Mark Kurapatti

Background: We describe key pearls and principles of a mini-open, thoracoscopically-assisted vertebral body tethering case for double-major scoliosis with 2 distinct anterior approaches: thoracic and thoracoabdominal. Description: The thoracic curve is addressed through a mini-thoracotomy combined with thoracoscopic portals utilizing single-lung ventilation to provide clear visualization. Key steps include precise fluoroscopic marking of vertebral levels, muscle-sparing entry between the ribs, controlled pleural entry and mobilization, and careful management of segmental vessels. Vertebral body screws are placed under direct and fluoroscopic guidance with strict adherence to orthogonal trajectories and avoidance of disc violation. Tether placement proceeds segment-by-segment, maximizing correction at the apex while maintaining appropriate laxity distally to prevent overcorrection. Major tethering principles include maintaining colinear screw alignment to prevent tether kinking and utilizing bicortical fixation when anatomy permits. These principles ensure uniform force transmission and minimize stress concentrations within the tether construct, optimizing tether durability. The lumbar curve is accessed through a thoracoabdominal exposure that includes mobilization of the diaphragm with cuffed detachment and blunt retroperitoneal dissection to safely identify the iliopsoas muscle and sympathetic chain. Double-screw constructs are used at most accessible lumbar levels, with priority given to the apical region to enhance durability under higher mechanical loads. Screws are positioned posteriorly within the vertebral body to help maintain lumbar lordosis and are inserted with a controlled trajectory to achieve bicortical fixation while avoiding a posterior cortical breach and maintaining a safe distance from the spinal canal. Two tethers are applied (first posterior, then anterior) to distribute corrective forces and reduce peak tether strain, balancing correction with load-sharing. Adherence to these principles optimizes lordosis preservation, construct longevity, and safe modulation during growth. Alternatives: The primary alternative treatment is posterior spinal fusion (PSF), the current standard surgical treatment for adolescent idiopathic scoliosis ¹ . PSF generally provides greater and more predictable curve correction, particularly for thoracic-major curves, but sacrifices motion across the fused spinal segments. Rationale: This surgical technique is appropriately applied in skeletally immature patients with flexible double-major adolescent idiopathic scoliosis who are undergoing vertebral body tethering through combined thoracic and thoracoabdominal anterior approaches ^1–7 . A representative scenario is a patient with a right thoracic and a left lumbar curve demonstrating ≥50% correction of both curves on preoperative bending radiographs, indicating sufficient flexibility for growth modulation. Ideal candidates typically have Cobb angles between 40° and 65° and are skeletally immature (Risser 0 to 2, Sanders 3 to 4). The principles demonstrated are particularly relevant when treating double-curve deformities that require 2 distinct anterior exposures, wherein precise screw alignment, safe vessel and soft-tissue management, and differential tether tensioning are critical to predictable growth modulation. In the thoracic spine, this technique is useful when placing vertebral body screws through a mini-thoracotomy with thoracoscopic assistance, wherein colinear screw alignment and segmental tensioning are necessary to avoid tether kinking and maintain physiologic thoracic kyphosis. In the lumbar spine, thoracoabdominal exposure requires diaphragm mobilization and screws are posteriorly positioned; dual-screw constructs and staged posterior-then-anterior tethering help preserve lumbar lordosis and improve construct durability. These use cases emphasize scenarios in which precise fluoroscopic planning, harmonious screw trajectories, and controlled tether laxity are essential to avoid overcorrection, minimize mechanical stress on the tether, and achieve durable correction through guided spinal growth. Expected Outcomes: In appropriately selected adolescents with double-curve adolescent idiopathic scoliosis, bilateral vertebral body tethering can provide meaningful correction of both curves while preserving spinal motion ^1–3 . Outcomes appear more favorable for thoracolumbar-major curves than thoracic-major curves, but patients should be counseled regarding risks of tether breakage, overcorrection, loss of correction, and potential revision or fusion. Long-term durability remains uncertain. Important Tips: Maintain optimal orthogonal fluoroscopic views throughout screw placement. Align screw tulips colinearly to avoid tether shear forces. Leave controlled laxity distally in patients with substantial remaining growth. Use bicortical fixation posteriorly in the lumbar spine for reliable fixation. Avoid placing screws too anteriorly or posteriorly, which increases the risk of a visceral or canal breach. Avoid overtensioning end segments, which increases the risk of overcorrection. Avoid grasping or damaging the tether with instruments. Avoid insufficient thoracotomy and/or portal placement, which can lead to poor exposure and suboptimal screw trajectory. Acronyms and Abbreviations: VBT = vertebral body tethering

Dural tear risk in endoscopic spine surgery is determined more by procedural complexity and surgeon experience than by the endoscopic technique alone, with the highest rates observed in interlaminar decompression for lumbar stenosis and the lowest in transforaminal procedures. Most incidental dural tears can now be managed endoscopically without routine conversion to open surgery, particularly when tears are recognized early and stratified according to size, location, cerebrospinal fluid flow, and neural element involvement. Patch- and graft-based techniques represent the current workhorse strategy for moderate dural tears (5-10 mm), whereas endoscopic suturing is increasingly feasible for larger or high-flow defects in experienced hands. There is currently no standardized postoperative management protocol for endoscopic dural tears, and practices regarding bed rest, mobilization, and drain usage remain highly variable across the literature. The clinical significance of dural tear is determined less by its occurrence than by the adequacy of its management as most patients achieve favorable long-term outcomes when tears are recognized and treated appropriately.

