Emanuele Quarto

Purpose Adult spinal deformity (ASD) surgery gives good clinical outcomes but has a high rate of mechanical complications (MC). In 2016, Lafage described the age-adjusted alignment thresholds (AAAT) to adapt the correction in relation to patient’s age proposing less aggressive corrections for the elderly population. The aim of this review was to clarify the effectiveness of AAAT to achieve good health-related quality of life (HRQoL) and their relationship with post-operative MC. Materials and methods We performed a review of the literature, including articles reporting data on post-operative HRQoL and MC rates in relation to the AAAT. Data were stratified according to whether they matched the AAAT, dividing the population in undercorrected (U), matched (M) and overcorrected (O). The quality of the included studies was assessed using the GRADE and MINORS systems. Results Six articles reporting data from 1,825 patients were included. The different categories (U, M and O) had homogeneous pre-operative sagittal parameters (p > 0.05) that became statistically different after surgeries (p < 0.05). Proximal junctional kyphosis (PJK) was more frequent in the O group compared to U (p = 0.05). Post-operative HRQoL parameters were similar in the 3 groups (p > 0.05). The quality of the included studies was generally low with a high bias risk. Conclusion The results extrapolated from this review are interesting, as for the same HRQoL the U group had a lower MC rate. Unfortunately, the results are inconsistent, mainly because of the low quality of the included studies and the lack of reporting of some important patient- and surgery-related factors.

Objective: The role of the craniocervical complex in spinal sagittal alignment has rarely been analyzed but it may play a fundamental role in postoperative mechanical complications. The aim of the study is to analyze the normative value of the cervical inclination angle (CIA) in an adult asymptomatic multiethnic population.Methods: Standing full-spine EOS of adult asymptomatic volunteers from 5 different countries were analyzed. The CIA was analyzed globally and then in each decade of life. Different ethnicities were compared. Comparisons between different groups was performed using a t-test and statistical significance was considered with a p-value < 0.05.Results: EOS of 468 volunteers were analyzed. The global mean CIA was 80.2° with a maximum difference of 9° between T1 and T12 (p < 0.001). The CIA remains constant until 60 years old then decreases significantly passing from a mean value before 20 years old of 82.25° to 73.65° after 70 years old. A statistically significant difference was found between the Arabics and other ethnicities with the formers having an inferior CIA: this was related to a mean older age (p < 0.05) and higher body mass index (p < 0.05) in the Arabics.Conclusion: The CIA remains constant until 60 years old and then reduces slightly but never under 70°. This angle is helpful to evaluate the lever arm at the upper instrumented vertebra after an adult spinal deformity surgery and could predict the occurrence of a proximal junctional kyphosis when its value is lower than normal. Further clinical studies must confirm this theory.

Purpose The objective is to analyse peri-operative blood loss (BL) and hidden blood loss (HBL) rates in spinal deformity complex cases surgery, with a focus on the strategies to prevent major bleeding. Methods We retrospectively analysed surgical and anaesthesiologic data of patients who had been operated for adolescent idiopathic scoliosis (AIS) or adult spinal deformities (ASD) with a minimum of five levels fused. A statistical comparison among AIS, ASD without a pedicle subtraction osteotomy (PSO) (ASD-PSO( −)) and ASD with PSO (ASD-PSO( +)) procedures was performed with a view to identifying patient- and/or surgical-related factors affecting peri-operative BL and HBL. Results One-hundred patients were included with a mean 9.9 ± 2.8 fused vertebrae and a mean 264.2 ± 68.3 minutes operative time (OT) (28.3 ± 9 min per level). The mean perioperative BL was 641.2 ± 313.8 ml (68.9 ± 39.5 ml per level) and the mean HBL was 556.6 ± 381.8 ml (60.6 ± 42.8 ml per level), with the latter accounting for 51.5% of the estimated blood loss (EBL). On multivariate regression analysis, a longer OT (p < 0.05; OR 3.38) and performing a PSO (p < 0.05; OR 3.37) were related to higher peri-operative BL, while older age (p < 0.05; OR 2.48) and higher BMI (p < 0.05; OR 2.15) were associated to a more significant post-operative HBL. Conclusion With the correct use of modern technologies and patient management, BL in major spinal deformity surgery can be dramatically reduced. Nevertheless, it should be kept in mind that 50% of patients estimated losses are hidden and not directly controllable. Knowing the per-level BL allows anticipating global losses and, possibly, the need of allogenic transfusions.

