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BACKGROUND: Surgical management of adolescent idiopathic scoliosis (AIS) and Scheuermann's kyphosis (SK) may be associated with several complications including extended length of stay and unplanned reoperations. Several studies have previously compared postoperative complications and functional outcomes for AIS and SK patients with mixed results. However, a meta-analysis compiling the literature on this topic is lacking. METHODS: Following the PRISMA guidelines, PubMed, Cochrane, and Google Scholar (pages 1-20) were accessed and explored until April 2024. The extracted data consisted of complications (overall and surgical-site infections [SSI]), readmissions, reoperations, and Scoliosis Research Society-22 (SRS-22) score. Mean differences (MD) with 95% CI were used for continuous data and odds ratio (OR) was utilized for dichotomous data were calculated across studies. RESULTS: Seven retrospective articles were included in the meta-analysis, including 4866 patients, with 399 in the SK group and 4467 in the AIS group. SK patients were found to have statistically significantly higher rates of overall complications (OR = 5.41; 95% CI 3.69-7.93, p < .001), SSI (OR = 11.30; 95% CI 6.14-20.82, p < .001), readmissions (OR = 2.81; 95% CI 1.21-6.53, p = 0.02), and reoperations (OR = 7.40; 95% CI 4.76-11.51, p < .001) than AIS patients. However, they had similar SRS-22 scores postoperatively (MD = -0.06; 95% CI -0.16 to 0.04, p = 0.26) despite the SK group having lower SRS-22 scores preoperatively (MD = -0.30; 95% CI -0.42 to -0.18, p < .001). CONCLUSION: In this meta-analysis of studies comparing spinal deformity surgery outcomes in AIS and SK patients, SK was associated with more complications, readmissions, and reoperations. SK did have equivalent SRS-22 scores postoperatively to AIS patients, highlighting the benefit of surgical treatment despite higher complication rates. This data may help inform healthcare institutions, payors, and quality monitoring organizations who examine outcomes of pediatric and adult spinal deformity surgery.

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Large Language Models (LLMs have the potential to revolutionize clinical medicine by enhancing healthcare access, diagnosis, surgical planning, and education. However, their utilization requires careful, prompt engineering to mitigate challenges like hallucinations and biases. Proper utilization of LLMs involves understanding foundational concepts such as tokenization, embeddings, and attention mechanisms, alongside strategic prompting techniques to ensure accurate outputs. For innovative healthcare solutions, it is essential to maintain ongoing collaboration between AI technology and medical professionals. Ethical considerations, including data security and bias mitigation, are critical to their application. By leveraging LLMs as supplementary resources in research and education, we can enhance learning and support knowledge-based inquiries, ultimately advancing the quality and accessibility of medical care. Continued research and development are necessary to fully realize the potential of LLMs in transforming healthcare.

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BACKGROUND: Postoperative delirium (POD) is frequently reported in the elderly after major surgery. Several risk factors have been identified, including age, surgical complexity, and comorbidities. METHODS: Posterior lumbar fusion patients were identified using PearlDiver and filtered into two cohorts based on presence or absence of POD within 7 days of surgery. Epidemiological analyses were performed to examine trends in POD by age and year. Comparative analyses were performed on patient demographics and baseline cognitive status. After matching by age, sex, and comorbidities, electrolyte disturbances and 90-day postoperative complications were analyzed. RESULTS: Among 476,482 no POD and 2,591 POD patients, mean age was 60.90 years, 57.6% were female, and mean CCI was 1.78. POD patients frequently had baseline cognitive impairment (p<0.001). Incidence of POD decreased from 0.7% in 2010 to 0.4% in 2022 (p<0.001) and increased with increasing patient age (p<0.001). POD patients had higher length of stay (12 vs 6 days, p<0.001) and 90-day costs ($20,605 vs $17,849, p<0.001). After matching, POD patients had higher hypernatremia (5.8% vs 3.5%, p=0.001) and hypocalcemia (5.0% vs 3.5%, p=0.026). POD patients had higher 90-day postoperative complications (p<0.05) than no POD patients. CONCLUSION: Nearly 0.5% of patients who underwent posterior spinal fusion between 2010-2022 developed delirium, although incidence rates have decreased over time. POD was common in elderly patients with electrolyte disturbances who underwent multi-level fusions. Patients suffering from POD had higher rates of 90-day postoperative complications. Ongoing efforts to deliver interventions to mitigate the consequences of POD among spine surgery patients are warranted.

