Michal Grabala

Background: Advances in spinal deformity surgery have expanded treatment options for pediatric and adolescent patients, but neurological complications remain among the most serious adverse events. Intraoperative neuromonitoring (IONM) enables early detection of spinal cord dysfunction, while preservation of adequate spinal cord perfusion remains an important component of perioperative neurological protection. Objective: This narrative review examines current evidence regarding neurological protection during complex spinal deformity surgery, with emphasis on spinal cord perfusion, IONM interpretation, hemodynamic management, and the potential interaction between mechanical and autonomic factors. An illustrative case of recurrent IONM deterioration associated with profound hemodynamic instability is included. Methods: A narrative review of contemporary literature was conducted, focusing on spinal cord perfusion, mechanisms of neurological injury, IONM, perioperative blood pressure management, corrective strategies, and postoperative neurological surveillance. Pediatric deformity studies were prioritized, while adult and mixed-population studies were included when relevant mechanistic or technical information was provided. The clinical case was analyzed separately from the literature synthesis. Results: Current evidence supports maintaining adequate systemic perfusion and promptly evaluating reversible physiological and mechanical contributors when IONM deterioration occurs. Blood pressure augmentation may restore signals in a subset of patients, but IONM changes cannot be assumed to be purely ischemic, and improved perfusion may not overcome persistent mechanical compromise. In the illustrative case, recurrent IONM signal loss occurred during corrective maneuvers and was associated with profound hypotension and bradycardia during a subsequent correction attempt. Motor and somatosensory evoked potentials were comparable to baseline by the end of surgery after release of corrective forces, hemodynamic management, and vasopressor support; they had recovered to 50% of baseline immediately before correction was resumed. Because these interventions were performed concurrently, the relative contribution of mechanical release, improved systemic perfusion, and possible autonomic mechanisms could not be determined. Motor and sensory function remained intact postoperatively, although she later reported sweating and temperature asymmetry during follow-up. Conclusions: Neurological protection during complex spinal deformity correction requires an integrated perioperative approach combining individualized surgical strategy, multimodal IONM, hemodynamic optimization, and postoperative surveillance. When IONM deterioration occurs, mechanical, hemodynamic, anesthetic, and technical causes should be assessed concurrently. The presented case supports consideration of a possible autonomic contribution to severe intraoperative hemodynamic instability, but does not establish a specific autonomic syndrome or causal pathway.

Background: Posterior spinal fusion (PSF) is an established treatment for progressive adolescent idiopathic scoliosis (AIS) requiring surgery. Thoracic and abdominal complications range from transient postoperative findings to uncommon emergencies. This narrative review examines their reported frequency, recognition, prevention, and management. Methods: Literature published between January 2000 and June 2026 was reviewed using PubMed/MEDLINE and Google Scholar, supplemented by reference-list screening. AIS-specific evidence was prioritized. Reports involving other deformities or surgical approaches and general management guidelines were used as explicitly identified contextual evidence. No pooled incidence estimates were calculated. Results: Reported frequencies depended strongly on outcome definitions, imaging protocols, surgical approach, and follow-up. Two retrospective AIS studies detected pleural effusion in 71.0% and 76.3% of patients on computed tomography approximately one week after PSF; in the latter study, all effusions were asymptomatic and required no treatment. These findings should not be equated with clinically significant pulmonary complications. Postoperative ileus was reported in 13.2% of one 318-patient AIS cohort aged 10–20 years, whereas superior mesenteric artery syndrome, chylothorax, hemothorax, and implant-related vascular injury were supported largely by small series or case reports. Enhanced recovery pathways were consistently associated with shorter hospitalization, but evidence that they prevent individual rare complications was limited. Accurate instrumentation, appropriate blood conservation, individualized nutritional assessment, opioid-sparing analgesia, and symptom-directed investigation support perioperative care. Conclusions: Thoracic and abdominal complications after PSF for AIS require separate interpretation of radiographic findings, clinically diagnosed events, and events requiring intervention. Persistent vomiting, progressive abdominal distension, respiratory deterioration, unexplained anemia, or hemodynamic instability warrant prompt reassessment. Management should follow the suspected diagnosis, patient physiology, and relevant pediatric or multidisciplinary guidance.

