone imbalances. The control group was composed of females with curves between 10 and 25 degrees and maintained an observation-only management strategy. The treatment group showed baseline curve measurements ranging from 10 to 23 degrees, and additionally took pregnenolone daily for 12 months. Results: At one-year follow-up, the treatment group showed curve measurements ranging from 13 to 24 degrees, while the control group ranged from 16 to 29 degrees (p < 0.05). Conclusions: The study showed that adolescent females taking pregnenolone daily for low progesterone had reduced scoliosis curve progression over 1 year compared to controls. Full article
(This article belongs to the Special Issue Advances in Scoliosis, Spinal Deformity and Other Spinal Disorders)
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13 pages, 3595 KiB  
Article
Combined Anterior–Posterior vs. Posterior-Only Approach in Adult Spinal Deformity Surgery: Which Strategy Is Superior?
J. Clin. Med. 2024, 13(3), 682; https://doi.org/10.3390/jcm13030682 - 24 Jan 2024
Viewed by 449
Abstract
Introduction: Whether a combined anterior–posterior (AP) approach offers additional benefits over the posterior-only (P) approach in adult spinal deformity (ASD) surgery remains unknown. In a cohort of patients undergoing ASD surgery, we compared the combined AP vs. the P-only approach in: (1) preoperative/perioperative [...] Read more.
Introduction: Whether a combined anterior–posterior (AP) approach offers additional benefits over the posterior-only (P) approach in adult spinal deformity (ASD) surgery remains unknown. In a cohort of patients undergoing ASD surgery, we compared the combined AP vs. the P-only approach in: (1) preoperative/perioperative variables, (2) radiographic measurements, and (3) postoperative outcomes. Methods: A single-institution, retrospective cohort study was performed for patients undergoing ASD surgery from 2009 to 2021. Inclusion criteria were ≥5-level fusion, sagittal/coronal deformity, and 2-year follow-up. The primary exposure was the operative approach: a combined AP approach or P alone. Postoperative outcomes included mechanical complications, reoperation, and minimal clinically important difference (MCID), defined as 30% of patient-reported outcome measures (PROMs). Multivariable linear regression was controlled for age, BMI, and previous fusion. Results: Among 238 patients undergoing ASD surgery, 34 (14.3%) patients underwent the AP approach and 204 (85.7%) underwent the P-only approach. The AP group consisted mostly of anterior lumbar interbody fusion (ALIF) at L5/S1 (73.5%) and/or L4/L5 (38.0%). Preoperatively, the AP group had more previous fusions (64.7% vs. 28.9%, p < 0.001), higher pelvic tilt (PT) (29.6 ± 11.6° vs. 24.6 ± 11.4°, p = 0.037), higher T1 pelvic angle (T1PA) (31.8 ± 12.7° vs. 24.0 ± 13.9°, p = 0.003), less L1-S1 lordosis (−14.7 ± 28.4° vs. −24.3 ± 33.4°, p < 0.039), less L4-S1 lordosis (−25.4 ± 14.7° vs. 31.6 ± 15.5°, p = 0.042), and higher sagittal vertical axis (SVA) (102.6 ± 51.9 vs. 66.4 ± 71.2 mm, p = 0.005). Perioperatively, the AP approach had longer operative time (553.9 ± 177.4 vs. 397.4 ± 129.0 min, p < 0.001), more interbodies placed (100% vs. 17.6%, p < 0.001), and longer length of stay (8.4 ± 10.7 vs. 7.0 ± 9.6 days, p = 0.026). Radiographically, the AP group had more improvement in T1PA (13.4 ± 8.7° vs. 9.5 ± 8.6°, p = 0.005), L1-S1 lordosis (−14.3 ± 25.6° vs. −3.2 ± 20.2°, p < 0.001), L4-S1 lordosis (−4.7 ± 16.4° vs. 3.2 ± 13.7°, p = 0.008), and SVA (65.3 ± 44.8 vs. 44.8 ± 47.7 mm, p = 0.007). These outcomes remained statistically significant in the multivariable analysis controlling for age, BMI, and previous fusion. Postoperatively, no significant differences were found in mechanical complications, reoperations, or MCID of PROMs. Conclusions: Preoperatively, patients undergoing the combined anterior–posterior approach had higher PT, T1PA, and SVA and lower L1-S1 and L4-S1 lordosis than the posterior-only approach. Despite increased operative time and length of stay, the anterior–posterior approach provided greater sagittal correction without any difference in mechanical complications or PROMs. Full article
