UNASSIGNED: Transforaminal anterior release (TFAR) is a technical extension of the transforaminal lumbar interbody fusion (TLIF) procedure with deliberate release of the anterior longitudinal ligament (ALL).
UNASSIGNED: In a retrospective, single-center observational cohort study, consecutive adult patients undergoing TLIF surgery at L4/L5 and/or L5/S1 between 01/2018 and 12/2022 for degenerative disc disease or deformity were considered. The TFAR group (with ALL release) was compared to a standard TLIF group (without ALL release), matched in a 1:3 ratio. Uni- and multivariable logistic regression models were built to estimate the likelihood of any adverse event (AE), reoperation, and excellent/good clinical outcome at 12 months.
UNASSIGNED: Of 438 patients, 18 undergoing TFAR were matched to 53 undergoing standard TLIF. TFAR procedures were frequently part of extensive, anterior-posterior or multilevel fusion procedures with longer surgery time and higher blood loss. The rates of intraoperative surgical AEs were similar (16.7 vs. 11.3%, p=.789). The rates and severities of surgical AEs, as well as reoperation rates and clinical outcomes were similar at time of discharge, 90 days, and 12 months postoperatively (all p>.05). TFAR allowed for an increase in total lumbar lordosis of 16.1° and in lumbar lordosis between L4 and S1 of 16.3° at discharge, which was maintained during follow-up. In both the uni- and multivariable models, patients undergoing TFAR were as likely as patients undergoing standard TLIF to experience any AE (adjusted OR 0.78, 95% CI 0.21-2.94), any reoperation (aOR 0.46, 95% CI 0.11-1.90) or excellent/good clinical outcome at 12 months (aOR 2.01, 95% CI 0.52-7.74).
UNASSIGNED: The TFAR technique has a safety profile which is comparable to the standard TLIF procedure, but it allows for a greater restoration of lumbar lordosis at L4-S1. We suggest considering the TFAR technique in selected patients with sagittal imbalance and mobile segments for restoration of lumbar lordosis.

OBJECTIVE: The purpose of this study was to assess how various realignment strategies affect mechanical failure and clinical outcomes in pelvic incidence (PI)-stratified cohorts following adult spinal deformity (ASD) surgery.
METHODS: Median and interquartile range statistics were calculated for demographics and surgical details. Further statistical analysis was used to define subsets within PI generating significantly different rates of mechanical failure. These subsets of PI were further analyzed as subcohorts for the outcomes and effects of realignment within each subcohort. Multivariate logistic regression analysis controlling for baseline frailty and lumbar lordosis (LL; L1-S1) analyzed the association of age-adjusted realignment and Global Alignment and Proportion (GAP) strategies with the incidence of mechanical failure and clinical improvement within PI-stratified groups.
RESULTS: A parabolic relationship between PI and mechanical failure was noted, whereas patients with either < 51° (n = 174, 39.1% of cohort) or > 63° (n = 114, 25.6% of cohort) of PI generated higher rates of mechanical failure (18.0% and 20.0%, respectively) and lower rates of good outcome (80.3% and 77.6%, respectively) than those with moderate PI (51°-63°). Patients with lower PI more often met good outcome criteria when undercorrected in age-adjusted PI-LL mismatch and sagittal age-adjusted score, and those not meeting good outcome criteria were more likely to deteriorate in GAP relative LL from first to final follow-up (OR 13.4, 95% CI 1.3-139.2). In those with moderate PI, patients were more likely to meet good outcome when aligned on the GAP lordosis distribution index (LDI; OR 1.7, 95% CI 0.9-3.3). Patients with higher PI meeting good outcome were more likely to be overcorrected in sagittal vertical axis (OR 2.4, 95% CI 1.1-5.2) at first follow-up and less likely to be undercorrected in T1 pelvic angle (OR 0.4, 95% CI 0.2-0.9) by final follow-up. When assessing GAP alignment, patients were more likely to meet good outcome when aligned on GAP LDI (OR 3.5, 95% CI 1.4-8.9).
CONCLUSIONS: There was a parabolic relationship between PI and both mechanical failure and clinical improvement following deformity correction in this study. Understanding the associations between this fixed parameter and poor outcomes can aid the surgeon in strategical planning when seeking to realign ASD.

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.

Mature mediastinal teratoma is a rare benign tumor in children. Few cases have been reported in the literature. Moreover, this tumor is often characterized by slow growth, reaching a large volume and frequently causing nonspecific symptoms, making its diagnosis more difficult. It raises the question of differential diagnosis with malignant mediastinal tumors in pediatric patients, requiring histological confirmation by biopsy or excision. The purpose of this article is to report an atypical clinical finding characterized by spinal deformity, and to contribute to medical knowledge concerning this uncommon pediatric tumor.