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Background: Several assessment tools have been developed to estimate a patient's likelihood risk of falling. None of these measures estimate the contributions of the visual, vestibular, and somatosensory systems to fall risk, especially in patients with degenerative lumbar spine disease. Methods: Degenerative lumbar spine patients with radiculopathy (LD) and healthy subjects who were 35-70 years old without spine complaints were recruited. Patient reported outcome measures (PROMs) were collected prior to testing. Fall risk assessment was completed using Computer Dynamic Posturography (CDP), a computer-controlled balance machine that allows cone of economy (CoE) and cone of pressure (CoP) measurements. All patients completed Sensory Organization Tests (SOT) which include normal and perturbed stability, both with and without visual cues. Results: In total, 43 spine patients and 12 healthy controls were included, with mean age 57.8 years, 39.5% females, and mean BMI of 29.3 kg/m2. Nearly all CoE and most CoP dimensions were found to be larger in LD patients compared to controls across nearly all subtests (p<.05), with the largest dimensions generally observed in the surrounding and support sway testing condition. In LD patients, ODI and PROMIS Pain Interference were negatively correlated with CoE and CoP measurements (p<.05). Conclusions: In this prospective study, body sway was assessed as a function of CoE and CoP using the CDP system and was found to be elevated in spine patients, especially when they experienced increasing levels of visual and vestibular stimulation. The ability to identify the primary drivers of balance disorders is essential in spine patients and may be helpful in the development of a patient-specific treatment plan, which may in the future aid with fall-prevention initiatives.

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PURPOSE: To evaluate the variability in intraoperative fluid management during adult spinal deformity (ASD) surgery, and analyze the association with complications, intensive care unit (ICU) requirement, and length of hospital stay (LOS). METHODS: Multicenter comparative cohort study. Patients ≥ 18 years old and with ASD were included. Intraoperative intravenous (IV) fluid data were collected including: crystalloids, colloids, crystalloid/colloid ratio (C/C), total IV fluid (tIVF, ml), normalized total IV fluid (nIVF, ml/kg/h), input/output ratio (IOR), input-output difference (IOD), and normalized input-output difference (nIOD, ml/kg/h). Data from different centers were compared for variability analysis, and fluid parameters were analyzed for possible associations with the outcomes. RESULTS: Seven hundred ninety-eight patients with a median age of 65.2 were included. Among different surgical centers, tIVF, nIVF, and C/C showed significant variation (p < 0.001 for each) with differences of 4.8-fold, 3.7-fold, and 4.9-fold, respectively. Two hundred ninety-two (36.6%) patients experienced at least one in-hospital complication, and ninety-two (11.5%) were IV fluid related. Univariate analysis showed significant relations for: LOS and tIVF (ρ = 0.221, p < 0.001), IOD (ρ = 0.115, p = 0.001) and IOR (ρ = -0.138, p < 0.001); IV fluid-related complications and tIVF (p = 0.049); ICU stay and tIVF, nIVF, IOD and nIOD (p < 0.001 each); extended ICU stay and tIVF (p < 0.001), nIVF (p = 0.010) and IOD (p < 0.001). Multivariate analysis controlling for confounders showed significant relations for: LOS and tIVF (p < 0.001) and nIVF (p = 0.003); ICU stay and IOR (p = 0.002), extended ICU stay and tIVF (p = 0.004). CONCLUSION: Significant variability and lack of standardization in intraoperative IV fluid management exists between different surgical centers. Excessive fluid administration was found to be correlated with negative outcomes. LEVEL OF EVIDENCE: III.

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STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Compare outcomes in patients undergoing one-level transforaminal lumbar interbody fusion (TLIF) at L4-S1. BACKGROUND: TLIF is frequently performed at L4-S1 to treat degenerative lumbar pathologies. However, the native alignment and biomechanics differ across L4-L5 and L5-S1, and there is limited data regarding comparative radiographic outcomes. METHODS: Patients who underwent one-level TLIF at L4-L5 or L5-S1 at a single academic institution were identified. Baseline demographics, procedural characteristics, change in postoperative spinopelvic alignment and patient-reported outcome measures (PROMs), and two-year postoperative surgical complications were compared. Multivariate regression analyses, accounting for age, gender, Charlson Comorbidity Index (CCI), and body mass index (BMI), were also performed. RESULTS: Across the 175 included patients, 125 had L4-L5 TLIF and 50 had L5-S1 TLIF. The mean age was 57.8 years, 56.6% were female, mean CCI was 0.9, and mean follow-up was 26.7 months. In the hospital, the two cohorts were not statistically different with regards to EBL and LOS. Two years postoperatively, multivariate linear regression analyses revealed that L5-S1 TLIF achieved 6.0° higher correction in L4-S1 lordosis ( P =0.012) than L4-L5 TLIF. At the same time, however, L5-S1 TLIF patients experienced significantly higher rates of pseudoarthrosis (8.0% vs 1.6%, P =0.036) and subsequent spine surgery (18.0% vs. 7.2%, P =0.034), specifically for pseudoarthrosis (6.0% vs. 0.0%, P =0.006), with this cohort having 8.7 times higher odds of subsequent spine surgery for pseudoarthrosis ( P =0.015) than L4-L5 TLIF patients on multivariate logistic analyses. PROMs, on the other hand, were not different across the two cohorts. CONCLUSIONS: Although L5-S1 TLIF yielded good radiographic correction, it was associated with higher rates of subsequent spine surgery for pseudoarthrosis compared to L4-L5 TLIF. These findings may be related to differences in native segmental alignment and biomechanics across the L4-L5 and L5-S1 motion segments and are important to consider during surgical planning. LEVEL OF EVIDENCE: IV.