(This article belongs to the Special Issue Advances in Scoliosis, Spinal Deformity and Other Spinal Disorders)
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13 pages, 1055 KiB  
Article
Evaluating Computer Vision, Large Language, and Genome-Wide Association Models in a Limited Sized Patient Cohort for Pre-Operative Risk Stratification in Adult Spinal Deformity Surgery
J. Clin. Med. 2024, 13(3), 656; https://doi.org/10.3390/jcm13030656 - 23 Jan 2024
Viewed by 614
Abstract
Background: Adult spinal deformities (ASD) are varied spinal abnormalities, often necessitating surgical intervention when associated with pain, worsening deformity, or worsening function. Predicting post-operative complications and revision surgery is critical for surgical planning and patient counseling. Due to the relatively small number [...] Read more.
Background: Adult spinal deformities (ASD) are varied spinal abnormalities, often necessitating surgical intervention when associated with pain, worsening deformity, or worsening function. Predicting post-operative complications and revision surgery is critical for surgical planning and patient counseling. Due to the relatively small number of cases of ASD surgery, machine learning applications have been limited to traditional models (e.g., logistic regression or standard neural networks) and coarse clinical variables. We present the novel application of advanced models (CNN, LLM, GWAS) using complex data types (radiographs, clinical notes, genomics) for ASD outcome prediction. Methods: We developed a CNN trained on 209 ASD patients (1549 radiographs) from the Stanford Research Repository, a CNN pre-trained on VinDr-SpineXR (10,468 spine radiographs), and an LLM using free-text clinical notes from the same 209 patients, trained via Gatortron. Additionally, we conducted a GWAS using the UK Biobank, contrasting 540 surgical ASD patients with 7355 non-surgical ASD patients. Results: The LLM notably outperformed the CNN in predicting pulmonary complications (F1: 0.545 vs. 0.2881), neurological complications (F1: 0.250 vs. 0.224), and sepsis (F1: 0.382 vs. 0.132). The pre-trained CNN showed improved sepsis prediction (AUC: 0.638 vs. 0.534) but reduced performance for neurological complication prediction (AUC: 0.545 vs. 0.619). The LLM demonstrated high specificity (0.946) and positive predictive value (0.467) for neurological complications. The GWAS identified 21 significant (p < 10−5) SNPs associated with ASD surgery risk (OR: mean: 3.17, SD: 1.92, median: 2.78), with the highest odds ratio (8.06) for the LDB2 gene, which is implicated in ectoderm differentiation. Conclusions: This study exemplifies the innovative application of cutting-edge models to forecast outcomes in ASD, underscoring the utility of complex data in outcome prediction for neurosurgical conditions. It demonstrates the promise of genetic models when identifying surgical risks and supports the integration of complex machine learning tools for informed surgical decision-making in ASD. Full article
(This article belongs to the Special Issue Advances in Scoliosis, Spinal Deformity and Other Spinal Disorders)
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11 pages, 240 KiB  
Article
The Predictors of Incidental Durotomy in Patients Undergoing Pedicle Subtraction Osteotomy for the Correction of Adult Spinal Deformity
J. Clin. Med. 2024, 13(2), 340; https://doi.org/10.3390/jcm13020340 - 07 Jan 2024
Viewed by 580
Abstract
Background: Pedicle subtraction osteotomy (PSO) is a powerful tool for sagittal plane correction in patients with rigid adult spinal deformity (ASD); however, it is associated with high intraoperative blood loss and the increased risk of durotomy. The objective of the present study [...] Read more.