BACKGROUND: This study aims to evaluate the prevalence and treatment of osteoporosis in patients undergoing long spinal fusion for adult spinal deformity (ASD) and compare the impact of osteoporosis treatment on surgical and radiographic outcomes.
METHODS: We conducted a retrospective study of adult patients aged ≥40 years who underwent thoracolumbar ASD surgery at a single academic center between 2015 and 2021. We recorded demographic information, procedural details, and pharmacologic treatments. Primary outcomes included preoperative and postoperative sagittal vertical axis, pelvic incidence-lumbar lordosis mismatch, and postoperative complications such as surgical site infection, pseudarthrosis, proximal junctional kyphosis (PJK), and proximal junctional failure. Patients with osteoporosis were compared to those without.
RESULTS: Among 168 patients, the prevalence of osteoporosis was 28.6%. Osteoporotic patients were older and predominantly female. At the time of surgery, 70.8% of osteoporotic patients were receiving pharmacologic treatment. Preoperative pelvic incidence-lumbar lordosis mismatch and sagittal vertical axis did not differ significantly between osteoporotic and nonosteoporotic cohorts. Both cohorts showed similar postoperative improvements. The osteoporotic cohort had a higher rate of PJK (35.4% vs. 17.5%, p=0.01), but no significant difference in proximal junctional failure rates. No significant differences were found between monotherapy and combination therapy outcomes for osteoporotic patients.
CONCLUSIONS: Osteoporotic patients undergoing ASD surgery exhibited similar surgical outcomes and alignment improvements compared to nonosteoporotic patients, despite a higher rate of PJK. Pharmacological treatment appears beneficial in managing osteoporosis-related surgical risks. These findings highlight the importance of identifying and treating osteoporosis in ASD patients to minimize complications.

OBJECTIVE: Adolescent idiopathic scoliosis (AIS) is a common spinal deformity with varying progression, complicating treatment decisions. Artificial intelligence (AI) and machine learning (ML) are increasingly prominent in orthopedic care, aiding in diagnosis, risk-stratification, and treatment guidance. This scoping review outlines AI applications in AIS.
METHODS: This study followed PRISMA-ScR guidelines and included articles that reported the development, use, or validation of AI models for treating, diagnosing, or predicting clinical outcomes in AIS.
RESULTS: 40 full-text articles were included, with most studies published in the last 5 years (77.5%). Common ML techniques were convolutional neural networks (55%), decision trees and random forests (15%), and artificial neural networks (15%). Most AI applications in AIS were for imaging analysis (25/40; 62.5%), focusing on automatic measurement of Cobb angle, and axial vertebral rotation (13/25; 52%) and curve classification/severity (13/25; 52%). Prediction was the second most common application (15/40; 37.5%), with studies predicting curve progression (9/15; 60%), and Cobb angles (9/15; 60%). Only 15 studies (37.5%) reported clinical implementation guidelines for AI in AIS management. 52.5% of studies reported model accuracy, with an average of 85.4%.
CONCLUSIONS: This review highlights the applications of AI in AIS care, notably including automatic radiographic analysis, curve type classification, prediction of curve progression, and AIS diagnosis. However, the current lack of clear clinical implementation guidelines, model transparency, and external validation of studied models limits clinician trust and the generalizability and applicability of AI in AIS management.

OBJECTIVE: The goal of this study is to characterize the self-reported prevalence of psychiatric comorbidities among patients with adolescent scoliosis.
METHODS: Eligible patients across the US were surveyed using ResearchMatch, a validated online platform. The survey collected patient demographics, type of scoliosis, scoliosis treatment received, and the mental health diagnoses and interventions.
RESULTS: Nearly all (98%) of the 162 respondents were patients themselves, the remainder of which were parents. The majority of whom were female (93%), Caucasian (85%), and diagnosed with idiopathic scoliosis (63%). The median age of diagnosis was 13 (IQR 11-18). Most respondents had mild to moderate scoliosis (65%), and 17% received surgical treatment. 76 of 158 (48%) responded that scoliosis affected their overall mental health, and 92 (58%) had received a mental health diagnosis-76% were diagnosed after their scoliosis diagnosis. Of the 92 with mental health diagnoses, the most common diagnoses were clinical depression (83%), anxiety (71%), negative body image (62%). Over 80% of patients received medical treatment or therapy. Of those with depression, 38.4% received counseling and 45.2% received medication. 52% of the respondents also had immediate family members with mental health diagnoses, with siblings (48%) having the highest proportion.
CONCLUSIONS: According to the CDC, the prevalence of US teenagers with diagnosed depression was found to be 3.9% and anxiety disorder to be 4.7%, notably higher among adolescent girls. In this national sample, over half of adolescent scoliosis patients report psychiatric comorbidity, often diagnosed years later. The most prevalent psychiatric condition is depression, anxiety, and body-image disturbances. These findings highlight the importance of awareness of the psychiatric impact of adolescent scoliosis, and importance of screening and treatment of comorbid mental health conditions.
METHODS: IV.

