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Ellingson AM, Hendricks CJ, Abbott AM, MacEwen MR, Polly DW. Impact of Rod Placement and Tulip Design on Screw-Rod Gripping Capacity in Spinopelvic Fixation: Evaluation Across a Spectrum of Recessed to Extended Lengths. Spine J 2025:S1529-9430(25)00245-1. [PMID: 40324484 DOI: 10.1016/j.spinee.2025.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2024] [Revised: 04/08/2025] [Accepted: 05/01/2025] [Indexed: 05/07/2025]
Abstract
BACKGROUND CONTEXT High rates of pelvic instrumentation failure (4.5-38%) have been reported, often attributed to issues within the screw-tulip-rod connection. While previous research has explored various aspects of this connection, the influence of tulip design and relative rod placement on mechanical failure remains unclear. PURPOSE This study aims to investigate how screw-tulip design and variations in rod placement relative to the tulip affect the integrity of the screw-tulip-rod connection, utilizing axial and torsional gripping capacity tests to evaluate mechanical stability. STUDY DESIGN/SETTING Biomechanical METHODS: Mechanical testing was conducted following ASTM F1798-21 to assess the interconnection mechanisms in pelvic fixation constructs. Using 5.5mm Cobalt Chromium rods with porous fusion/fixation (PFFS) screws, axial gripping capacity (AGC) tests measured the axial load before translatory slippage of the rod, while torsional gripping capacity (TGC) tests assessed the torque required to induce rotational slippage. Variations in rod placement at the tulip head were tested in recessed (-2mm, -1mm), flush (0mm), and extended positions (+1mm, +10mm), simulating failure during flexion, extension, and rotation for both open and closed tulip-head designs. ANOVA was used to evaluate the effects of rod placement on connection failure, with significance set at p<0.05. RESULTS AGC and TGC tests revealed significant reductions for recessed rod placements, indicating suboptimal placement. At -1mm and -2mm, AGC for simulated flexion decreased by 28.8% (p<0.010) and 45.6% (p<0.001) for the open-head design and 30.5% (p<0.018) and 57.5% (p<0.001) for the closed-head design, respectively, compared to the non-recessed rod placement. TGC also showed a significant decline at -2mm, with a 25.4% reduction compared to the +1mm extended length (p<0.001) and a 20.3% reduction compared to the -1mm recessed length (p=0.005), irrespective of head design. The open and closed-head designs exhibited similar trends; however, the closed-head design was shown to better resist structural failure at recessed lengths. At -2mm simulating extension, the closed-head design was 54.8% greater than the open-head design for AGC (p<.001) and 28.3% greater for TGC. CONCLUSION Our findings underscore that both flush (0mm) and extended (+1, +10mm) rod placements relative to the screw-tulip offer sufficient gripping capacity whereas recessed placements (-1, -2mm) have substantial reductions. The closed-head design was shown to better resist structural failure at recessed placements. CLINICAL SIGNIFICANCE Rod placement relative to the most distal pelvic screw during spinopelvic fixation varries in surgical practice - whether flush to, extended past, or recessed into the screw-head. Biomechanical evaluating of the axial and torsion gripping capacities at these positions provies a foundation for clinical decision-making.
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Affiliation(s)
- Arin M Ellingson
- Divisions of Physical Therapy and Rehabilitation Science, Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, MN 55455, USA; Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN.
| | - Cale J Hendricks
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN
| | - Ashley M Abbott
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN
| | - Matthew R MacEwen
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN
| | - David W Polly
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN; Department of Neurosurgery, University of Minnesota, Minneapolis, MN
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Ravinsky R, Lewis S, Fisher C, Polly D, On behalf of the AO Spine Knowledge Forum Deformity. AO Spine Clinical Practice Recommendations: Spinopelvic Fixation - What are the Key Items to Understand Performance? Global Spine J 2025:21925682251336746. [PMID: 40293504 PMCID: PMC12037523 DOI: 10.1177/21925682251336746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2024] [Revised: 03/20/2025] [Accepted: 04/07/2025] [Indexed: 04/30/2025] Open
Abstract
Study DesignLiterature review with clinical recommendations.ObjectiveTo highlight important studies related to spinopelvic fixation and provide recommendations to practicing clinicians on interpretation and utilization of the evidence included in these studies.MethodsImportant literature related to spinopelvic fixation was reviewed and clinical recommendations were formulated. Recommendations were graded as strong or conditional.ResultsThree articles were selected and reviewed for the strength of methodology and scientific evidence. Article 1: Biomechanical analysis of lumbosacral fixation in Lumbar Fusion and Stabilization was granted conditional recommendation to consider biomechanical factors associated with different pelvic constructs. Article 2: Low profile pelvic fixation: anatomic parameters for sacral alar-iliac fixation vs traditional iliac fixation was granted strong recommendation to consider risk and benefits in choosing S2AI vs traditional iliac screw for pelvic fixation. Article 3: Rates of loosening, failure, and revision of iliac fixation in adult deformity surgery was granted a conditional recommendation, for taking into account different potential failure mechanisms in S2AI vs traditional iliac screws in pelvic fixation.ConclusionsCurrently evolving strategies have included multiple points of pelvic fixation, multiple rods to the pelvis and strategies with concomitant fusion of the sacro-iliac joints. The high mechanical failure rate at the lumbosacral junction indicates that there is still further opportunity for optimization. It is important to consider the risks and benefits of different pelvic fixation methods to optimize the outcomes for individual patients.