Background: Pedicle subtraction osteotomy (PSO) is a powerful tool for sagittal plane correction in patients with rigid adult spinal deformity (ASD); however, it is associated with high intraoperative blood loss and the increased risk of durotomy. The objective of the present study was to identify intraoperative techniques and baseline patient factors capable of predicting intraoperative durotomy. Methods: A tri-institutional database was retrospectively queried for all patients who underwent PSO for ASD. Data on baseline comorbidities, surgical history, surgeon characteristics and intraoperative maneuvers were gathered. PSO aggressiveness was defined as conventional (Schwab 3 PSO) or an extended PSO (Schwab type 4). The primary outcome of the study was the occurrence of durotomy intraoperatively. Univariable analyses were performed with Mann–Whitney U tests, Chi-squared analyses, and Fisher’s exact tests. Statistical significance was defined by p < 0.05. Results: One hundred and sixteen patients were identified (mean age 61.9 ± 12.6 yr; 44.8% male), of whom 51 (44.0%) experienced intraoperative durotomy. There were no significant differences in baseline comorbidities between those who did and did not experience durotomy, with the exception that baseline weight and body mass index were higher in patients who did not suffer durotomy. Prior surgery (OR 2.73; 95% CI [1.13, 6.58]; p = 0.03) and, more specifically, prior decompression at the PSO level (OR 4.23; 95% CI [1.92, 9.34]; p < 0.001) was predictive of durotomy. A comparison of surgeon training showed no statistically significant difference in durotomy rate between fellowship and non-fellowship trained surgeons, or between orthopedic surgeons and neurosurgeons. The PSO level, PSO aggressiveness, the presence of stenosis at the PSO level, nor the surgical instrument used predicted the odds of durotomy occurrence. Those experiencing durotomy had similar hospitalization durations, rates of reoperation and rates of nonroutine discharge. Conclusions: In this large multisite series, a history of prior decompression at the PSO level was associated with a four-fold increase in intraoperative durotomy risk. Notably the use of extended (versus) standard PSO, surgical technique, nor baseline patient characteristics predicted durotomy. Durotomies occurred in 44% of patients and may prolong operative times. Additional prospective investigations are merited. Full article
(This article belongs to the Special Issue Advances in Scoliosis, Spinal Deformity and Other Spinal Disorders)
12 pages, 1335 KiB  
Article
Nighttime versus Fulltime Brace Treatment for Adolescent Idiopathic Scoliosis: Which Brace to Choose? A Retrospective Study on 358 Patients
J. Clin. Med. 2023, 12(24), 7684; https://doi.org/10.3390/jcm12247684 - 14 Dec 2023
Viewed by 831
Abstract
The purpose of this study is to retrospectively compare the effectiveness of fulltime Boston Brace (BB) and Providence Nighttime Brace (PNB) treatments in moderate scoliotic curves (20–40°) at a single institution and to carry out analyses for different subgroups. Inclusion criteria: idiopathic scoliosis, [...] Read more.