Purpose In 2017, the GAP score was proposed as a tool to reduce mechanical complications (MC) in adult spinal deformity (ASD) surgery: the reported MC rate for the GAP proportioned category was only 6%, which is clearly lower to the MC rate reported in the literature. The aim of this study is to analyse if the most recent literature confirms the promising results of the original article. Materials and methods Using the PRISMA flow chart, we reviewed the literature to analyse GAP score capacity in predicting MC occurrence. We included articles clearly reporting ASD surgery MC stratified by GAP categories and the score’s overall capacity to predict MC using the area under the curve (AUC). The quality of the included studies was evaluated using GRADE and MINORS systems. Results Eleven retrospective articles (1,517 patients in total) were included. The MC distribution per GAP category was as follows: GAP-P, 32.8%; GAP-MD, 42.3%; GAP-SD, 55.4%. No statistically significant difference was observed between the different categories using the Kruskal–Wallis test (p = 0.08) and the two-by-two Pearson-Chi square test (P Vs MD, p = 0.300; P Vs SD, p = 0.275; MD Vs SD, p = 0.137). The global AUC was 0.68 ± 0.2 (moderate accuracy). The included studies were of poor quality according to the GRADE system and had a high risk of bias based on the MINORS criteria. Conclusion The actual literature does not corroborate the excellent results reported by the original GAP score article. Further prospective studies, possibly stratified by type of MC and type of surgery, are necessary to validate this score.

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a chronic relapsing disease of unknown aetiology. The diagnosis of this disease is still very complicated. The treatment is medical but, in some cases, a surgical decompression might be required. In rare cases it develops a radicular hypertrophy that can cause a cervical myelopathy; this pathology should be put in differential diagnosis with neurofibromatosis 1 and CharcotMarie-Tooth (CMT) syndromes. The cases of CIDP cervical myelopathy reported in the literature are rare and even more rarely a surgical decompression was described. Here we report a first and unique case of CIDP cervical myelopathy treated with an open-door laminoplasty technique with 10-year postoperative follow-up (FU). The surgical decompression revealed to be effective in stopping the progression of myelopathy without destabilizing the spine. The patient that before surgery presented a severe tetraparesis could return to walk and gain back his self-care autonomy. At 10-year FU he did not complain of neck pain and did not develop a cervical kyphosis. In case of cervical myelopathy caused by radicular hypertrophy, CIDP should be kept in mind in the differential diagnosis and an open-door laminoplasty is indicated to stop myelopathy progression.

Purpose: Identifying perioperative factors that may influence the outcomes of long spine fusion for the treatment of adult deformity is key for tailored surgical planning and targeted informed consent. The aim of this study was to analyze the association between demographic or perioperative factors and clinical outcomes 2 years after long spine fusion for the treatment of adult deformity. Methods: This study is a multivariate analysis of retrospectively collected data. All patients who underwent long fusion of the lumbar spine for adult spinal deformity (January 2016–June 2019) were included. The outcomes of interest were the Oswestry disability index (ODI), visual analogic scale (VAS) preoperatively and at 1 and 2 years’ follow up, age, body mass index, American Society of Anaesthesiologists (ASA) score, upper and lowest instrumented vertebrae (UIV and LIV, respectively), length of surgery, estimated blood loss, and length of hospital stay. Results: Data from 192 patients were available. The ODI at 2 years correlated weakly to moderately with age (r = 0.4), BMI (r = 0.2), ASA (r = 0.3), and LIV (r = 0.2), and strongly with preoperative ODI (r = 0.6). The leg VAS at 2 years moderately correlated with age (r = 0.3) and BMI (r = 0.3). Conclusion: ODI and VAS at 2 years’ follow-up had no to little association to preoperative age, health status, LIV, or other peroperative data, but showed a strong correlation with preoperative ODI and pain level.