Background: Congenital thoracic kyphoscoliosis caused by vertebral malformations is a challenging condition that may progress during skeletal growth, leading to spinal imbalance, pain, cosmetic deformity, and neurological compromise. Conventional correction often requires extensive anterior, posterior, or combined approaches associated with substantial surgical morbidity. We describe a single-position surgical technique combining a lateral retropleural asymmetric vertebral resection with percutaneous posterior instrumentation performed entirely in the lateral decubitus position. Methods: A 15-year-old boy with progressive congenital thoracic kyphoscoliosis secondary to a T10 butterfly vertebra underwent surgical correction after failure of conservative treatment. The procedure was performed entirely in the left lateral decubitus position under multimodal intraoperative neurophysiological monitoring. Bilateral percutaneous pedicle screws were inserted from T7 to L1 under fluoroscopic guidance without repositioning the patient. A muscle-sparing lateral retropleural approach was then used to perform T10 asymmetric vertebral column resection, anterior column reconstruction with an expandable cage, and definitive deformity correction using posterior rod compression. The technical rationale, operative workflow, and reconstruction strategy are described. Results: The procedure was completed without intraoperative neurological deterioration or the need for patient repositioning. Postoperative imaging demonstrated satisfactory restoration of coronal and sagittal alignment, appropriate implant positioning, and spinal canal decompression. The patient experienced marked improvement in pain, shoulder balance, rib hump deformity, and overall posture while maintaining normal neurological function. The main thoracic curve improved from 32° to 6°, thoracic kyphosis from 78° to 63°, VAS from 5 to 0, ODI from 42 to 5, and SRS-22R from 3.85 to 4.85. Solid fusion was confirmed at 3 years. A postoperative pneumothorax, attributed to pleural violation during exposure, represented the only complication and resolved completely following pleural drainage. At 36-month follow-up, radiographs and computed tomography confirmed maintenance of deformity correction, stable instrumentation, and solid anterior and posterior fusion without implant failure or loss of correction. Conclusions: Single-position lateral retropleural asymmetric vertebral resection combined with percutaneous pedicle screw fixation is a technically feasible option for selected patients with congenital thoracic kyphoscoliosis. Avoiding intraoperative repositioning while combining anterior reconstruction and posterior stabilization through a reduced-access retropleural approach may simplify the surgical workflow and minimize soft-tissue disruption without compromising deformity correction. Further clinical experience is required to establish its reproducibility and comparative advantages.

Background: Surgical site infections (SSIs) following spinal and thoracic procedures are associated with prolonged hospitalization and increased morbidity, with incidence rates of 2–15% in spinal surgery and 3–12% in thoracic procedures. Multiple patient-related and procedure-specific factors contribute to wound complications, including diabetes mellitus, obesity, smoking, extended surgical time, excessive tissue dissection, and hardware implantation. Implementing evidence-based prevention and early intervention strategies is essential in high-risk surgical cohorts. Methods: This narrative review followed searches in PubMed, Scopus, ScienceDirect, Cochrane Library, and Embase for studies published between January 2000 and October 2025. Eligible peer-reviewed articles examined SSI incidence, risk factors, or prevention strategies in adult patients undergoing thoracic or spinal surgery. Data extraction focused on operative parameters, antibiotic prophylaxis regimens, negative-pressure wound therapy (NPWT) use, and patient outcomes. Results: Evidence from found recent studies was synthesized. Key findings demonstrated that operative duration > 4 h increased SSI odds by 41% per additional hour, and blood loss > 500 mL doubled infection risk. Prophylactic NPWT reduced deep SSI rates by 50% in high-risk patients (BMI ≥ 35, diabetes, multilevel instrumentation). Intrawound vancomycin powder reduced deep SSIs by 50–60%, particularly in multilevel fusions. Administering prophylactic antibiotics within 30 min of incision was significantly more effective than at 60 min, with a 23% relative risk reduction. Weight-adjusted antibiotic dosing in obese patients lowered SSI rates from 5.1% to 2.9%. Conclusions: Operative parameters strongly predict SSI risk. An integrated risk- and evidence-based approach to wound management following spinal and thoracic surgeries—combining optimized antibiotic prophylaxis, risk-stratified NPWT application, and operative technique modifications—can significantly reduce SSI incidence. Successful implementation requires institutional commitment, multidisciplinary collaboration, and continuous quality improvement to optimize patient outcomes.