The purpose of this study is to retrospectively compare the effectiveness of fulltime Boston Brace (BB) and Providence Nighttime Brace (PNB) treatments in moderate scoliotic curves (20–40°) at a single institution and to carry out analyses for different subgroups. Inclusion criteria: idiopathic scoliosis, age ≥ 10 years, curve 20–40°, Risser ≤ 3 or Sanders stage ≤ 6 and curve apex below T6 vertebra. Exclusion criteria: incomplete radiological or clinical follow-up and previous treatment. The primary outcome was failure according to the SRS outcome assessment: increase in main curve > 5° and/or increase in main curve beyond 45° and/or surgery. The subgroup analyses were secondary outcomes. In total, 249 patients in the PNB and 109 in the BB groups were included. The BB showed a higher success rate compared to the PNB (59% and 46%, respectively) in both crude and adjusted comparisons (p = 0.029 and p = 0.007, respectively). The subgroup analyses showed higher success rates in pre-menarchal females, thoracic curves and curves > 30° in the BB group compared to the PNB group. Based on the findings, fulltime braces should be the treatment of choice for more immature patients and patients with larger and thoracic curves while nighttime braces might be sufficient for post-menarchal females and patients with lumbar and smaller curves. Full article
(This article belongs to the Special Issue Advances in Scoliosis, Spinal Deformity and Other Spinal Disorders)
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10 pages, 2518 KiB  
Article
A Change in Global Sagittal Alignment after Transforaminal Epidural Steroid Injections in Lumbar Spinal Stenosis
J. Clin. Med. 2023, 12(14), 4727; https://doi.org/10.3390/jcm12144727 - 17 Jul 2023
Viewed by 677
Abstract
Patients’ functional adaptation to pain can affect global sagittal alignment. This study evaluated the short-term spinal sagittal alignment change after transforaminal epidural steroid injection (TFESI) in lumbar spinal stenosis patients. Patients with lumbar spinal stenosis who underwent TFESI were retrospectively examined. Clinical outcomes [...] Read more.
Patients’ functional adaptation to pain can affect global sagittal alignment. This study evaluated the short-term spinal sagittal alignment change after transforaminal epidural steroid injection (TFESI) in lumbar spinal stenosis patients. Patients with lumbar spinal stenosis who underwent TFESI were retrospectively examined. Clinical outcomes were assessed using the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI). Before and two weeks after the intervention, whole-spine lateral standing view radiographs were taken. Radiographic parameters including the Sagittal Vertical Axis (SVA), C2C7 Cobb, Thoracic Kyphosis (TK), Lumbar Lordosis (LL), Pelvic Incidence (PI), Pelvic Tilt (PT), Sacral Slope (SS), and Lumbopelvic Mismatch (PI-LL) were measured. Ninety-nine patients (mean age 64.3 ± 9.2 years) were included in this study. Both VAS and ODI outcomes were statistically improved after two weeks of intervention. Radiographic parameters showed that SVA, PT, and PI-LL mismatch were significantly decreased, while C2C7 Cobb, TK, SS, and LL were significantly increased after the intervention. SVA was improved by 29.81% (52.76 ± 52.22 mm to 37.03 ± 41.07 mm, p < 0.001). PT also decreased significantly from 28.71° ± 10.22° to 23.84° ± 9.96° (p < 0.001). Transforaminal epidural steroid injection (TFESI) significantly improves VAS, ODI, and global sagittal parameters in lumbar spinal stenosis patients. Full article
(This article belongs to the Special Issue Advances in Scoliosis, Spinal Deformity and Other Spinal Disorders)
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Review

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13 pages, 285 KiB  
Review
Perioperative Blindness in Spine Surgery: A Scoping Literature Review
J. Clin. Med. 2024, 13(4), 1051; https://doi.org/10.3390/jcm13041051 - 12 Feb 2024
Viewed by 445
Abstract
Perioperative vision loss (POVL) is a devastating surgical complication that impacts both the recovery from surgery and quality of life, most commonly occurring after spine surgery. With rates of spine surgery dramatically increasing, the prevalence of POVL will increase proportionately. This scoping review [...] Read more.