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Spinal alignment analysis play an important role in evaluating patients and planning surgical corrections for adult spinal deformity. The history of these parameters is relatively short with the first parameter, the Cobb angle, introduced in 1948 as part of an effort to improve scoliosis evaluation. New developments in the field were limited for nearly 30 years before better imaging technology encouraged new theories and later data about spinal alignment and the relationship between the spine and pelvis. These efforts would ultimately contribute to the creation of foundational spinal alignment parameters, including pelvic incidence, pelvic tilt, and sacral slope. By the 1990s, spinal alignment had become a sustained area of investigation for spinal surgeons and researchers. Novel alignment parameters have since been introduced as our knowledge has evolved and has allowed for valuable research that demonstrates the clinical and surgical value of alignment measurement. This manuscript will explore the history of spinal alignment analysis over the decades.

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STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Compare outcomes in patients undergoing one-level or two-level anterior lumbar interbody fusion (ALIF) at L4-S1. BACKGROUND: Although ALIF may deliver restoration of lumbar lordosis and improvement in clinical outcomes, it also carries risk of complications including major vascular injury. Whether one-level and two-level ALIF offers similar outcomes is not known. METHODS: Adults who underwent one-level L4-L5 or L5-S1 ALIF and two-level L4-S1 ALIF at a single academic institution were identified. Patient demographics, procedural characteristics, improvement in spinopelvic alignment, and one-year postoperative patient-reported outcome measures (PROMs) and complications were compared. Multivariate regression analyses, accounting for age, gender, and Charlson Comorbidity Index (CCI), were also performed. RESULTS: In total, 158 ALIF patients (111 one-level and 47 two-level) were included, with mean age of 51.4 years, 57.0% female, mean CCI of 1.2, and mean follow-up of 27.0 months. Surgical time (147.3 min vs. 124.6 min, P=0.002) and hospital length of stay (3.5 d vs. 2.9 d, P=0.036) were higher for two-level ALIF. One-year postoperatively, two-level ALIF patients had more caudal apex of lordosis (P=0.016) and 4.1 mm (P=0.002) and 2.0 mm (P=0.019) higher L4-L5 anterior and posterior disc heights, respectively. PROMs were not statistically different across groups (P>0.05). Finally, two-level ALIF patients were 10.9 times more likely to have in-hospital complications (P=0.040), such as intraoperative vascular injury (11.1% vs. 1.5%, P=0.040) or postoperative ileus (7.4% vs. 0.0%, P=0.027), than one-level ALIF patients. CONCLUSION: In this investigation with greater than one-year follow-up, two-level ALIF in the L4-S1 spine had higher procedural time, length of stay, and approach-related complications than one-level ALIF. Although there were minor improvements in alignment with two-level ALIF, PROMs were comparable with improvements from baseline to last follow-up. These findings may help surgeons carefully weigh the risks and benefits of one- versus two-level ALIF when determining surgical plans for patients. LEVEL OF EVIDENCE: IV.