Background: Massive intraoperative blood loss (IBL) is a serious complication in complex spine surgeries such as deformity correction, multilevel fusion, tumor resection, and revision procedures. While no strict definition exists, blood loss exceeding 1500 mL or 20% of estimated blood volume is generally considered clinically significant. Excessive bleeding increases the risk of hemodynamic instability, transfusion-related complications, postoperative infection, and prolonged hospitalization. Methods: This narrative review summarizes the current understanding of the incidence, risk factors, anatomical vulnerabilities, and evidence-based strategies for managing IBL in spine surgery through comprehensive literature analysis of recent studies and clinical guidelines. Results: Key risk factors include patient characteristics (anemia, obesity, advanced age, medication use), surgical variables (multilevel instrumentation, revision status, operative time), and pathological conditions (hypervascular tumors, severe deformity). Perioperative medication management is critical, requiring discontinuation of NSAIDs (5–7 days), antiplatelet agents (5–7 days), and NOACs (48–72 h) preoperatively to minimize bleeding risk. The thoracolumbar junction and hypervascular spinal lesions are especially prone to bleeding due to dense vascular anatomy. Evidence-based management strategies include comprehensive preoperative optimization, intraoperative hemostatic techniques, antifibrinolytic agents, topical hemostatic products, cell salvage technology, and structured transfusion protocols. Conclusions: Effective management of massive IBL requires a multimodal approach combining preoperative risk assessment and medication optimization, intraoperative hemostatic strategies including tranexamic acid administration, advanced monitoring techniques, and coordinated transfusion protocols. Particular attention to perioperative management of anticoagulant and antiplatelet medications is essential for bleeding risk mitigation. Understanding patient-specific risk factors, surgical complexity, and anatomical considerations enables surgeons to implement targeted prevention and management strategies, ultimately improving patient outcomes and reducing complications in high-risk spine surgery procedures.

Background: Severe spinal deformity manifests as a pronounced deviation from the normal curvature of the spine in the frontal, sagittal, and horizontal planes, where the coronal plane curvature exceeds 90 degrees and may coincide with hyperkyphotic deformity. The most severe deformities exhibit rigidity, with flexibility below 30%. If left untreated or improperly treated, these deformities can result in serious complications associated with progression of the curvature. A combination of surgical techniques is frequently employed to attain optimal outcomes and minimize the risk of complications. The overall medical condition of the patient, their capacity to endure extensive procedures, the expertise of the surgeon, and the resources available all play significant roles in determining the course of management. A systematic and thorough review of the relevant literature was conducted utilizing a variety of electronic databases. The primary objective of this study was to scrutinize the surgical techniques commonly employed in complex spine surgeries for the management of severe scoliosis without resection vertebral body techniques, with higher potential risk of major complications, including permanent neurological deficit. Conclusions: Halo-gravity traction, halo femoral traction, and all techniques for releases of the spine (anterior, posterior, or combine), as well as thoracoplasty, have demonstrated significant effectiveness in managing severe and rigid idiopathic scoliosis. The combination of several of these methods can lead to optimal alignment correction without the need to perform high-risk techniques involving three-column osteotomies. Surgeons must customize the indications based on factors such as available resources, characteristics of the deformity, and the patient’s individual profile. Surgical correction of severe scoliosis without vertebral body resection surgeries decreases the potential risks related to neurological and pulmonary complications while providing significant clinical improvement outcomes. The powerful Ponte osteotomy is indicated for severe scoliosis, curves with poor flexibility, for better restoration of hypokyphosis, and decrease of hyperkyphosis. These corrective techniques combined with HGT or temporary internal distraction rods are recommended as viable options for managing individuals with severe rigid spine deformity characteristics. Therefore, they also should be considered and performed by a proficient surgical team. The presence of neuromonitoring is crucial throughout these procedures.