Perioperative vision loss (POVL) is a devastating surgical complication that impacts both the recovery from surgery and quality of life, most commonly occurring after spine surgery. With rates of spine surgery dramatically increasing, the prevalence of POVL will increase proportionately. This scoping review aims to aggregate the literature pertinent to POVL in spine surgery and consolidate recommendations and preventative measures to reduce the risk of POVL. There are several causes of POVL, and the main contribution following spine surgery is ischemic optic neuropathy (ION). Vision loss often manifests immediately following surgery and is irreversible and severe. Diffusion weighted imaging has recently surfaced as a diagnostic tool to identify ION. There are no effective treatments; therefore, risk stratification for counseling and prevention are vital. Patients undergoing prone surgery of long duration and/or with significant expected blood loss are at greatest risk. Future research is necessary to develop effective treatments. Full article
(This article belongs to the Special Issue Advances in Scoliosis, Spinal Deformity and Other Spinal Disorders)

Other

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22 pages, 569 KiB  
Systematic Review
Limited Intervention in Adult Scoliosis—A Systematic Review
J. Clin. Med. 2024, 13(4), 1030; https://doi.org/10.3390/jcm13041030 - 11 Feb 2024
Viewed by 361
Abstract
Background/Objectives: Adult scoliosis is traditionally treated with long-segment fusion, which provides strong radiographic correction and significant improvements in health-related quality of life but comes at a high morbidity cost. This systematic review seeks to examine the literature behind limited interventions in adult scoliosis [...] Read more.
Background/Objectives: Adult scoliosis is traditionally treated with long-segment fusion, which provides strong radiographic correction and significant improvements in health-related quality of life but comes at a high morbidity cost. This systematic review seeks to examine the literature behind limited interventions in adult scoliosis patients and examine the best approaches to treatment. Methods: This is a MEDLINE- and PubMed-based literature search that ultimately included 49 articles with a total of 21,836 subjects. Results: Our search found that long-segment interventions had strong radiographic corrections but also resulted in high perioperative morbidity. Limited interventions were best suited to patients with compensated deformity, with decompression best for neurologic symptoms and fusion needed to treat neurological symptoms secondary to up-down stenosis and to provide stability across unstable segments. Decompression can consist of discectomy, laminotomy, and/or foraminotomy, all of which are shown to provide symptomatic relief of neurologic pain. Short-segment fusion has been shown to provide improvements in patient outcomes, albeit with higher rates of adjacent segment disease and concerns for correctional loss. Interbody devices can provide decompression without posterior element manipulation. Future directions include short-segment fusion in uncompensated deformity and dynamic stabilization constructs. Conclusions: Limited interventions can provide symptomatic relief to adult spine deformity patients, with indications mostly in patients with balanced deformities and neurological pain. Full article
(This article belongs to the Special Issue Advances in Scoliosis, Spinal Deformity and Other Spinal Disorders)
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10 pages, 1124 KiB  
Systematic Review
Assessing the Accuracy of Spinal Instrumentation Using Augmented Reality (AR): A Systematic Review of the Literature and Meta-Analysis
J. Clin. Med. 2023, 12(21), 6741; https://doi.org/10.3390/jcm12216741 - 25 Oct 2023
Viewed by 749
Abstract
Technological advancements, particularly in the realm of augmented reality (AR), may facilitate more accurate and precise pedicle screw placement. AR integrates virtual data into the operator’s real-world view, allowing for the visualization of patient-specific anatomy and navigated trajectories. We aimed to conduct a [...] Read more.
Technological advancements, particularly in the realm of augmented reality (AR), may facilitate more accurate and precise pedicle screw placement. AR integrates virtual data into the operator’s real-world view, allowing for the visualization of patient-specific anatomy and navigated trajectories. We aimed to conduct a meta-analysis of the accuracy of pedicle screw placement using AR-based systems. A systematic review of the literature and meta-analysis was performed using the PubMed/MEDLINE database, including studies reporting the accuracy of pedicle screw placement using AR. In total, 8 studies with 163 patients and 1259 screws were included in the analysis. XVision (XVS) was the most commonly used AR system (595 screws) followed by the Allura AR surgical navigation system (ARSN) (462 screws). The overall accuracy was calculated as 97.2% (95% CI 96.2–98.1% p < 0.001). Subgroup analysis revealed that there was no statistically significant difference in the accuracy rates achieved by XVS and Allura ARSN (p = 0.092). AR enables reliable, accurate placement of spinal instrumentation. Future research efforts should focus on comparative studies, cost effectiveness, operative time, and radiation exposure. Full article
(This article belongs to the Special Issue Advances in Scoliosis, Spinal Deformity and Other Spinal Disorders)
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