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BACKGROUND: Recombinant human bone morphogenetic protein-2 (rhBMP-2) has not shown superior benefit overall in cost-effectiveness during adult spinal deformity (ASD) surgery. STUDY DESIGN/SETTING: Retrospective PURPOSE: Generate a risk score for pseudarthrosis to inform the utilization of rhBMP-2, balancing costs against quality of life and complications. METHODS: ASD patients with 3-year data were included. Quality of life gained was calculated from ODI to SF-6D and translated to quality-adjusted life years (QALYs). Cost was calculated using the PearlDiver database and CMS definitions for complications and comorbidities. Established weights were generated for predictive variables via logistic regression to yield a predictive risk score for pseudarthrosis that accounted for frailty, diabetes, depression, ASA grade, thoracolumbar kyphosis and three-column osteotomy use. Risk score categories, established via conditional inference tree (CIT)-derived thresholds were tested for cost-utility of rhBMP-2 usage, controlling for age, prior fusion, and baseline deformity and disability. RESULTS: 64% of ASD patients received rhBMP-2 (308/481). There were 17 (3.5%) patients that developed pseudarthrosis. rhBMP-2 use overall did not lower pseudarthrosis rates (OR: 0.5, [0.2-1.3]). Pseudarthrosis rates for each risk category were: No Risk (NoR) 0%; Low-Risk (LowR) 1.6%; Moderate Risk (ModR) 9.3%; High-Risk (HighR) 24.3%. Patients receiving rhBMP-2 had similar QALYs overall to those that did not (0.163 vs. 0.171, p = .65). rhBMP-2 usage had worse cost-utility in the LowR cohort (p < .001). In ModR patients, rhBMP-2 usage had equivocal cost-utility ($53,398 vs. $61,581, p = .232). In the HighR cohort, the cost-utility was reduced via rhBMP-2 usage ($98,328 vs. $211,091, p < .001). CONCLUSION: Our study shows rhBMP-2 demonstrates effective cost-utility for individuals at high risk for developing pseudarthrosis. The generated score can aid spine surgeons in the assessment of risk and enhance justification for the strategic use of rhBMP-2 in the appropriate clinical contexts. LEVEL OF EVIDENCE: III.

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Spondylolisthesis is a common condition with a prevalence of 4-6% in childhood and 5-10% in adulthood. The Meyerding Classification, developed in 1932, assigns grades (I to V) based on the degree of slippage observed on standing, neutral lateral lumbar radiographs. Despite its historical significance and reliability, more factors should be evaluated to predict spondylolisthesis progression, especially in low-grade cases. The manuscript highlights areas for improvement in spondylolisthesis classification, emphasizing the need for considering factors beyond vertebral slippage. Factors such as global and segmental alignment, pelvic incidence, overhang, the number of affected levels, and the use of lateral flexion-extension radiographs to assess for stability using the kyphotic angle and slippage degree are identified as crucial in predicting progression and determining effective management strategies.

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BACKGROUND: Total hip and knee arthroplasty (THA/TKA) are reliable surgical procedures for alleviating pain and optimizing function. Spinal fusion has also been shown to be beneficial, however the comparative benefit of THA/TKA to lumbar spinal fusion is incompletely understood. METHODS: This study analyzed a single-center database of patients who underwent primary lumbar spinal fusion, elective primary TKA, or THA. Patient-reported outcome measures (PROMs) included Veterans-Rand (VR12) Physical and Mental Component Score (PCS/MCS) for TKA/THA and PROMIS (Patient-Reported Outcomes Measurement Information System) Global Mental and Physical Health (GPH/GMH) for spinal fusion. RESULTS: A total of 356 patients who underwent TKA, 290 who underwent THA, and 125 who underwent spinal fusion were included. Joint replacement patients were older, with higher body mass index in the TKA group. Spine patients had a lower improvement in physical health than the joint patients (TKA: 9.4 ± 11.2, THA: 15.2 ± 11.2, Spine: 6.2 ± 8.7, P < 0.001) and a lower proportion of patients reaching the minimal clinically important difference (MCID). Spine patients had higher GMH improvements compared with TKA patients (TKA: -1.1 ± 10.7, THA: 1.1 ± 11.9, Spine: 1.8 ± 8.4, P = 0.009) and the highest proportion of patients reaching the MCID. CONCLUSIONS: Spinal fusion, total knee arthroplasty, and total hip arthroplasty all significantly improved PROMs at 1-year follow-up. At baseline, spinal fusion patients had better physical function scores and worse mental health scores compared with joint arthroplasty patients, while spinal fusion resulted in mean smaller gains in patient reported physical function and higher gains in patient reported mental health function compared with arthroplasty.

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STUDY DESIGN: Biomechanical Study. OBJECTIVE: This study aims to evaluate the biomechanical adjacent segment effects of multi-level posterior cervical fusion constructs that terminate at C7 compared to those that terminate at T1 in cadaveric specimens. BACKGROUND: The cervicothoracic junction poses unique challenges for spine surgeons. Deciding to terminate multi-level posterior cervical fusion constructs at C7 or extend them across the cervicothoracic junction remains a controversial issue. METHODS: Six cadaveric specimens underwent biomechanical testing in the intact state and after instrumentation with constructs from C3 and terminating at either C7 or T1. Range of motion (ROM) was assessed in flexion-extension, lateral bending, and axial rotation globally and at cranial and caudal adjacent segments. RESULTS: There was a significant decrease in overall flexion/extension by both C7 (-35.5°, P=0.002) and T1 (-39.8°, P=0.002) instrumentation compared to the intact spine. T1 instrumentation had significantly lower (-4.3°, P=0.008) flexion/extension ROM compared to C7 instrumentation. There were significant decreases in axial rotation by both C7 (-31.4°, P=0.009) and T1 (-36.8°, P=0.009) instrumentation compared to the intact spine, but no significant differences were observed between the two. There were also significant decreases in lateral bending by both C7 (-27.9°, P=0.022) and T1 (-33.7°, P=0.022) instrumentation compared to the intact spine, but no significant differences were observed between the two. No significant differences were observed in ROM at cranial or caudal adjacent segments between constructs terminating at C7 and those extending to T1. CONCLUSION: This biomechanical investigation demonstrates that constructs that cross the cervicothoracic junction experience less overall spinal motion in flexion-extension compared to those that terminate at C7. However, contrary to prior studies there is no difference in cranial and caudal adjacent segment motion. Surgeons should make clinical decisions regarding the caudal extent of fusion in multi-level posterior cervical fusions without major concerns about adjacent segment motion.