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Affiliation(s)
- Robert Ravinsky
- Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Stephen Lewis
- Division of Orthopaedics, Toronto Western Hospital/University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Charles Fisher
- Division of Spine Surgery, University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - David Polly
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - On behalf of the AO Spine Knowledge Forum Deformity
- Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, SC, USA
- Division of Orthopaedics, Toronto Western Hospital/University Health Network, University of Toronto, Toronto, Ontario, Canada
- Division of Spine Surgery, University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
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Garcia R, Odland K, Lender P, Polly D. S2AI and iliac screw prominence and removal for symptomatic prominence: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2025; 34:1398-1408. [PMID: 39920316 DOI: 10.1007/s00586-025-08714-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2024] [Revised: 12/27/2024] [Accepted: 01/31/2025] [Indexed: 02/09/2025]
Abstract
PURPOSE Sacropelvic fixation plays a crucial role in complex spinal surgeries, particularly in adult spinal deformity (ASD) and other conditions requiring lumbosacral stabilization. This systematic review and meta-analysis aims to compare the rates of symptomatic screw prominence and screw removal between S2-alar-iliac (S2AI) and iliac screws, as well as those examining each screw type independently, to provide a comprehensive understanding and guide surgical decision-making and improve patient outcomes. METHODS A systematic review following PRISMA guidelines was conducted using Medline, SPORTDiscus, Cochrane Library, and Scopus databases. Inclusion criteria encompassed studies evaluating screw prominence or removal rates for S2AI and iliac screws, individually or in comparison, involving adult patients with sacropelvic fixation. Data on demographics, comorbidities, surgical characteristics, and outcomes were extracted. Statistical analysis included relative risk difference (RR) calculations using a random effects model, with heterogeneity assessed via the I² statistic. RESULTS Eighteen studies were included, comprising 1462 patients: 648 with S2AI screws and 814 with iliac screws. Symptomatic screw prominence was significantly lower for S2AI screws (1.9%, 12/648) compared to iliac screws (6.3%, 51/814), with a pooled RR difference of 0.08 (95% CI 0.04, p < 0.001). Screw removal rates due to prominence were 0% (0/12) for S2AI screws versus 27.5% (14/51) for iliac screws. Low heterogeneity was observed for both outcomes (I² = 3.32% for prominence, I² = 0.0% for removal). CONCLUSION S2AI screws demonstrate significantly lower rates of symptomatic prominence and screw removal compared to iliac screws, supporting their clinical and economic advantages in sacropelvic fixation for ASD. Technological advancements and innovations in implant design further enhance the efficacy of S2AI screws. These findings advocate for their adoption as an effective fixation technique, reducing hardware complications and improving patient outcomes. Future studies will aim to explore factors influencing prominence risk and optimize surgical strategies in ASD treatment.
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Affiliation(s)
- Rafael Garcia
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, USA.
| | - Kari Odland
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, USA
| | - Paul Lender
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, USA
| | - David Polly
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, USA
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Odland K, Chanbour H, Zuckerman SL, Polly DW. Spinopelvic fixation failure in the adult spinal deformity population: systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:2751-2762. [PMID: 38619634 DOI: 10.1007/s00586-024-08241-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 03/13/2024] [Accepted: 03/26/2024] [Indexed: 04/16/2024]
Abstract
INTRODUCTION Despite modern fixation techniques, spinopelvic fixation failure (SPFF) after adult spinal deformity (ASD) surgery ranges from 4.5 to 38.0%, with approximately 50% requiring reoperation. Compared to other well-studied complications after ASD surgery, less is known about the incidence and predictors of SPFF. AIMS/OBJECTIVES Given the high rates of SPFF and reoperation needed to treat it, the purpose of this systematic review and meta-analysis was to report the incidence and failure mechanisms of SPF after ASD surgery. MATERIALS/METHODS The literature search was executed across four databases: Medline via PubMed and Ovid, SPORTDiscus via EBSCO, Cochrane Library via Wiley, and Scopus. Study inclusion criteria were patients undergoing ASD surgery with spinopelvic instrumentation, report rates of SPFF and type of failure mechanism, patients over 18 years of age, minimum 1-year follow-up, and cohort or case-control studies. From each study, we collected general demographic information (age, gender, and body mass index), primary/revision, type of ASD, and mode of failure (screw loosening, rod breakage, pseudarthrosis, screw failure, SI joint pain, screw protrusion, set plug dislodgment, and sacral fracture) and recorded the overall rate of SPF as well as failure rate for each type. For the assessment of failure rate, we required a minimum of 12 months follow-up with radiographic assessment. RESULTS Of 206 studies queried, 14 met inclusion criteria comprising 3570 ASD patients who underwent ASD surgery with pelvic instrumentation (mean age 65.5 ± 3.6 years). The mean SPFF rate was 22.1% (range 3-41%). Stratification for type of failure resulted in a mean SPFF rate of 23.3% for the pseudarthrosis group; 16.5% for the rod fracture group; 13.5% for the iliac screw loosening group; 7.3% for the SIJ pain group; 6.1% for the iliac screw group; 3.6% for the set plug dislodgement group; 1.1% for the sacral fracture group; and 1% for the iliac screw prominence group. CONCLUSION The aggregate rate of SPFF after ASD surgery is 22.1%. The most common mechanisms of failure were pseudarthrosis, rod fracture, and iliac screw loosening. Studies of SPFF remain heterogeneous, and a consistent definition of what constitutes SPFF is needed. This study may enable surgeons to provide patient specific constructs with pelvic fixation constructs to minimize this risk of failure.
