EDITORIAL
SPINE DEFORMITIES
Objective. To perform a systematic analysis of the literature evaluating the effectiveness of growth-friendly systems in the treatment of early onset scoliosis.
Material and Methods. A subject search was conducted in the Google Scholar database for the terms “growing rods”, “early onset scoliosis”, “treatment”, “surgery” and “growth-friendly” using AND or OR logical operators with a search depth of 10 years. At the first stage, 824 abstracts of publications were selected. The second stage of search was carried out in accordance with the PICOS criteria, 38 abstracts of original studies, case series and reviews of surgical techniques for spinal deformity correction with preservation of growth potential were selected. The evaluation criteria were divided into four groups: general data, correction of the frontal and sagittal components of the deformity, complications and unplanned scenarios.
Results. In the analyzed studies, gender equality of distribution was observed, and the average age at the time of the primary operation was 6.6 years for patients with traditional growing rods (TGR) and Schilla/Luque trolley and 4.9 years for patients with Vertical Expandable Prosthetic Titanium Rib (VEPTR). From the point of view of the magnitude of spinal deformity correction, the VEPTR systems demonstrated the minimum result (18 % correction), and the TGR and Schilla results were comparable (42.1 and 53.1 %, respectively), as well as the indicators of the dynamics of body lengthening.
Conclusion. The use of VEPTR systems is associated with a high risk of complications and a somewhat lower efficiency of spinal deformity correction, however, VEPTR is indispensable in the treatment of thoracic insufficiency syndrome, as well as severe deformities of the axial skeleton in young children using non-vertebral fixation points. Growth modulation systems (Schilla and Luque trolley) showed deformity correction results similar to those of TGR.
Objective. To analyze and summarize the data of modern literature on the issues of surgical treatment and natural course of the spine and spinal cord pathology in patients with various types of caudal regression syndrome (CRS).
Material and Methods. A systematic review of the literature on the issue of treatment of the spine and spinal cord pathology in patients with CRS was performed. Selection criteria were: articles for the period 2002–2022, original studies of populations/patients with various forms of CRS with a description of treatment methods and long-term results of treatment or observation. A total of 28 articles on the treatment of various forms of CRS with the described results of treatment of 212 patients were analyzed: 29 patients with CRS in combination with open neural tube defects and 183 patients with closed forms of CRS. Evaluation criteria included number of patients, gender, type of spinal cord pathology, type of sacral agenesis, presence of the spine and lower extremities deformities, concomitant pathology, operations performed and their complications, and results.
Results. The studied patients underwent the following surgeries on the spine and spinal cord: untethering of the spinal cord, correction and stabilization surgeries on the spine, plasty of the spinal cord herniation, plasty of the terminal meningocele, and removal of the presacarial volumetric mass. The greatest number of complications occurred after operations on the spine and sacrum. The majority of patients (67 %) with sacral agenesis by the end of the follow-up period (average 14 years) walked independently or with the help of devices, and a minority of them (33 %) could not walk. More than half of patients with CRS (67 %) had a neurogenic bladder, urinary incontinence, or suffered from a chronic urinary tract infection. Fecal incontinence and constipation were less common (46 %).
Conclusions. Patients with CRS have a good potential for improvement/recovery of walking and pelvic organ dysfunction. This is extremely important to timely carry out multimodality treatment of patients with CRS who have neurosurgical, orthopedic, urogenital and colorectal problems in CRS, and to start early motor rehabilitation and physiotherapy.
Objective. To assess sagittal balance parameters in children with spondylolisthesis before and after surgical treatment and to analyze their correlation with quality of life.
Material and Methods. A retrospective analysis of postural radiographs of 98 children and adolescents was performed. The patients were divided into 2 groups: Group 1 included 43 patients under 17 years of age (mean age 12.0 ± 2.6 years) without spinal pathology, and Group 2 – 55 patients under 17 years of age (mean age 13.3 ± 2.5 years) with spondylolisthesis before and after surgical treatment. In patients of Group 1, the main spinopelvic parameters (PT, PI, SS, LL, PI-LL, TK) were calculated and studied. In patients of Group 2, parameters characterizing local lumbosacral kyphosis (SA, Dub-LSA, LSJA) were calculated and studied in addition to the main ones. The obtained results were compared with the conditional norm for children. The intensity of pain syndrome and quality of life were assessed using questionnaires and scales (Ped`s QL, ODI, VAS) before surgical treatment, at the time of discharge from the hospital, and after 3 months since surgery. Statistical data analysis was carried out using the statistical programming language and the R environment (version 3.6.1) in RStudio IDE (version 1.2.1335) with representation in the M ± SD format for normally distributed random variables and Me [Q1; Q3] for variables with abnormal distribution. Categorical indicators were presented as an absolute number and a percentage ratio. The null hypothesis in statistical tests was rejected at a significance level of p < 0.05
Results. A decrease in the intensity of pain syndrome and an improvement in the quality of life were observed after surgical treatment in all cases. Statistical analysis of the relationship between parameters characterizing local lumbosacral kyphosis (Dub-LSA, SA, LSJA) and the results of using questionnaires and scales (Ped`s QL, ODI, VAS) showed a statistically significant positive correlation (r = 0.57; p = 0.004) of the LSJA score and pain intensity assessed before surgery, as well as a statistically significant negative correlation (r = -0.47; p = 0.004) of the LSJA score before surgery and the results of the PED`s QL questionnaire after surgery. In a comparison group analysis, it was found that after surgical treatment, there was a tendency towards normalization of sagittal parameters, though their complete recovery to normal values was not achieved. Local lumbosacral kyphosis was completely eliminated in all cases.