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PURPOSE: Adult spinal deformity (ASD) patients with sagittal plane deformity (N) or structural lumbar/thoraco-lumbar (TL) curves can be treated with fusions stopping at the TL junction or extending to the upper thoracic (UT) spine. This study evaluates the impact on cost/cumulative quality-adjusted life year (QALY) in patients treated with TL vs UT fusion. METHODS: ASD patients with > 4-level fusion and 2-year follow-up were included. Index and total episode-of-care costs were estimated using average itemized direct costs obtained from hospital records. Cumulative QALY gained were calculated from preoperative to 2-year postoperative change in Short Form Six-Dimension (SF-6D) scores. The TL and UT groups comprised patients with upper instrumented vertebrae (UIV) at T9-T12 and T2-T5, respectively. RESULTS: Of 566 patients with type N or L curves, mean age was 63.2 ± 12.1 years, 72% were female and 93% Caucasians. Patients in the TL group had better sagittal vertical axis (7.3 ± 6.9 vs. 9.2 ± 8.1 cm, p = 0.01), lower surgical invasiveness (- 30; p < 0.001), and shorter OR time (- 35 min; p = 0.01). Index and total costs were 20% lower in the TL than in the UT group (p < 0.001). Cost/QALY was 65% lower (492,174.6 vs. 963,391.4), and 2-year QALY gain was 40% higher, in the TL than UT group (0.15 vs. 0.10; p = 0.02). Multivariate model showed TL fusions had lower total cost (p = 0.001) and higher QALY gain (p = 0.03) than UT fusions. CONCLUSION: In Schwab type N or L curves, TL fusions showed lower 2-year cost and improved QALY gain without increased reoperation rates or length of stay than UT fusions. LEVEL OF EVIDENCE: III.

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STUDY DESIGN: Retrospective analysis of prospectively collected data. OBJECTIVE: Evaluate the impact of prior cervical constructs on upper instrumented vertebrae (UIV) selection and postoperative outcomes among patients undergoing thoracolumbar deformity correction. BACKGROUND: Surgical planning for adult spinal deformity (ASD) patients involves consideration of spinal alignment and existing fusion constructs. METHODS: ASD patients with (ANTERIOR or POSTERIOR) and without (NONE) prior cervical fusion who underwent thoracolumbar fusion were included. Demographics, radiographic alignment, patient-reported outcome measures (PROMs), and complications were compared. Univariate and multivariate analyses were performed on POSTERIOR patients to identify parameters predictive of UIV choice and to evaluate postoperative outcomes impacted by UIV selection. RESULTS: Among 542 patients, with 446 NONE, 72 ANTERIOR, and 24 POSTERIOR patients, mean age was 64.4 years and 432 (80%) were female. Cervical fusion patients had worse preoperative cervical and lumbosacral deformity, and PROMs (P<0.05). In the POSTERIOR cohort, preoperative LIV was frequently below the cervicothoracic junction (54%) and uncommonly (13%) connected to the thoracolumbar UIV. Multivariate analyses revealed that higher preoperative cervical SVA (coeff=-0.22, 95%CI=-0.43--0.01, P=0.038) and C2SPi (coeff=-0.72, 95%CI=-1.36--0.07, P=0.031), and lower preoperative thoracic kyphosis (coeff=0.14, 95%CI=0.01-0.28, P=0.040) and thoracolumbar lordosis (coeff=0.22, 95%CI=0.10-0.33, P=0.001) were predictive of cranial UIV. Two-year postoperatively, cervical patients continued to have worse cervical deformity and PROMs (P<0.05) but had comparable postoperative complications. Choice of thoracolumbar UIV below or above T6, as well as the number of unfused levels between constructs, did not affect patient outcomes. CONCLUSIONS: Among patients who underwent thoracolumbar deformity correction, prior cervical fusion was associated with more severe spinopelvic deformity and PROMs preoperatively. The choice of thoracolumbar UIV was strongly predicted by their baseline cervical and thoracolumbar alignment. Despite their poor preoperative condition, these patients still experienced significant improvements in their thoracolumbar alignment and PROMs after surgery, irrespective of UIV selection. LEVEL OF EVIDENCE: IV.