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Affiliation(s)
- Kari Odland
- Department of Orthopedic Surgery, University of Minnesota, 2450 Riverside Avenue South, Suite R200, Minneapolis, MN, 55454, USA.
| | - Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University, Nashville, TN, 37204, USA
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University, Nashville, TN, 37204, USA
| | - David W Polly
- Department of Orthopedic Surgery, University of Minnesota, 2450 Riverside Avenue South, Suite R200, Minneapolis, MN, 55454, USA
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Ormseth AF, Odland K, Haselhuhn JJ, Holton KJ, Polly DW. Pelvic Fixation Construct Trends in Spinal Deformity Surgery. Indian J Orthop 2024; 58:396-401. [PMID: 38544543 PMCID: PMC10963699 DOI: 10.1007/s43465-024-01116-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/29/2024] [Indexed: 02/24/2025]
Abstract
Purpose Although many techniques exist, spinopelvic fixation continues to present challenges in the management of adult spinal deformity. Shear forces, complex anatomy, and bone quality are common reasons why spine surgeons continue to explore options for fixation. Methods A retrospective chart reviewed of patients receiving pelvic fixation for adult spinal deformity over a 12-year period was conducted. Patients were divided into 3 cohorts based on date of surgery: (1) 2010 to 2013, (2) 2014 to 2017, and (3) 2018 to 2021. Pelvic fixation constructs in the study included traditional iliac screws, stacked S2-alar-iliac (S2AI screws), and triangular titanium implants. Results Of the 494 patients with multiple implant constructs who met the inclusion criteria for this study, patients undergoing pelvic fixation surgery who received at least 2 implants increased by approximately 5% every 4 years (90.2%, 94.6%, 99.1% respectively). Over the 12-year span, the implementation of the S2AI screw grew 120%. Conclusion At our institution, there is a trend toward using multiple bilateral implant constructs for pelvic fixation, with nearly a tenfold percentage increase between the most recent cohorts. These include iliac screws with S2AI screws, multiple stacked S2AI screws, and S2AI screws used in conjunction with triangular titanium implants in hopes to decrease implant failure.
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Affiliation(s)
- Andrew F. Ormseth
- The Department of Orthopedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN 55455 USA
| | - Kari Odland
- The Department of Orthopedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN 55455 USA
| | - Jason J. Haselhuhn
- The Department of Orthopedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN 55455 USA
| | - Kenneth J. Holton
- The Department of Orthopedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN 55455 USA
| | - David W. Polly
- The Department of Orthopedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN 55455 USA
- The Department of Neurosurgery, University of Minnesota, Minneapolis, MN USA
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Yoshida S, Iida S, Akagawa R, Oya S, Saita K, Ogihara S. Metastatic renal cell carcinoma of the lumbar spine with long posterior instrumented fusion and repetitive dislodgement of the set screws of the S2 alar-iliac screw. Surg Neurol Int 2023; 14:439. [PMID: 38213444 PMCID: PMC10783691 DOI: 10.25259/sni_859_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 11/22/2023] [Indexed: 01/13/2024] Open
Abstract
Background S2 alar-iliac screws (S2AIS) are widely used to anchor the pelvis to a lumbar fusion. Here, we report a patient who experienced repetitive dislodgement of the set screws of the S2AIS following a posterior instrumented fusion. Case Description A 68-year-old male presented with an L3 metastasis and L2-L3 subluxation attributed to renal cell cancer. Following an L2-L5 posterior decompression and T9-pelvic fusion utilizing bilateral S2AIS fixation, the set screws of the S2AIS repeatedly dislodged, requiring two additional operations. The final surgery required multiple anchors to the ilium and provided adequate fixation until the patient's expiration. Conclusion The set screw fixing force was weaker than the fixing force of the S2AIS; multiple iliac anchors effectively salvaged this condition.
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Affiliation(s)
- Shinsuke Yoshida
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Shunpei Iida
- Department of Orthopaedic Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Rei Akagawa
- Department of Orthopaedic Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Soichi Oya
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Kazuo Saita
- Department of Orthopaedic Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Satoshi Ogihara
- Department of Orthopaedic Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
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Turner JD, Schupper AJ, Mummaneni PV, Uribe JS, Eastlack RK, Mundis GM, Passias PG, DiDomenico JD, Harrison Farber S, Soliman MA, Shaffrey CI, Klineberg EO, Daniels AH, Buell TJ, Burton DC, Gum JL, Lenke LG, Bess S, Mullin JP. Evolving concepts in pelvic fixation in adult spinal deformity surgery. SEMINARS IN SPINE SURGERY 2023; 35:101060. [DOI: 10.1016/j.semss.2023.101060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2025]
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Kankam SB, Zarei M, Moghadam N, Jouibari MF, Bazzazi AM, Yaseen Khan FM, Moosavi M, Shafizadeh M, Roohollahi F, Makki BE, Khadivi M, Rostami M. Clinicoradiological Outcomes and Complication Profiles of Bilateral Dual Sacral-Alar-Iliac Screws versus Bilateral Single Sacral-Alar-Iliac Screws in Patients with Spinal Deformity Who Underwent Grade 3 or 4 Spinal Osteotomies: A Retrospective Comparative Study. World Neurosurg 2023; 178:e646-e656. [PMID: 37543201 DOI: 10.1016/j.wneu.2023.07.139] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE To compare short-term clinical and radiological outcomes and complication profiles between bilateral dual sacral-2-alar-iliac (S2AI) screw and bilateral single S2AI screw fixation techniques in patients who underwent grade 3 or 4 spinal osteotomies. METHODS A retrospective review of 83 patients treated with bilateral dual S2AI screws and 32 patients treated with bilateral single S2AI screws was conducted between 2018 and 2020 with a minimum 1-year follow-up. Clinical and radiological outcomes of patients and incidence of perioperative complications, including rod breakage, screw dislodgment, proximal junctional kyphosis, proximal junctional failure, need for reoperation, and systemic adverse effects, were collected and statistically compared between the groups. RESULTS With a mean follow-up of 18.2 months, rod fracture (6.0% vs. 18.7%, P = 0.03), screw dislodgment (0 vs. 12.5%, P < 0.01), and S2AI screw loosening (1.2% vs. 18.7%, P < 0.01) were significantly lower in the dual S2AI screws group than in the single S2AI screws group. However, the reoperation rate was similar between the 2 groups (24.1% vs. 34.3%, P = 0.26). No significant differences in clinical and radiological outcomes as well as proximal junctional kyphosis (10.8% vs. 18.7%, P = 0.25) and proximal junctional failure (9.6% vs. 18.7%, P = 0.18) were identified between the 2 groups. CONCLUSIONS The dual S2AI screw fixation technique showed more advantages over the single S2AI screw fixation technique with reduced incidence of screw dislodgment, rod fractures, and sacral-alar-iliac screw loosening.