Background: Early-onset scoliosis (EOS) refers to spinal deformities that develop and are diagnosed before the age of 10. The most important goals of the surgical treatment of EOS are to stop the progression of curvature, achieve the best possible correction, preserve motion, and facilitate spinal growth. The objectives of this multicenter study were to analyze the risk of complications among patients with EOS treated using magnetically controlled growing rods (MCGRs) and assess the patients’ and their parents’ quality of life after diagnosis and treatment with a minimum two-year follow-up. Methods: Patients given an ineffective nonoperative treatment qualified for surgery with MCGRs. This study involved 161 patients (90 females and 71 males) who were classified according to the etiology of curvature. The intraoperative and postoperative complications and those that occurred during the continuation of treatment with MCGRs were recorded and analyzed. The 24-item Early-Onset Scoliosis Questionnaire (EOSQ-24) was used to evaluate the patients’ quality of life and satisfaction with the treatment. Results: Implant-related complications requiring instrumentation revision were recorded in 26% of the patients. Medical complications occurred in 45% of the population. The EOSQ-24 revealed a significant improvement in the average scores during the follow-up. Conclusions: The treatment of early-onset scoliosis with MCGRs carries 66% risks of incurring medical and mechanical complications, the latter 26% of patients requiring revision procedures. Children with neuromuscular scoliosis, females, and with curvature greater than 90 degrees are at a higher risk of developing complications. Limiting the number of elective surgeries necessitated to prolong the instrumentation and treatment process for patients with MCGRs can greatly enhance their quality of life and satisfaction throughout the follow-up period.

Background: Scoliosis, the most prevalent spinal deformity in children, is often associated with adolescent idiopathic scoliosis (AIS). Curves surpassing 50 degrees can deteriorate, especially thoracic curves, leading to pulmonary limitations. Surgical intervention is usually advised for curvatures exceeding 50 degrees to halt further progression. Severe AIS is notably more frequent in females, yet knowledge regarding subsequent pregnancies and associated risks is scarce. Female patients often inquire about conception, pregnancy, labor, and future back pain (BP) concerns. Reports on the long-term outcomes after pediatric AIS treatment and pregnancy consequences remain limited. Uncertainty looms over the likelihood of increased back pain (BP), cesarean sections (CSs), or other pregnancy-related issues following surgical AIS management. In this investigation, an attempt was made to scrutinize the existing research on individuals afflicted with scoliosis who received either conservative or surgical treatment, with the aim of delineating crucial and pragmatic findings that can serve as a compass for spine surgeons when counseling young patients with adolescent idiopathic scoliosis regarding the ailment, its repercussions, the available treatment modalities, and the associated outcomes. A comprehensive analysis pinpointed the optimal data at hand. Consequently, the primary objective of this investigation was to assess the patient-reported and clinical consequences in scoliosis patients who have undergone segmental posterior fusion and subsequently conceived. Conclusions: While the majority of individuals with AIS are capable of conceiving and bearing children, they may encounter greater challenges in fertility than healthy women unaffected by AIS. Pregnant women with a prior history of spinal fusion for AIS can undergo pregnancy and childbirth with no significant escalation in perinatal complications. Women who have undergone surgical procedures for AIS have been observed to exhibit a prevalence of back pain comparable with that of healthy pregnant women; however, a higher incidence of low back pain is evident when spinal fusion is extended to the L3 or L4 vertebra. Although back pain is a common occurrence in pregnant women with AIS, the spinal alterations induced by pregnancy are typically minor and transient. In comparison with healthy women, individuals with a history of spinal fusion necessitate cesarean sections more frequently. The degree of correction loss during pregnancy is lower in previous reports involving pedicle screw instrumentation than in previous reports involving Harrington or hybrid segmental instrumentation.