OBJECTIVE: Pelvic incidence minus lumbar lordosis mismatch (PI-LL) is directly related to poor quality of life in adult degenerative scoliosis (ADS) patients. The purpose of the study was to determine the most appropriate postoperative PI-LL value for patients with ADS.
METHODS: The medical records of patients with ADS in our department were retrospectively collected. The data included age, sex, body mass index, age-adjusted Charlson comorbidity index, osteopenia, length of hospital stay, operative duration, estimated blood loss, American Society of Anesthesiologists score, number of fusion levels, lumbar lordosis, sagittal vertical axis, pelvic incidence, PI-LL, Scoliosis Research Society-22 score, Oswestry Disability Index score, and mechanical complications.
RESULTS: A total of 316 patients were enrolled. PI-LL, lumbar lordosis, sagittal vertical axis, Scoliosis Research Society-22 score, Oswestry Disability Index score at the time of last follow-up were 20.7 ± 8.5°, 23.4 ± 14.1°, 4.0 ± 2.1 cm, 3.7 ± 0.9, and 18.1 ± 5.5, respectively. In terms of mechanical complications, 88 patients (27.8%), 34 patients (10.8%), and 19 patients (6.0%) had proximal junctional kyphosis, distal junctional kyphosis, and implant-related complications, respectively. In the fully adjusted model, compared with 0 grade PI-LL group and ++ grade PI-LL group, + grade PI-LL group had the best clinical outcomes and the fewest mechanical complications. The stability of these conclusions was verified in sensitivity analyses.
CONCLUSIONS: Optimal PI-LL value should be 10°-20° after corrective surgery in patients with ADS, which is associated with excellent clinical outcomes and lower complication rates. Previous criteria may be at risk of overcorrection, which may lead to proximal junctional kyphosis.

Chest deformities in children with scoliosis may result in cardiopulmonary disorders, lowering cardiopulmonary capacity levels. However, results regarding the dependence of cardiopulmonary capacity on the severity level of scoliosis remain controversial. We aimed to use dynamic cardiopulmonary exercise testing (CPET) to investigate exercise capacity in reference to spinal deformity in patients with mild or moderate idiopathic scoliosis by means of multivariate analyses. Methods: We included 92 children and adolescents aged 10-17 years with mild and moderate idiopathic scoliosis and 94 healthy peers. The study consisted of three parts: (1) medical record analyses; (2) anthropometric measurements; and (3) CPET. Results: Our results revealed that the mean VO2peak and VO2peak/kg values of the participants with scoliosis were 0.27 L/min and 0.37 mL/min/kg lower than their healthy peers, respectively, regardless of age and gender. Furthermore, the occurrence of scoliosis correlates with a mean decrease in minute ventilation volume by 10.10 L/min, tidal volume by 0.11 L, breathing frequency by 3.78 bpm, and breathing reserve by 14.34%, regardless of the age and gender of the participants. Children and adolescents with mild-to-moderate scoliosis during CPET exhibit a lower ventilation capacity and lower VO2 max than healthy adolescents matched in age but their cardiorespiratory fitness parameters do not depend on the Cobb angle value and the angle rotation of the primary spinal curvature. Conclusions: Physical therapy and activity should be recommended to prevent cardiorespiratory failure in later life in patients with scoliosis. This study may also provide CPET reference values for healthy children and adolescents with scoliosis.

In recent years, advances in the surgical treatment of adult spinal deformity (ASD) have led to improved outcomes. Although these advances have helped drive the development of deformity surgery to meet the rising volume of patients seeking surgical treatment, many challenges have yet to be solved. Instrumentation failure remains one of the most common major complications following deformity surgery, associated with significant morbidity due to elevated re-operation rates among those experiencing mechanical complications. The two most frequently encountered subtypes of instrumentation failure are rod fracture (RF) and proximal junctional kyphosis/proximal junctional failure (PJK/PJF). While RF and PJK/PJF are both modes of instrumentation failure, they are two distinct entities with different clinical implications and treatment strategies. Considering that RF and PJK/PJF continue to represent a major challenge for patients with ASD and deformity surgeons alike, this review aims to discuss the incidence, risk factors, clinical impact, treatment strategies, preventive measures, and future research directions for each of these substantial complications.