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Affiliation(s)
- Samuel Berchi Kankam
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran; Harvard Chan School of Public Health, Boston, Massachusetts, USA
| | - Mohammad Zarei
- Spine Center of Excellence, Yas Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran; Department of Orthopedics, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Navid Moghadam
- Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Morteza Faghih Jouibari
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Mohammad Bazzazi
- Spine Center of Excellence, Yas Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mersad Moosavi
- Spine Center of Excellence, Yas Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Milad Shafizadeh
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Faramarz Roohollahi
- Spine Center of Excellence, Yas Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Bassel Eldeen Makki
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Khadivi
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran; Spine Center of Excellence, Yas Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Rostami
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran; Spine Center of Excellence, Yas Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.
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Kankam SB, Zarei M, Moghadam N, Jouibari MF, Bazzazi AM, Yaseen Khan FM, Moosavi M, Shafizadeh M, Roohollahi F, Makki BE, Khadivi M, Rostami M. Clinicoradiological Outcomes and Complication Profiles of Bilateral Dual Sacral-Alar-Iliac Screws versus Bilateral Single Sacral-Alar-Iliac Screws in Patients with Spinal Deformity Who Underwent Grade 3 or 4 Spinal Osteotomies: A Retrospective Comparative Study. World Neurosurg 2023; 178:e646-e656. [DOI: https:/10.1016/j.wneu.2023.07.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Noureldine MHA, Farooq J, Kumar JI, Pressman E, Coughlin E, Mhaskar R, Alikhani P. Improved Outcomes with Concurrent Instrumentation and Fusion of the Sacroiliac Joint in Patients with Long Lumbosacral Constructs. Global Spine J 2023; 13:2001-2006. [PMID: 35012363 PMCID: PMC10556918 DOI: 10.1177/21925682211069095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective Cohort Study. OBJECTIVE Spinal fusion, specifically constructs connected to pelvic bones, has been consistently reported as a predisposing factor to sacroiliac joint (SIJ) pain. The aim of this study is to compare SIJ outcomes in patients with constructs to the pelvis following instrumentation vs instrumentation plus fusion of the SIJ. METHODS Data of study subjects was extracted from a prospectively maintained database as well as retrospectively collected from records at a tertiary academic medical center in the United States between 2018 and 2020. RESULTS A cohort of 103 patients was divided into 2 groups: 65 in Group 1 [S2AI screw without fusion device] and 38 in Group 2 [S2AI screw with fusion device]. None of the patients in Group 2 developed postoperative SIJ pain compared to 44.6% in Group 1. Sacroiliac joint fusion occurred in all Group 2 but none of Group 1 patients. The postoperative Visual Analogue Scale (VAS) for lower extremity (LE) pain (.8 vs .5; P = .03) and postoperative Oswestry Disability Index (ODI) (18.7 vs 14.2; P < .01) were significantly higher in Group 1. The rate of distal junctional break, failure, and/or kyphosis (DJBFK) and time to DJBFK were not significantly different between the two groups, and the rate of DJBFK did not change in the presence of multiple covariates. CONCLUSION The SIJs carry the heavy load of long lumbosacral fusion constructs extending to the pelvis. Simultaneous SIJ instrumentation and fusion decreases the risk of disability, prevents the development of postoperative SIJ pain, and may also protect the S2AI screw from loosening and failure.
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Affiliation(s)
- Mohammad Hassan A. Noureldine
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Jeffrey Farooq
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Jay I. Kumar
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Elliot Pressman
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Emily Coughlin
- Department of Internal Medicine, University of South Florida, Tampa, FL, USA
| | - Rahul Mhaskar
- Department of Internal Medicine, University of South Florida, Tampa, FL, USA
| | - Puya Alikhani
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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Kankam SB, Zarei M, Moghadam N, Jouibari MF, Bazzazi AM, Yaseen Khan FM, Moosavi M, Shafizadeh M, Roohollahi F, Makki BE, Khadivi M, Rostami M. Clinicoradiological Outcomes and Complication Profiles of Bilateral Dual Sacral-Alar-Iliac Screws versus Bilateral Single Sacral-Alar-Iliac Screws in Patients with Spinal Deformity Who Underwent Grade 3 or 4 Spinal Osteotomies: A Retrospective Comparative Study. World Neurosurg 2023. [DOI: https:/doi.org/10.1016/j.wneu.2023.07.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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12
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Luo Y, Li Y, He L, Yin E, Gu M, Xu Z, Chen H, Hou Z, Yi C. Lumbopelvic fixation with S2 alar-iliac screws for U-shaped sacral fractures. Injury 2023; 54 Suppl 2:S8-S14. [PMID: 35180997 DOI: 10.1016/j.injury.2022.02.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/10/2022] [Accepted: 02/06/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To investigate the surgical methods and clinical effects of lumbopelvic fixation (LPF) with S2 alar-iliac (S2AI) screws for U-shaped sacral fractures. METHODS From December 2019 to August 2020, 14 patients with U-shaped sacral fractures were treated with LPF using S2AI screws. Demographics, fracture classification, mechanism of injury, surgical treatment, complications and clinical results were assessed. All patients had a LPF with or without nerve decompression. The reduction quality was evaluated according to the Matta criteria. Neurological function was evaluated according to the Gibbons grading. The activities of daily life were evaluated according to the Majeed scoring system at the last follow-up. RESULTS Among 14 consecutive patients with U-shaped sacral fractures, the age at injury ranged from 13 to 72 years (average 30.3 ± 17.5 years). There were 4 males and 10 females. All patients were followed up for 6-15 months (average 7.8 ± 2.7 months). Thirteen patients were fixed with bilateral S2AI screws, and one patient was fixed only unilaterally due to unilateral spinopelvic dissociation. The excellent and good rate of postoperative pelvic reduction quality was 92% (excellent 10, good 3, fair 1). At the latest follow-up, the excellent and good rate of pelvic function was 100% (excellent 9, good 5) and all patients achieved different extents of neurological recovery. One patient had a postoperative superficial surgical site infection, which healed after debridement. Radiological examination at 3-6 months after operation showed that all fractures had healed. No complications were found in any patients during follow-up, such as implant fracture, loss of reduction, deep wound infection, wound dehiscence and screw protrusion discomfort. CONCLUSION LPF with S2AI screws for the treatment of U-shaped sacral fractures has exhibited distinct advantages, including firm fixation, a low rate of surgical site complications and satisfactory clinical efficacy. This approach provides sufficient stability to accelerate the commencement of postoperative rehabilitation.