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BACKGROUND: Prior reviews investigating the impact of pregnancy on adolescent idiopathic scoliosis (AIS) have reached different conclusions and a meta-analysis of curve progression among pregnant females with AIS and its effects on clinical outcomes has not previously been performed. METHODS: A comprehensive search of major bibliographic databases (PubMed, Embase, and Scopus) was conducted for articles pertaining to spinal curve progression during pregnancy among patients with AIS. Patient demographics, scoliotic curve outcomes, and patient-reported quality of life measures were extracted. RESULTS: Ten studies, including 857 patients with a mean age of 28.7 years, were included. Before pregnancy, 42.1% had undergone spinal fusion and 59.0% had a thoracic curve. Based on prepregnancy and postpregnancy radiographs, the curve increased from 33.9°-38.5°, and meta-analysis revealed a curve progression of 3.6° (range = -5.85 to 1.25, P = 0.003), primarily arising from loss of correction in the unfused group (Unfused = -5.0, P = 0.040; Fused = -3.0, P = 0.070). At the same time, 45.9% patients reported increased low back pain and many reported a negative body self-image and limitations in sexual function. However, 5 studies noted that pregnancy and number of pregnancies were not associated with curve progression, and multiple studies identified similar quality of life-related changes in non-pregnant patients with AIS. CONCLUSIONS: Among unfused pregnant females with AIS, the spinal curvature increased significantly by 5.0° from before to after pregnancy. However, these changes may be independent of pregnancy status and occur with time. Such curve progression can contribute to a negative body self-image, low back pain, and functional limitations irrespective of pregnancy state.

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PURPOSE: To assess impact of baseline disability on HRQL outcomes. METHODS: CD patients with baseline (BL) and 2 year (2Y) data included, and ranked into quartiles by baseline NDI, from lowest/best score (Q1) to highest/worst score (Q4). Means comparison tests analyzed differences between quartiles. ANCOVA and logistic regressions assessed differences in outcomes while accounting for covariates (BL deformity, comorbidities, HRQLs, surgical details and complications). RESULTS: One hundred and sixteen patients met inclusion (Age:60.97 ± 10.45 years, BMI: 28.73 ± 7.59 kg/m2, CCI: 0.94 ± 1.31). The cohort mean cSVA was 38.54 ± 19.43 mm and TS-CL: 37.34 ± 19.73. Mean BL NDI by quartile was: Q1: 25.04 ± 8.19, Q2: 41.61 ± 2.77, Q3: 53.31 ± 4.32, and Q4: 69.52 ± 8.35. Q2 demonstrated greatest improvement in NRS Neck at 2Y (-3.93), compared to Q3 (-1.61, p = .032) and Q4 (-1.41, p = .015). Q2 demonstrated greater improvement in NRS Back (-1.71), compared to Q4 (+ 0.84, p = .010). Q2 met MCID in NRS Neck at the highest rates (69.9%), especially compared to Q4 (30.3%), p = .039. Q2 had the greatest improvement in EQ-5D (+ 0.082), compared to Q1 (+ 0.073), Q3 (+ 0.022), and Q4 (+ 0.014), p = .034. Q2 also had the greatest mJOA improvement (+ 1.517), p = .042. CONCLUSIONS: Patients in Q2, with mean BL NDI of 42, consistently demonstrated the greatest improvement in HRQLs whereas those in Q4, (NDI 70), saw the least. BL NDI between 39 and 44 may represent a disability "Sweet Spot," within which operative intervention maximizes patient-reported outcomes. Furthermore, delaying intervention until patients are severely disabled, beyond an NDI of 61, may limit the benefits of surgery.