Conclusion. Correction of the angle of lumbosacral kyphosis during surgical treatment of children with spondylolisthesis directly correlates with indicators characterizing the quality of life, which makes its elimination the main purpose of the operation. The degree of correction of the sagittal balance parameters (PT, SS, LL) has no significant impact on the quality of life, and their correction to the target calculated values is not required at an initially high PI value. In cases of decompensation of the sagittal and coronal balances of the trunk with low grades of spondylolisthesis, combined with impaired gait and anterior inclination of the torso (lumbar-femoral rigidity syndrome), the instrumental restoration of segmental lordosis at the level of L5–S1 and decompression of neural structures lead to correction of sagittal balance and normalization of gait.
SPINE INJURIES
Objective. To identify the mechanism of deformity compensation in patients with post-traumatic kyphosis of the thoracolumbar junction, based on the analysis of X-ray results of surgical treatment.
Material and Methods. The study included data obtained from medical records of 69 patients (47 women, 22 men) operated on for painful post-traumatic kyphosis at the levels of T12, L1 and L2 vertebra. Patients underwent staged surgical interventions in a single surgical session. Demographic data and X-ray results of surgical treatment were evaluated.
Results. As a result of surgical interventions, post-traumatic kyphosis (LK) was corrected to an average of 1.9°. After correction of kyphosis, statistically significant changes in the parameters of sagittal spinal curvatures were revealed: an increase in thoracic kyphosis (TK), a decrease in lumbar lordosis (LL), including due to lower lumbar lordosis (LowLL). At the same time, the parameters of the spinopelvic balance (PT, SS) did not change. Statistically significant correlations (p < 0.001) were detected between the magnitude of local kyphosis correction (LK preOP-LKpostOP), which amounted to 33.63° ± 8.77°, and parameters of lumbar lordosis ΔLL, thoracic kyphosis ΔTK and ΔPI-LL. Parameters of global sagittal balance and pelvic balance did not show correlations with the magnitude of kyphosis correction. The X-ray study of patients in Group I (without signs of initial sagittal imbalance) and Group II (with signs of sagittal imbalance) revealed a statistically significant difference in global balance (GT) and spinopelvic balance (PT, SS, LowLL), both before and after correction intervention in the thoracolumbar junction area, despite comparable indicators of sagittal spinal curvatures and the magnitude of post-traumatic kyphosis,.
Conclusion. The main compensation mechanism includes changes in the spinal departments adjacent to kyphosis: a decrease in thoracic kyphosis and an increase in lumbar lordosis, rather than changes in the global or spinopelvic balance.
Objective. To analyze the peculiarities of changes in intestinal microbiota in spinal cord injury.
Material and Methods. The literature search was carried out for the period of 2012–2022 in the PubMed, ScienceDirect, eLibrary and GoogleScholar databases for the following keywords: spinal cord injury, microbiota, and dysbacteriosis. Out of 220 literature sources, 40 full-text articles were selected which analyze the influence of spinal cord injury on the state of the intestinal microbiota using an innovative method of metagenomic high-throughput 16S sequencing.
Results. Literature data on the pathogenesis of organ dysfunction in spinal cord injury, as well as its impact on the state of the intestinal microbiota are presented. The results of experimental and clinical studies of the intestinal microbiota in spinal cord injury and its influence on the development and course of the pathological condition are reported.
Conclusion. Understanding how the intestinal microbiota changes after spinal cord injury and what role it plays in potentiating inflammation or protecting the spinal cord from secondary injury and infections is very important in determining the strategy and tactics for managing patients. Possession of methods for correcting intestinal microbiota disorders in SCI is important in the treatment of such patients.
DEGENERATIVE DISEASES OF THE SPINE
Objective. To analyze the clinical efficacy of anterior fusion through a minimally invasive retroperitoneal approach in the treatment of patients with pseudoarthrosis after decompression and stabilization surgery for degenerative spinal stenosis.