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Affiliation(s)
- Yangxing Luo
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Yue Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Li He
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Enzhi Yin
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Meiqi Gu
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Zhe Xu
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Hua Chen
- Department of Orthopaedic Trauma, Chinese PLA General Hospital (301 Hospital), Beijing 100853, China
| | - Zhiyong Hou
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang 050051, China
| | - Chengla Yi
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
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Lee NJ, Marciano G, Puvanesarajah V, Park PJ, Clifton WE, Kwan K, Morrissette CR, Williams JL, Fields M, Hassan FM, Angevine PD, Mandigo CE, Lombardi JM, Sardar ZM, Lehman RA, Lenke LG. Incidence, mechanism, and protective strategies for 2-year pelvic fixation failure after adult spinal deformity surgery with a minimum six-level fusion. J Neurosurg Spine 2023; 38:208-216. [PMID: 36242579 DOI: 10.3171/2022.8.spine22755] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the incidence, mechanism, and potential protective strategies for pelvic fixation failure (PFF) within 2 years after adult spinal deformity (ASD) surgery. METHODS Data for ASD patients (age ≥ 18 years, minimum of six instrumented levels) with pelvic fixation (S2-alar-iliac [S2AI] and/or iliac screws) with a minimum 2-year follow-up were consecutively collected (2015-2019). Patients with prior pelvic fixation were excluded. PFF was defined as any revision to pelvic screws, which may include broken rods across the lumbosacral junction requiring revision to pelvic screws, pseudarthrosis across the lumbosacral junction requiring revision to pelvic screws, a broken or loose pelvic screw, or sacral/iliac fracture. Patient information including demographic data and health history (age, sex, BMI, smoking status, American Society of Anesthesiologists score, osteoporosis), operative (total instrumented levels [TIL], three-column osteotomy [3CO], interbody fusion), screw (iliac, S2AI, length, diameter), rod (diameter, kickstand), rod pattern (number crossing lumbopelvic junction, lowest instrumented vertebra [LIV] of accessory rod[s], lateral connectors, dual-headed screws), and pre- and postradiographic (lumbar lordosis, pelvic incidence, pelvic tilt, major Cobb angle, lumbosacral fractional curve, C7 coronal vertical axis [CVA], T1 pelvic angle, C7 sagittal vertical axis) parameters was collected. All rods across the lumbosacral junction were cobalt-chrome. All iliac and S2AI screws were closed-headed tulips. Both univariate and multivariate analyses were performed to determine risk factors for PFF. RESULTS Of 253 patients (mean age 58.9 years, mean TIL 13.6, 3CO 15.8%, L5-S1 interbody 74.7%, mean pelvic screw diameter/length 8.6/87 mm), the 2-year failure rate was 4.3% (n = 11). The mechanisms of failure included broken rods across the lumbosacral junction (n = 4), pseudarthrosis across the lumbosacral junction requiring revision to pelvic screws (n = 3), broken pelvic screw (n = 1), loose pelvic screw (n = 1), sacral/iliac fracture (n = 1), and painful/prominent pelvic screw (n = 1). A higher number of rods crossing the lumbopelvic junction (mean 3.8 no failure vs 2.9 failure, p = 0.009) and accessory rod LIV to S2/ilium (no failure 54.2% vs failure 18.2%, p = 0.003) were protective for failure. Multivariate analysis demonstrated that accessory rod LIV to S2/ilium versus S1 (OR 0.2, p = 0.004) and number of rods crossing the lumbar to pelvis (OR 0.15, p = 0.002) were protective, while worse postoperative CVA (OR 1.5, p = 0.028) was an independent risk factor for failure. CONCLUSIONS The 2-year PFF rate was low relative to what is reported in the literature, despite patients undergoing long fusion constructs for ASD. The number of rods crossing the lumbopelvic junction and accessory rod LIV to S2/ilium relative to S1 alone likely increase construct stiffness. Residual postoperative coronal malalignment should be avoided to reduce PFF.