Study Design Retrospective Cohort Study Objective Biplanar full-body X-ray imaging is a low-dose, high-resolution technology crucial for assessing scoliosis and guiding treatment. Accurate coronal curvature measurement is essential for quantifying severity and planning surgery. Traditional methods are manual, time-consuming, and prone to interobserver variability. Deep learning offers potential for standardization and rapid analysis. RadImageNet, a pretrained model trained on annotated medical images, provides a strong foundation for developing AI-driven radiology tools. This study specifically evaluates whether RadImageNet transfer learning can support adult scoliosis severity classification on standardized AP biplanar full-body radiographs, a task distinct from prior work focused on direct Cobb-angle measurement or adolescent screening. Methods A total of 816 standardized anteroposterior (AP) full-body radiographs from adult patients with degenerative or idiopathic scoliosis and scoliosis-negative cases were used, with an 80/20 split for training/validation and testing, respectively. No external validation cohort was available. Scoliosis severity was classified into three categories based on the highest Cobb angle from the proximal thoracic, main thoracic, and thoracolumbar curves: no scoliosis (0°–10°), mild scoliosis (10°–30°), and severe scoliosis (> 30°). Cobb-angle labels were derived from resident-generated vertebral-column segmentations and reviewed before final severity assignment; formal interobserver reliability for the final categories was not assessed. A convolutional neural network classifier was developed using a pretrained ResNet-50 backbone from RadImageNet, predicting three output classes. To enhance generalizability, data augmentation techniques - including horizontal flipping, random brightness and contrast adjustments, and resizing to 224 × 224 pixels - were applied for 100 epochs. Model performance was evaluated on the test set using metrics such as accuracy, precision, recall, F1-score, Cohen’s Kappa, Matthews Correlation Coefficient, and area under the curve receiver operating characteristic (AUROC). Approximate 95% confidence intervals were calculated for key test-set metrics. Smooth Grad-CAM + + was employed to generate class activation maps for visual interpretability. Results The fine-tuned RadImageNet model achieved an overall accuracy of 76.2% (95% CI, 69.2%-82.1%) and AUROC scores of 0.853 (95% CI, 0.767–0.939) for no scoliosis, 0.766 (95% CI, 0.693–0.839) for mild scoliosis, and 0.843 (95% CI, 0.723–0.962) for severe scoliosis, indicating acceptable but variable class discrimination. The model demonstrated its highest performance for mild scoliosis with a precision of 0.79 (95% CI, 0.72–0.85), recall of 0.90 (95% CI, 0.84–0.95), and an F1 score of 0.85 (95% CI, 0.79–0.89). Misclassifications predominantly occurred between adjacent severity levels. Additionally, class activation maps confirmed that the thoracic and lumbar regions were key contributors to the model’s predictions. Conclusions Fine-tuning a pretrained medical image CNN, specifically a RadImageNet-based ResNet-50 model, for scoliosis grading may support adjunctive scoliosis severity categorization; however, it does not directly measure Cobb angle, progression, sagittal balance, or surgical-planning parameters and requires external validation before clinical screening use.

Background: Labral reconstruction has become an essential technique for treating irreparable acetabular labral pathology. While both segmental and circumferential reconstruction techniques are utilized, it remains unclear whether one provides superior clinical outcomes. Purpose: To compare patient-reported outcomes, complications, and reoperation rates between segmental and circumferential labral reconstruction. Study Design: Meta-analysis. Methods: A systematic review of the PubMed, Embase, and Scopus databases was performed in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on February 2, 2025. Studies were included if they reported clinical outcomes after arthroscopic hip labral reconstruction using either segmental or circumferential techniques. Data were extracted on patient characteristics, surgical details, patient-reported outcome measures, complications, revision arthroscopy, and conversion to total hip arthroplasty (THA). Meta-analyses were performed using random-effects models, and heterogeneity was assessed using the I ² statistic. Results: A total of 28 studies consisting of 1817 hips were included, with 1086 undergoing segmental and 731 undergoing circumferential reconstruction. Patient characteristics were similar between groups, except for a lower proportion of women in the segmental cohort than circumferential cohort (44.6% vs 73.2%; P < .001). Both techniques resulted in significant improvements in all patient-reported outcomes, including the Harris Hip Score, Hip Outcome Score–Activities of Daily Living, Hip Outcome Score–Sports, International Hip Outcome Tool–12 score, Short Form–12 score, and visual analog scale pain score, with no significant differences between groups (all P > .05). Complication rates and revision rates were comparable ( P = .05 and P = .06, respectively). However, circumferential reconstruction was associated with a significantly lower conversion to THA compared with segmental reconstruction ( P = .01). Conclusion: Both segmental and circumferential labral reconstruction techniques provide significant and comparable improvements in functional outcomes and pain. Circumferential reconstruction was associated with a lower pooled rate of conversion to THA; however, causality cannot be inferred given the heterogeneity, nonrandomized design, and differences in follow-up duration between studies.