Purpose Report clinical and radiological long-term follow-up (FU) outcome of bone impaction grafting (BIG) and anti-protrusio cage (APC) technique in hip revision surgery. Materials and methods We analysed data on complications, as well as the clinical and radiological outcome of patients treated using this technique at our institution. We evaluated the acetabular bone stock renovation, acetabular component stability and its radiological migration. The clinical parameters considered were the Visual Analogue Scale (VAS) and the modified Harris Hip Score (mHHS). Results Forty hips, with a mean 14.3-year FU, were included. This technique showed good clinical long-term results in an elderly and low-demanding population (mean age at surgery 71.4 ± 12.1 years). The radiological results were not as good as clinical results: 67.5% of cases had a radiographic evidence of resorption of less than 1/3 of the bone graft; 27.5% had a resorption ranging from 1/3 and ½ of the graft, and 5% had more than ½ of the graft. Paprosky type III B reported worse results in terms of graft resorption and a greater migration of the APC (p < 0.001). The survival rate was 95% and a 2.5% rate of septic failure was recorded. Conclusion Impaction grafting with femoral head and APC is an effective technique for treating high-grade acetabular defects. APC reconstructs the hip centre of rotation, avoiding loading forces on the underlying bone graft that can be correctly integrated. At long-term FU, satisfactory clinical results, not strictly correlated to radiological signs of integration, were observed; Paprosky type III B reported worse results in terms of graft resorption and a greater migration of the APC.

Purpose: Total hip arthroplasties (THAs) are rising worldwide, as the functional request of patients who undergo this procedure. The trabeculae oriented pattern (TOP) is a modern cup, which follows the philosophy of the tissue sparing surgery (TSS). Focusing on clinical and radiological results and complications, the authors aim to highlight the outcomes of the TOP at a long-term follow-up (FU). Methods: A retrospective analysis was completed on THA performed with the TOP cup between 1997 and 2015. Five hundred and eighty-eight patients sustained surgery, for a total of 662 cup implanted. Four hundred and sixty patients (524 hips) were examined. Mean FU was 12 ± 4.9 years (range 5–22). Clinical (HHS, OHS and VAS) and radiological data were obtained. Every complication, reoperation or revision was recorded and analyzed. Results: Clinical evaluation revealed a HHS of 87.1 ± 13.8 an OHS of 41.3 ± 5.4, and a VAS of 1.2 ± 1.1. Acetabular osteolysis was observed in 53 hips. Overall survival rate of the cup was 90.5% (50 revisions), the main causes of cup substitution being aseptic loosening (AL) of the cup combined with the stem (26), of the cup only (13 cases) and periprosthetic joint infection (7 cases). Conclusion: TOP cup has demonstrated a good overall survivorship at a long-term FU, even compared with other coated cups, providing excellent clinical result with low rate of complications. Its association with a neck sparing stem permits a physiologic load transmission, reducing the stress shielding effect that could cause early implant mobilization.

Background: In the past decade, lateral lumbar interbody fusion (LLIF) has gained in popularity. A proposed advantage is the achievement of indirect neural decompression. However, evidence of the effectiveness of LLIF in neural decompression in lumbar degenerative conditions remains unclear. Questions/Purposes: We sought to extrapolate clinical and radiological results and consequently the potential benefits and limitations of LLIF in indirect neural decompression in degenerative lumbar diseases. Methods: We conducted a systematic review of the literature in English using the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist. Scores on the Oswestry Disability Index (ODI) and visual analog scale (VAS) for back and leg pain were extracted, as were data on the following radiological measurements: disc height (DH), foraminal height (FH), foraminal area (FA), central canal area (CA). Results: In the 42 articles included, data on 2445 patients (3779 levels treated) with a mean follow-up of 14.8 ± 5.9 months were analyzed. Mean improvements in VAS back, VAS leg, and ODI scale scores were 4.1 ± 2.5, 3.9 ± 2.2, and 21.9 ± 7.2, respectively. Post-operative DH, FH, FA, and CA measurements increased by 68.6%, 21.9%, 37.7%, and 29.3%, respectively. Conclusion: Clinical results indicate LLIF as an efficient technique in indirect neural decompression. Analysis of radiological data demonstrates the effectiveness of symmetrical foraminal decompression. Data regarding indirect decompression of central canal and lateral recess are inconclusive and contradictory. Bony stenosis appears as an absolute contraindication. The role of facet joint degeneration is unclear. This systematic review provides a reference for surgeons to define the potential and limitations of LLIF in indirect neural elements decompression.