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Lee NJ, Park PJ, Puvanesarajah V, Clifton WE, Kwan K, Morrissette CR, Williams JL, Fields MW, Leung E, Hassan FM, Angevine PD, Mandigo CE, Lombardi JM, Sardar ZM, Lehman RA, Lenke LG. How common is acute pelvic fixation failure after adult spine surgery? A single-center study of 358 patients. J Neurosurg Spine 2023; 38:91-97. [PMID: 36029261 DOI: 10.3171/2022.7.spine22498] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/06/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE There is a paucity of literature on pelvic fixation failure after adult spine surgery in the early postoperative period. The purpose of this study was to determine the incidence of acute pelvic fixation failure in a large single-center study and to describe the lessons learned. METHODS The authors performed a retrospective review of adult (≥ 18 years old) patients who underwent spinal fusion with pelvic fixation (iliac, S2-alar-iliac [S2AI] screws) at a single academic medical center between 2015 and 2020. All patients had a minimum of 3 instrumented levels. The minimum follow-up was 6 months after the index spine surgery. Patients with prior pelvic fixation were excluded. Acute pelvic fixation failure was defined as revision of the pelvic screws within 6 months of the primary surgery. Patient demographics and operative, radiographic, and rod/screw parameters were collected. All rods were cobalt-chrome. All iliac and S2AI screws were closed-headed screws. RESULTS In 358 patients, the mean age was 59.5 ± 13.6 years, and 64.0% (n = 229) were female. The mean number of instrumented levels was 11.5 ± 5.5, and 79.1% (n = 283) had ≥ 6 levels fused. Three-column osteotomies were performed in 14.2% (n = 51) of patients, and 74.6% (n = 267) had an L5-S1 interbody fusion. The mean diameter/length of pelvic screws was 8.5/86.6 mm. The mean number of pelvic screws was 2.2 ± 0.5, the mean rod diameter was 6.0 ± 0 mm, and 78.5% (n = 281) had > 2 rods crossing the lumbopelvic junction. Accessory rods extended to S1 (32.7%, n = 117) or S2/ilium (45.8%, n = 164). Acute pelvic fixation failure occurred in 1 patient (0.3%); this individual had a broken S2AI screw near the head-neck junction. This 76-year-old woman with degenerative lumbar scoliosis and chronic lumbosacral zone 1 fracture nonunion had undergone posterior instrumented fusion from T10 to pelvis with bilateral S2AI screws (8.5 × 90 mm); i.e., transforaminal lumbar interbody fusion L4-S1. The patient had persistent left buttock pain postoperatively, with radiographically confirmed breakage of the left S2AI screw 68 days after surgery. Revision included instrumentation removal at L2-pelvis and a total of 4 pelvic screws. CONCLUSIONS The acute pelvic fixation failure rate was exceedingly low in adult spine surgery. This rate may be the result of multiple factors including the preference for multirod (> 2), closed-headed pelvic screw constructs in which large-diameter long screws are used. Increasing the number of rods and screws at the lumbopelvic junction may be important factors to consider, especially for patients with high risk for nonunion.
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Martin CT, Holton KJ, Elder BD, Fogelson JL, Mikula AL, Kleck CJ, Calabrese D, Burger EL, Ou-Yang D, Patel VV, Kim HJ, Lovecchio F, Hu SS, Wood KB, Harper R, Yoon ST, Ananthakrishnan D, Michael KW, Schell AJ, Lieberman IH, Kisinde S, DeWald CJ, Nolte MT, Colman MW, Phillips FM, Gelb DE, Bruckner J, Ross LB, Johnson JP, Kim TT, Anand N, Cheng JS, Plummer Z, Park P, Oppenlander ME, Sembrano JN, Jones KE, Polly DW. Catastrophic acute failure of pelvic fixation in adult spinal deformity requiring revision surgery: a multicenter review of incidence, failure mechanisms, and risk factors. J Neurosurg Spine 2023; 38:98-106. [PMID: 36057123 DOI: 10.3171/2022.6.spine211559] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 06/17/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE There are few prior reports of acute pelvic instrumentation failure in spinal deformity surgery. The objective of this study was to determine if a previously identified mechanism and rate of pelvic fixation failure were present across multiple institutions, and to determine risk factors for these types of failures. METHODS Thirteen academic medical centers performed a retrospective review of 18 months of consecutive adult spinal fusions extending 3 or more levels, which included new pelvic screws at the time of surgery. Acute pelvic fixation failure was defined as occurring within 6 months of the index surgery and requiring surgical revision. RESULTS Failure occurred in 37 (5%) of 779 cases and consisted of either slippage of the rods or displacement of the set screws from the screw tulip head (17 cases), screw shaft fracture (9 cases), screw loosening (9 cases), and/or resultant kyphotic fracture of the sacrum (6 cases). Revision strategies involved new pelvic fixation and/or multiple rod constructs. Six patients (16%) who underwent revision with fewer than 4 rods to the pelvis sustained a second acute failure, but no secondary failures occurred when at least 4 rods were used. In the univariate analysis, the magnitude of surgical correction was higher in the failure cohort (higher preoperative T1-pelvic angle [T1PA], presence of a 3-column osteotomy; p < 0.05). Uncorrected postoperative deformity increased failure risk (pelvic incidence-lumbar lordosis mismatch > 10°, higher postoperative T1PA; p < 0.05). Use of pelvic screws less than 8.5 mm in diameter also increased the likelihood of failure (p < 0.05). In the multivariate analysis, a larger preoperative global deformity as measured by T1PA was associated with failure, male patients were more likely to experience failure than female patients, and there was a strong association with implant manufacturer (p < 0.05). Anterior column support with an L5-S1 interbody fusion was protective against failure (p < 0.05). CONCLUSIONS Acute catastrophic failures involved large-magnitude surgical corrections and likely resulted from high mechanical strain on the pelvic instrumentation. Patients with large corrections may benefit from anterior structural support placed at the most caudal motion segment and multiple rods connecting to more than 2 pelvic fixation points. If failure occurs, salvage with a minimum of 4 rods and 4 pelvic fixation points can be successful.
