Marco Damilano

Purpose To propose a pelvic incidence (PI)-based asymptomatic spine classification, quantitatively define differences among Roussouly morphotypes, and develop a morphotype-oriented algorithm to guide surgical planning. Methods A retrospective analysis of 102 asymptomatic adults undergoing full-spine EOS radiographs was performed. Patients were classified according to the original Roussouly criteria. Spinopelvic parameters were measured using validated software. Receiver operating characteristic (ROC) curve analysis assessed the discriminative capacity of sagittal variables, with optimal cutoffs determined using the Youden index. A one-versus-rest ROC approach was applied for three-group comparisons. Linear regression analysis evaluated the relationship between lumbar lordosis (LL), PI, and Roussouly type. Results Although mean PI increased across types, significant overlap was observed among Types 1–3 for PI < 50°. In the binary comparison between Types 1 and 2, L5–S1 lordosis showed the highest discriminative performance (AUC 0.92; 95% CI 0.848–0.997; p < 0.001), with a cutoff of 19° differentiating Type 2 (≤ 19°) from Type 1 (> 19°). In the three-group analysis (Types 1–3), L5–S1 remained the most discriminative parameter (Type 2 vs. rest AUC 0.85). Thoracolumbar junction morphology differed consistently: kyphotic in Type 1, neutral in Type 2, and neutral-to-lordotic in Type 3. Conclusion Sagittal alignment cannot be defined by PI alone. Integration of distal lordosis (L5–S1) and thoracolumbar morphology improves morphotype differentiation and may support more precise surgical planning.

Background and Objectives: Malnutrition’s prevalence and its relationship with functional ability in patients with end-stage spine pathologies, i.e., any disease of the vertebral bodies, intervertebral discs, and associated joints requiring surgical intervention, are yet to be explored. This retrospective study aimed to investigate the association between malnutrition, disability, and physical health in patients undergoing elective spine surgery in our Italian hospital. Materials and Methods: Data between 2016 and 2019, recorded at pre-admission visits, were extracted from our institutional spine registry (ClinicalTrials.gov number: NCT03644407), excluding minor patients or those undergoing emergency or oncological surgery. The measures were the Oswestry disability index (ODI) and the physical health (PH) summary of the 36-item Short-Form Health Survey. Clinical data were linked to nine laboratory parameters from pre-operative routine blood tests, and equations to ascertain the risk of malnutrition and its diagnosis were attributed. Results: The study sample included 2258 spine patients (58.15% females) who underwent surgery in our Italian hospital. The ODI and PH significantly varied across body weight difference (BWd) strata in younger adults (adjusted-p = 0.046, η² = 0.04; adjusted-p = 0.036, η² = 0.06) and adults (adjusted-p = 0.001, η² = 0.02; adjusted-p = 0.004, η² = 0.02). Protein malnutrition with acute/chronic inflammation (PMAC) in both adults (adjusted-p < 0.001, η² = 0.04; adjusted-p < 0.001, η² = 0.04) and older adults (adjusted-p = 0.010, η² = 0.04; adjusted-p = 0.009, η² = 0.05) had also a discernible impact in determining the ODI and PH. In older adults, the ODI was associated with iron deficit malnutrition (IDM) (adjusted-p = 0.005, η² = 0.06) and both the ODI and PH were associated with vitamin B deficit (VBD) (adjusted-p = 0.037, η² = 0.01; adjusted-p = 0.049, η² = 0.01). Trend monotonicity was diagnosis- and sex-specific, with meaningful ordered patterns being observed mostly in young males and older females. Conclusions: Functional ability showed an association with malnutrition in younger adults and adults when using BWd, in adults and older adults when using PMAC, and in older adults when using IDM and VBD. The authors advocate for the inclusion of nutritional management in the pre-operative evaluation to potentially enhance recovery after spine surgery.

Study design: A systematic review of the literature about differential diagnosis between spine infection and bone tumors of the spine. Background and Purpose: The differential diagnosis between spine infection and bone tumors of the spine can be misled by the prevalence of one of the conditions over the other in different areas of the world. A review of the existing literature on suggestive or even pathognomonic imaging aspects of both can be very useful for correctly orientating the diagnosis and deciding the most appropriate area for biopsy. The purpose of our study is to identify which imaging technique is the most reliable to suggest the diagnosis between spine infection and spine bone tumor. Methods: A primary search on Medline through PubMed distribution was made. We identified five main groups: tuberculous, atypical spinal tuberculosis, pyogenic spondylitis, and neoplastic (primitive and metastatic). For each group, we evaluated the commonest localization, characteristics at CT, CT perfusion, MRI, MRI with Gadolinium, MRI diffusion (DWI) and, in the end, the main features for each group. Results: A total of 602 studies were identified through the database search and a screening by titles and abstracts was performed. After applying inclusion and exclusion criteria, 34 articles were excluded and a total of 22 full-text articles were assessed for eligibility. For each article, the role of CT-scan, CT-perfusion, MRI, MRI with Gadolinium and MRI diffusion (DWI) in distinguishing the most reliable features to suggest the diagnosis of spine infection versus bone tumor/metastasis was collected. Conclusion: Definitive differential diagnosis between infection and tumor requires biopsy and culture. The sensitivity and specificity of percutaneous biopsy are 72% and 94%, respectively. Imaging studies can be added to address the diagnosis, but a multidisciplinary discussion with radiologists and nuclear medicine specialists is mandatory.

Study design A single-centre retrospective study. Background and purpose This study aims to investigate the rate of L5 radiculopathy, to identify imaging features associated with the complication and to evaluate the clinical outcomes in adult spine deformity patients undergoing L5-S1 ALIF with hyperlordotic cages. Methods Design: retrospective cohort study. A single-centre prospective database was queried to analyse patients undergoing hyperlordotic (HL) ALIF with posterior fusion to correct spinal deformity. Clinical status was evaluated by back and leg pain numeric rate scale and Oswestry Disability Index pre-operatively and at 3-, 6- and 12-month follow-up. Spinopelvic parameters, such as pelvic incidence, pelvic tilt, lumbar lordosis and L5-S1 lordosis, posterior disc height (PDH) and anterior disc height, were assessed pre-operatively and post-operatively on standardized full-spine standing EOS images. The sagittal foraminal area was measured pre- and post-operatively on a CT scan. Results Thirty-nine patients with a mean age of 63.2 ± 8.6 years underwent HL-ALIF from January 2016 to December 2019. Seven of them developed post-operative root pain (5) or weakness (2) (Group A), while thirty-two did not (Group B). Root impairment was associated with greater segmental correction magnitude, 26° ± 11.1 in Group A versus 15.1° ± 9.9 in Group B (p < 0.05), and to smaller post-operative PDH, 5.9 mm ± 2.7 in Group A versus 8.3 mm ± 2.6 (p < 0.05). Conclusions Post-operative root problems were observed in 17.9% of patients undergoing HL-ALIF for adult spine deformity. L5 radiculopathy was associated with larger sagittal angular corrections and smaller post-operative posterior disc height. One patient (2.6%) needed L5 root decompression. At 12 months of follow-up, results were equivalent between groups. Level of evidence I Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

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.