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BACKGROUND: Hip osteoarthritis (OA) is common in patients with adult spinal deformity (ASD). Limited data exist on the prevalence of hip OA in patients with ASD, or on its impact on baseline and postoperative alignment and patient-reported outcome measures (PROMs). Therefore, this paper will assess the prevalence and impact of hip OA on alignment and PROMs. METHODS: Patients with ASD who underwent L1-pelvis or longer fusions were included. Two independent reviewers graded hip OA with the Kellgren-Lawrence (KL) classification and stratified it by severity into non-severe (KL grade 1 or 2) and severe (KL grade 3 or 4). Radiographic parameters and PROMs were compared among 3 patient groups: Hip-Spine (hip KL grade 3 or 4 bilaterally), Unilateral (UL)-Hip (hip KL grade 3 or 4 unilaterally), or Spine (hip KL grade 1 or 2 bilaterally). RESULTS: Of 520 patients with ASD who met inclusion criteria for an OA prevalence analysis, 34% (177 of 520) had severe bilateral hip OA and unilateral or bilateral hip arthroplasty had been performed in 8.7% (45 of 520). A subset of 165 patients had all data components and were examined: 68 Hip-Spine, 32 UL-Hip, and 65 Spine. Hip-Spine patients were older (67.9 ± 9.5 years, versus 59.6 ± 10.1 years for Spine and 65.8 ± 7.5 years for UL-Hip; p < 0.001) and had a higher frailty index (4.3 ± 2.6, versus 2.7 ± 2.0 for UL-Hip and 2.9 ± 2.0 for Spine; p < 0.001). At 1 year, the groups had similar lumbar lordosis, yet the Hip-Spine patients had a worse sagittal vertebral axis (SVA) measurement (45.9 ± 45.5 mm, versus 25.1 ± 37.1 mm for UL-Hip and 19.0 ± 39.3 mm for Spine; p = 0.001). Hip-Spine patients also had worse Veterans RAND-12 Physical Component Summary scores at baseline (25.7 ± 9.3, versus 28.7 ± 9.8 for UL-Hip and 31.3 ± 10.5 for Spine; p = 0.005) and 1 year postoperatively (34.5 ± 11.4, versus 40.3 ± 10.4 for UL-Hip and 40.1 ± 10.9 for Spine; p = 0.006). CONCLUSIONS: This study of operatively treated ASD revealed that 1 in 3 patients had severe hip OA bilaterally. Such patients with severe bilateral hip OA had worse baseline SVA and PROMs that persisted 1 year following ASD surgery, despite correction of lordosis. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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BACKGROUND: Vertebral fractures are associated with enduring back pain, diminished quality of life, as well as increased morbidity and mortality. Existing epidemiological data for cervical and thoracic vertebral fractures are limited by insufficiently powered studies and a failure to evaluate the mechanism of injury. QUESTION/PURPOSE: What are the temporal trends in incidence, patient characteristics, and injury mechanisms of cervical and thoracic vertebral fractures in the United States from 2003 to 2021? METHODS: The United States National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) database collects data on all nonfatal injuries treated in US hospital emergency departments and is well suited to capture epidemiological trends in vertebral fractures. As such, the NEISS-AIP was queried from 2003 to 2021 for cervical and thoracic fractures. The initial search by upper trunk fractures yielded 156,669 injuries; 6% (9900) of injuries, with a weighted frequency of 638,999 patients, met the inclusion criteria. The mean age was 62 ± 25 years and 52% (334,746 of 638,999) of patients were females. Descriptive statistics were obtained. Segmented regression analysis, accounting for the year before or after 2019 when the NEISS sampling methodology was changed, was performed to assess yearly injury trends. Multivariable logistic regression models with age and sex as covariates were performed to predict injury location, mechanism, and disposition. RESULTS: The incidence of cervical and thoracic fractures increased from 2.0 (95% CI 1.4 to 2.7) and 3.6 (95% CI 2.4 to 4.7) per 10,000 person-years in 2003 to 14.5 (95% CI 10.9 to 18.2) and 19.9 (95% CI 14.5 to 25.3) in 2021, respectively. Incidence rates of cervical and thoracic fractures increased for all age groups from 2003 to 2021, with peak incidence and the highest rate of change in individuals 80 years or older. Most injuries occurred at home (median 69%), which were more likely to impact older individuals (median [range] age 75 [2 to 106] years) and females (median 61% of home injuries); injuries at recreation/sports facilities impacted younger individuals (median 32 [3 to 96] years) and male patients (median 76% of sports facility injuries). Falls were the most common injury mechanism across all years, with females more likely to be impacted than males. The proportion of admissions increased from 33% in 2003 to 50% in 2021, while the proportion of treated and released patients decreased from 53% to 35% in the same period. CONCLUSION: This epidemiological study identified a disproportionate increase in cervical and thoracic fracture incidence rates in patients older than 50 years from 2003 to 2021. Furthermore, high hospital admission rates were also noted resulting from these fractures. These findings indicate that current osteoporosis screening guidelines may be insufficient to capture the true population at risk of osteoporotic fractures, and they highlight the need to initiate screening at an earlier age. LEVEL OF EVIDENCE: Level III, prognostic study.