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Affiliation(s)
| | - Kenneth J Holton
- 1Department of Orthopaedic Surgery, University of Minnesota, Minneapolis
| | - Benjamin D Elder
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jeremy L Fogelson
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Anthony L Mikula
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Christopher J Kleck
- 3Department of Orthopedics, University of Colorado, School of Medicine, Aurora, Colorado
| | - David Calabrese
- 3Department of Orthopedics, University of Colorado, School of Medicine, Aurora, Colorado
| | - Evalina L Burger
- 3Department of Orthopedics, University of Colorado, School of Medicine, Aurora, Colorado
| | - David Ou-Yang
- 3Department of Orthopedics, University of Colorado, School of Medicine, Aurora, Colorado
| | - Vikas V Patel
- 3Department of Orthopedics, University of Colorado, School of Medicine, Aurora, Colorado
| | - Han Jo Kim
- 4Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Francis Lovecchio
- 4Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Serena S Hu
- 5Department of Orthopaedic Surgery, Stanford University, Stanford, California
| | - Kirkham B Wood
- 5Department of Orthopaedic Surgery, Stanford University, Stanford, California
| | - Robert Harper
- 5Department of Orthopaedic Surgery, Stanford University, Stanford, California
| | - S Tim Yoon
- 6Department of Orthopaedics, Emory University, Atlanta, Georgia
| | | | - Keith W Michael
- 6Department of Orthopaedics, Emory University, Atlanta, Georgia
| | - Adam J Schell
- 6Department of Orthopaedics, Emory University, Atlanta, Georgia
| | | | - Stanley Kisinde
- 7Scoliosis and Spine Tumor Center, Texas Back Institute, Plano, Texas
| | - Christopher J DeWald
- 8Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Michael T Nolte
- 8Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Matthew W Colman
- 8Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Frank M Phillips
- 8Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Daniel E Gelb
- 9Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jacob Bruckner
- 9Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Lindsey B Ross
- 10Department of Neurologic Surgery, Cedars-Sinai Medical Center, Los Angeles
| | - J Patrick Johnson
- 10Department of Neurologic Surgery, Cedars-Sinai Medical Center, Los Angeles
| | - Terrence T Kim
- 11Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Neel Anand
- 11Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Joseph S Cheng
- 12Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio; and
| | - Zach Plummer
- 12Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio; and
| | - Paul Park
- 13Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Mark E Oppenlander
- 13Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | | | - Kristen E Jones
- 1Department of Orthopaedic Surgery, University of Minnesota, Minneapolis
| | - David W Polly
- 1Department of Orthopaedic Surgery, University of Minnesota, Minneapolis
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Tang Z, Hu Z, Zhu Z, Qiao J, Mao S, Ling C, Qiu Y, Liu Z. The Utilization of Dual Second Sacral Alar-Iliac Screws for Spinopelvic Fixation in Patients with Severe Kyphoscoliosis. Orthop Surg 2022; 14:1457-1468. [PMID: 35698273 PMCID: PMC9251291 DOI: 10.1111/os.13348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/17/2022] [Accepted: 05/18/2022] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES As a new pelvic fixation technique, the dual S2AI screws fixation technique could provide highly stable distal strength, and have wide clinical prospect in the correction of severe kyphoscoliosis. However, the ideal trajectory parameters, indications and clinical outcomes of this technique have not been reported so far. This study aimed to determine the anatomical parameters of dual S2AI screws in the normal Chinese adult population, investigating the indications of this technique and evaluating the feasibility and clinical outcomes. METHODS Fifteen males and 15 females with normal pelvis underwent a pelvic CT scan to determine ideal dual S2AI screws trajectories. Sagittal angle (SA), transverse angle (TA), maximal length (ML), sacral length, and skin distance were measured. Subsequently, we retrospectively reviewed the data of 16 patients (seven males and nine females) who underwent dual S2AI screw fixation and 23 patients who underwent single S2AI screw fixation between January 2014 and December 2019. Preoperative, postoperative, and latest follow-up measurements of Cobb angle, coronal balance (CB), spinal pelvic obliquity (SPO), and regional kyphosis (RK) were obtained. The mean follow-up time was 16.7 ± 7.1 months (range: 12-30 months). Independent t-test was used to determine the difference in the analysis of the trajectories. The paired sample non-parametric Wilcoxon test was performed to assess the changes in radiographic parameters between different time points and different groups. RESULTS For both male and females, the proximal S2AI screws had significantly higher TA and ML, but a lower SA than distal screws. Females showed significantly more caudal (SA: 25.03° ± 2.32° vs. 29.82° ± 2.47°, t = 7.742, P < 0.001) trajectories of distal screw. Additionally, ML in the females were significantly shorter than that in males (106.81 mm ± 6.79 mm vs. 101.63 mm ± 6.55 mm, t = 3.007, P = 0.003, 124.41 mm ± 7.57 mm vs. 116.23 mm ± 7.03 mm, t = 4.337, P < 0.001). Eight had unilateral and eight had bilateral dual S2AI screw placement. Respectively, both the single S2AI and dual S2AI groups showed significant postoperative improvement of Cobb angle, RK angle and SPO angle. In patients with dual S2AI screws fixation, two patients found that screws loosening occurred in one of dual screws at 1-year follow-up, and in patients with single S2AI screws fixation, six patients found screw loosing as well as two patients found screw breakage at 1-year follow-up. None of all patients had any prominent loss of correction. CONCLUSION The ideal trajectory of dual S2AI screw could be well established. The dual S2AI screw fixation technique is feasible in patients with severe kyphoscoliosis, and provides satisfactory correction of deformity with few postoperative complications.