Randomized controlled trials (RCTs) are essential for guiding the treatment of vertebral compression fractures with kyphoplasty, yet the statistical robustness of their findings has not been thoroughly evaluated. This systematic review assessed the fragility of dichotomous outcomes in kyphoplasty RCTs using the fragility index (FI), reverse fragility index (rFI), and fragility quotient (FQ). A comprehensive search of PubMed, Embase, and MEDLINE identified eligible RCTs, yielding 282 dichotomous outcomes for analysis. The overall median FI was 4 (interquartile range [IQR], 4-5), corresponding to a median FQ of 0.020 (IQR, 0.013-0.040). Statistically significant outcomes (n=18) demonstrated greater fragility, with a median FI of 2 (IQR, 1-4) and FQ of 0.015 (IQR, 0.011-0.029), compared with nonsignificant outcomes (n=264; FI, 5 [IQR, 4-5]; FQ, 0.020 [IQR, 0.013-0.041]). Subgroup analyses revealed that pain and complication outcomes had median FIs of 4 and 5, respectively, with FQs ranging from 0.016 to 0.025. Cement leakage outcomes were the most fragile (FI, 4; FQ, 0.048). More than half of the analyzed outcomes involved a greater number of patients lost to follow-up than their corresponding FI, underscoring the need for cautious interpretation of kyphoplasty trial results and supporting the inclusion of fragility metrics in future trial reporting to better inform clinical decision-making.

Biportal endoscopic (BE) spine surgery has gained increasing attention as a minimally invasive alternative to conventional spinal procedures, yet the distribution of procedural applications and anatomic targets within influential BE-specific publications has not been clearly synthesized. This study aimed to synthesize influential publications on BE spine surgery to describe the evolution of procedural applications, anatomic focus, and clinically relevant themes reflected in the literature. A comprehensive search of the Web of Science database was performed using terms related to biportal and multiportal endoscopic spine techniques. Influential articles were identified using citation frequency as a screening criterion, and relevant study characteristics, including publication year, authorship, institutional affiliation, geographic region, journal, and spinal region addressed, were extracted. Full-text screening confirmed inclusion of true biportal endoscopic spinal procedures and categorized the anatomical region and surgical technique addressed. Publications spanned 1997 to 2023, with a marked increase after 2018 and peak productivity in 2022. Influential publications were most frequently published in World Neurosurgery, with substantial contributions originating from South Korea, including work by Dae-Jung Choi. Most studies focused on lumbar procedures, primarily decompression techniques and transforaminal lumbar interbody fusion. Overall, this review highlights the rapid clinical growth of BE spine surgery, with influential literature emphasizing lumbar applications and underscoring the need for further research on outcomes, learning curves, and broader international adoption.

Systematic review and meta-analysis. To perform a comprehensive meta-analysis comparing clinical outcomes of uniportal versus biportal endoscopic spine surgery across decompression procedures in patients with lumbar degenerative disease (LDD). Uniportal endoscopic spine surgery has been a widely adopted minimally invasive technique, whereas biportal endoscopy has recently emerged as a promising alternative with potential advantages in surgical outcomes. A systematic review and meta-analysis of comparative studies was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, Embase, and Scopus databases were searched to identify relevant studies. Eleven studies encompassing 374 uniportal and 368 biportal patients were included. Outcomes analyzed were Oswestry Disability Index (ODI), Visual Analog Scale (VAS) scores for back and leg pain, complication rates, operative time, and length of hospital stay. Biportal endoscopic surgery was associated with a significantly lower ODI at 1-3 months and at final follow-up compared with uniportal surgery. However, uniportal discectomy demonstrated significantly shorter operative time and length of hospital stay than biportal discectomy. No significant differences were observed between approaches in terms of VAS scores, complication rates, or ODI at other time points. Both uniportal and biportal endoscopic spine surgeries yield comparable postoperative outcomes in LDD. Although biportal surgery showed a modest advantage in ODI improvement, it did not reach the minimal clinically important difference. Uniportal surgery demonstrated greater efficiency in terms of operative time and recovery, particularly for discectomy procedures.