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Adolescent idiopathic scoliosis (AIS) is an abnormal coronal curvature of the spine that most commonly presents in adolescence. While it may be asymptomatic, AIS can cause pain, cosmetic deformity, and physical and psychological disability with curve progression. As adolescents with AIS enter adulthood, condition outcomes vary with some experiencing curve stabilization and others noting further curve progression, chronic pain, osteoporosis/fractures, declines in pulmonary and functional capacity, among others. Regular monitoring and individualized management by healthcare professionals are crucial to address the diverse challenges and provide appropriate support for a fulfilling adult life with AIS. This review examines the prevalence, risk factors, presenting symptoms, diagnosis, management, and complications of AIS in the adult population, informing targeted interventions by clinicians caring for adult patients with AIS.

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BACKGROUND: Surgical site infections (SSIs) represent a major challenge in spine surgery, leading to severe morbidity, mortality, and increased costs. The local application of antibiotics, particularly vancomycin, has emerged as a potential strategy. Individual randomized controlled trials (RCTs) have disagreed about the efficacy of topical vancomycin in preventing SSIs after spine surgery, and so a meta-analysis that pools data from those RCTs might be helpful to inform clinicians' decisions on the topic. QUESTIONS/PURPOSES: This meta-analysis of RCTs asked: Does intrawound topical vancomycin reduce the risk of (1) SSIs, (2) deep SSIs, and (3) superficial SSIs in patients undergoing spine surgery? METHODS: PubMed, Cochrane, and Google Scholar (pages 1-20) were searched up through March 13, 2024 (search performed on March 13, 2024). Inclusion criteria consisted of English or non-English-language RCTs comparing the implementation of topical vancomycin in spine surgery to its nonuse and assessing its efficacy in preventing SSI, while exclusion criteria consisted of nonrandomized comparative studies, single-arm noncomparative studies, comparative studies based on national databases or from the same center as other included studies, studies posted to preprint servers, studies reporting incomplete/nonrelevant outcomes, and studies adding another SSI preventive measure. The studies were assessed using the Cochrane Risk of Bias tool. Heterogeneity was evaluated by Q tests and I2 statistics. We used a random-effects model when considerable heterogeneity was observed (all SSIs, deep SSIs); otherwise, a fixed-effects model was used (all SSIs subanalysis, superficial SSIs). Furthermore, the fragility index was calculated for each of the assessed outcomes when there was no difference between the two groups to assess how many patients were needed to experience the outcomes for a difference to become present. The studied outcomes were the risks of SSIs, deep SSIs, and superficial SSIs. Deep SSIs were defined by the included trials as SSIs underneath the fascia, otherwise they were considered superficial. Six RCTs representing a total of 2140 patients were included, with 1053 patients in the vancomycin group and 1087 in the control group. Using an alpha of 0.05, our meta-analysis had 80% power to detect a risk difference of 1.5% for the primary outcome between patients who did and did not receive vancomycin. The age of the patients in the vancomycin group ranged from 37 to 52 years, while the age in the control group ranged from 34 to 52 years. The surgical procedures consisted of both instrumented and noninstrumented spinal procedures. Overall, the risk of bias in the included studies was either low or unclear, with none of the studies having a high risk of bias in any of the assessed categories (selection bias, performance bias, detection bias, attrition bias, and reporting bias). RESULTS: We found no difference in the risk of SSI between the vancomycin and control groups (3.0% [32 of 1053] versus 3.9% [42 of 1087], relative risk 0.74 [95% CI 0.35 to 1.57]; p = 0.43). Ten additional patients (4.8% infection risk) in the control group would need to experience an SSI for a difference to be observed between the two groups. We found no difference in the risk of deep SSI between the vancomycin and control groups (1.8% [15 of 812] versus 2.7% [23 of 860], relative risk 0.69 [95% CI 0.24 to 2.00]; p = 0.50). Seven additional patients (3.5% infection risk) in the control group would need to experience a deep SSI for a difference to be observed between the two groups. We found no difference in the risk of superficial SSI between the vancomycin and control groups (1.0% [6 of 620] versus 1.4% [9 of 662], relative risk 0.68 [95% CI 0.25 to 1.89]; p = 0.46). Seven additional patients (2.4% infection risk) in the control group would need to experience a superficial SSI for a difference to be observed between the two groups. CONCLUSION: This meta-analysis of randomized trials examining use of topical vancomycin in spine surgery failed to show efficacy in reducing infection, and thus we do not recommend routine use of topical vancomycin for this indication. Future large-scale trials would be needed if surgeons believe that between-group differences smaller than those for which we were powered here (this meta-analysis had 80% power to detect a between-group difference of 1.5% in infection risk) are clinically important, and large database surveys may be informative in terms of assessing for postoperative adverse events associated with the use of vancomycin powder. LEVEL OF EVIDENCE: Level I, therapeutic study.