Background: Costello syndrome (CS) is a rare genetic syndrome in which, due to the occurrence of a mutation in the HRAS gene on chromosome 11 that causes the manifestation, a set of features such as a characteristic appearance, many congenital defects, intellectual disability and a genetic predisposition to cancer, friendly personality, and others can be identified. CS is very rare, with an incidence of ~1/300,000, but it belongs to one of the largest groups of congenital syndromes, called RASopathies, occurring with an incidence of 1/1000 people. Scoliosis and kyphosis, as well as other spinal defects, are common, in 63% and 58% of patients, respectively, and a study conducted among adult patients showed the presence of scoliosis in 75% of patients; there may be excessive lordosis of the lumbar section and inverted curvatures of the spine (lordosis in the thoracic section and kyphosis in the lumbar section). The aim of our study is to present a case report of treatment of severe scoliosis of 130 degrees in a 14-year-old patient with Costello syndrome, with coexisting Chiari II syndrome and syrinx in the absence of skeletal maturity. This patient underwent foramen magnum decompression 3 months before planned surgical correction for severe scoliosis. The patient was qualified for surgical treatment using magnetically controlled growing rods (MCGR). After spine surgery using MCGR, we gradually performed MCGR distraction over the next 2 years; we performed the final surgery, conversion to posterior spinal fusion (PSF) with simultaneous multi-level Ponte osteotomy, which gave a very good and satisfactory surgical result. In the perioperative period, two serious complications occurred: pneumothorax caused by central catheter and gastrointestinal bleeding due to previously undiagnosed gastrointestinal varices. This case shows that the treatment of severe and neglected scoliosis is complicated and requires special preparation and a surgical plan with other cooperating specialists. The scoliosis was corrected from 130 degrees to approximately 48 degrees, sagittal balance was significantly improved, and the surgical outcome was very pleasing, significantly improving quality of life and function for the patient.

Background: Congenital kyphosis is a spinal deformity that arises from the inadequate anterior development or segmentation of the vertebrae in the sagittal plane during the initial embryonic stage. Consequently, this condition triggers atypical spinal growth, leading to the manifestation of deformity. Concurrently, other congenital abnormalities like renal or cardiac defects within the gastrointestinal tract may co-occur with spinal deformities due to their shared formation timeline. In light of the specific characteristics of the deformity, the age range of the patient, deformity sizes, and neurological conditions, surgical intervention emerges as the optimal course of action for such cases. The selection of the appropriate surgical approach is contingent upon the specific characteristics of the anomaly. Case Presentation: This investigation illustrates the utilization of a surgical posterior-only strategy for correcting pediatric congenital kyphoscoliosis through the implementation of a vertebral column resection method along with spine reconstruction employing a mesh cage. The individual in question, a 16-year-old female, exhibited symptoms such as a progressive rib hump, shoulder asymmetry, and back discomfort. Non-invasive interventions like bracing proved ineffective, leading to the progression of the spinal curvature. After the surgical procedure, diagnostic imaging displayed a marked enhancement across all three spatial dimensions. After a postoperative physical assessment, it was noted that the patient experienced significant enhancements in shoulder alignment and rib hump prominence, with no discernible neurological or other adverse effects. Conclusions: Surgical intervention is considered the optimal approach for addressing such congenital anomalies. Typically, timely surgical intervention leads to favorable results and has the potential to halt the advancement of deformity and curvature enlargement.