Material and Methods. Twenty six patients with previously performed decompression and stabilization surgeries for degenerative spinal canal stenosis underwent repeated surgical interventions using anterior/anterolateral fusion due to clinical and radiographic signs of pseudoarthrosis resistant to complex conservative therapy for at least 12 weeks. The outcomes of surgical treatment were analyzed based on the assessment of clinical and radiological characteristics before and after surgery.
Results. At a follow-up examination 12 months after surgery, leg pain aggravated after exercise bothered 5 patients (19.2 %). According to CT data, 16 (61.5 %) patients had signs of the formation of grade 1 interbody bone block. In 2 (7.7 %) patients, instability of the fixation system developed and there were no signs of union, which required repeated surgical interventions.
Conclusion. Anterior interbody fusion in the treatment of patients with pseudoarthrosis allows safe removal of the preinstalled interbody implant and creation of optimal conditions for the formation of interbody fusion. Despite clinical improvement, significant functional disorders persist in most patients.
TUMORS AND INFLAMMATORY DISEASES OF THE SPINE
Objective. To analyze long-term results of treatment of a patient with recurrent lumbar aspergillosis and to systematize the literature data.
Material and Methods. Long-term follow-up results of treatment of recurrent Aspergillus spondylitis in a 48-year-old patient who underwent primary surgery for reconstruction of the anterior spinal column through the anterior approach were studied. Literature data on the treatment of spinal aspergillosis from 2000 to 2022 were systematized.
Results. The key method for the etiological verification of spinal aspergillosis is percutaneous bone biopsy from the lesion, followed by histological and bacteriological examination of the material. Isolated anterior spinal column reconstruction through the anterior approach ensures the achievement of local control of the infection process, but a short course of antimycotic chemotherapy after surgery is a factor of disease recurrence. The optimal duration of antimycotic chemotherapy in the postoperative period is at least 3 months, with voriconazole being the drug of choice.
Conclusion. Spondylitis caused by Aspergillus spp. is a special form of inflammatory spine disease requiring obligatory percutaneous bone biopsy for etiological verification. A multidisciplinary therapeutic approach including a course of conservative antimycotic therapy for at least 3 months, surgical debridement and reconstruction of the affected spinal motion segments provide the best clinical results.
GENERAL ISSUE
Objective. To analyze the attitude of neurosurgeons to the technology of enhanced recovery after spine and spinal cord surgery in the Russian Federation.
Material and Methods. In March 2022, a continuous cohort comparative sociological study was conducted among 83 neurosurgeons of the Russian Federation, during which they were asked to fill out a specially designed online questionnaire consisting of 22 questions on the Google Forms platform.
Results. The vast majority of respondents (95.2 %) noted the lack of information in the Russian literature on the technology of enhanced recovery after surgery (ERAS). Nevertheless, most neurosurgeons, regardless of specialization, are familiar with the terms “fast track” (79.5 %) and “ERAS” (60.2 %). Only 44.6 % of specialists declared the implementation of ERAS recommendations into their daily clinical practice, while 78.3 % of neurosurgeons draw attention to the existence of problems that hamper adoption of enhanced recovery protocols (ERP) in Russia. The interviewed respondents are confident that it is possible to introduce ERP into spinal neurosurgery in adults (91.6 %) and children (85.5 %) in Russia. Every second respondent (50.6 %) considers it possible to directly extrapolate foreign ERP into clinical practice in Russian healthcare. Spinal neurosurgeons are more aware of ERAS than cerebral neurosurgeons (p = 0.017), and they also more often use elements of ERAS in their clinical practice (p = 0.002). In other parameters, the respondents did not differ significantly depending on their specialization. Only 7.2 % of interviewed neurosurgeons work in private clinics. All of them are engaged in spinal surgery and introduce the ERAS technology into their clinical practice. Less than half (40.0 %) of neurosurgeons in public clinics implement elements of the ERAS (p = 0.007). More than half (69.7 %) of specialists and every second manager consider the introduction of ERAS in a neurosurgical clinic to be progressive, and only a few of them (3.6 %), on the contrary, believe that the quality of medical care may decrease with the introduction of ERAS. Neurosurgeons (n = 13) identified 7 clinics of the Russian Federation, where the enhanced recovery protocol after spine surgery is implemented. In total, according to the results of the study, 23 elements of the ERAS protocol are implemented in the practice of respondents (n = 20) in the conditions of Russian healthcare.
Conclusions. Despite the lack of publications in the Russian literature and the existing organizational problems in the context of domestic healthcare, neurosurgeons have a positive attitude towards the introduction of ERAS protocol into clinical practice. This protocol or its individual elements are already successfully implemented in a group of clinics in Russia.
RECOMMENDED BY A SPECIALIST
Recommended by a specialist
BULLETIN OF THE ASSOCIATION OF SPINE SURGEONS
Bulletin of the association of spine surgeons
JUBILEE
MEETING FOR SPINE SPECIALISTS
Meeting for spine specialists
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