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Affiliation(s)
- Ziyang Tang
- Department of Spine Surgery, Nanjing Drum Tower HospitalThe Clinical College of Nanjing Medical UniversityNanjing210008China
| | - Zongshan Hu
- Department of Spine Surgery, Nanjing Drum Tower HospitalThe Affiliated Hospital of Nanjing University Medical SchoolNanjing210008China
| | - Zezhang Zhu
- Department of Spine Surgery, Nanjing Drum Tower HospitalThe Clinical College of Nanjing Medical UniversityNanjing210008China
- Department of Spine Surgery, Nanjing Drum Tower HospitalThe Affiliated Hospital of Nanjing University Medical SchoolNanjing210008China
| | - Jun Qiao
- Department of Spine Surgery, Nanjing Drum Tower HospitalThe Affiliated Hospital of Nanjing University Medical SchoolNanjing210008China
| | - Saihu Mao
- Department of Spine Surgery, Nanjing Drum Tower HospitalThe Affiliated Hospital of Nanjing University Medical SchoolNanjing210008China
| | - Chen Ling
- Department of Spine Surgery, Nanjing Drum Tower HospitalThe Clinical College of Nanjing Medical UniversityNanjing210008China
| | - Yong Qiu
- Department of Spine Surgery, Nanjing Drum Tower HospitalThe Clinical College of Nanjing Medical UniversityNanjing210008China
- Department of Spine Surgery, Nanjing Drum Tower HospitalThe Affiliated Hospital of Nanjing University Medical SchoolNanjing210008China
| | - Zhen Liu
- Department of Spine Surgery, Nanjing Drum Tower HospitalThe Clinical College of Nanjing Medical UniversityNanjing210008China
- Department of Spine Surgery, Nanjing Drum Tower HospitalThe Affiliated Hospital of Nanjing University Medical SchoolNanjing210008China
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Radio-anatomical study of anterior-posterior placement sacroiliac screw channel. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:2572-2578. [PMID: 35687271 DOI: 10.1007/s00586-022-07257-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 04/19/2022] [Accepted: 05/01/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE The outlet of the classic sacroiliac screw (SIS) cannot be precisely controlled by aiming devices, which may lead to malpositioned implants and neurovascular and visceral injury. This study aimed to radio-anatomically measure the parameters of the channel for anterior-posterior placement SIS (AP-SIS), which can be placed percutaneously with an aiming device. METHODS Pelvic CT scan data of 80 healthy adults (40 males and 40 females) with an average age of 45 years (range 20-70 years) were collected. The length (L), width (W), height (H), cortical bone spacing (M), camber angle (E), anteversion angle (F), cross-sectional safety angle (P) and sagittal safety angle (Q) of the channel were measured by CT or Mimics software. RESULTS The L, W, H, M, E, F, P and Q measures of S1 were 109.2 ± 8.0 mm, 18.5 ± 1.9 mm, 21.7 ± 1.7 mm, 8.1 ± 0.4 mm, 44.2 ± 3.2°, 42.4 ± 3.6°, 16.8 ± 1.1°, and 19.4 ± 2.0°, respectively, for S1, and 113.5 ± 9.4 mm, 18.2 ± 1.5 mm, 21.7 ± 1.7 mm, 7.7 ± 0.4 mm, 44.7 ± 3.2°, 31.2 ± 2.7°, 13.8 ± 1.0° and 15.4 ± 1.4°, respectively, for S2. Of the L measures, the intra-iliac segment was slightly longer than the intra-sacral segment. All parameters showed significant sex-related differences (p < 0.05). CONCLUSION The AP-SIS channels of S1-2 have sufficient width and length to accommodate a cancellous screw with a Φ 7.0-8.0 mm and a length 90-130 mm. The intra-iliac segment is a long channel screw with better mechanical properties over classic SIS.
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18
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Kozaki T, Hashizume H, Oka H, Ohashi S, Kumano Y, Yamamoto E, Minamide A, Yukawa Y, Iwasaki H, Tsutsui S, Takami M, Nakata K, Taniguchi T, Fukui D, Nishiyama D, Yamanaka M, Tamai H, Taiji R, Murata S, Murata A, Yamada H. Lumbar Fusion including Sacroiliac Joint Fixation Increases the Stress and Angular Motion at the Hip Joint: A Finite Element Study. Spine Surg Relat Res 2022; 6:681-688. [PMID: 36561150 PMCID: PMC9747219 DOI: 10.22603/ssrr.2021-0231] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/14/2022] [Indexed: 12/25/2022] Open
Abstract
Introduction Adult spinal fusion surgery improves lumbar alignment and patient satisfaction. Adult spinal deformity surgery improves saggital balance not only lumbar lesion, but also at hip joint coverage. It was expected that hip joint coverage rate was improved and joint stress decreased. However, it was reported that adjacent joint disease at hip joint was induced by adult spinal fusion surgery including sacroiliac joint fixation on an X-ray study. The mechanism is still unclear. We aimed to investigate the association between lumbosacral fusion including sacroiliac joint fixation and contact stress of the hip joint. Methods A 40-year-old woman with intact lumbar vertebrae underwent computed tomography. A three-dimensional nonlinear finite element model was constructed from the L4 vertebra to the femoral bone with triangular shell elements (thickness, 2 mm; size, 3 mm) for the cortical bone's outer surface and 2-mm (lumbar spine) or 3-mm (femoral bone) tetrahedral solid elements for the remaining bone. We constructed the following four models: a non-fusion model (NF), a L4-5 fusion model (L5F), a L4-S1 fusion model (S1F), and a L4-S2 alar iliac screw fixation model (S2F). A compressive load of 400 N was applied vertically to the L4 vertebra and a 10-Nm bending moment was additionally applied to the L4 vertebra to stimulate flexion, extension, left lateral bending, and axial rotation. Each model's hip joint's von Mises stress and angular motion were analyzed. Results The hip joint's angular motion in NF, L5F, S1F, and S2F gradually increased; the S2F model presented the greatest angular motion. Conclusions The average and maximum contact stress of the hip joint was the highest in the S2F model. Thus, lumbosacral fusion surgery with sacroiliac joint fixation placed added stress on the hip joint. We propose that this was a consequence of adjacent joint spinopelvic fixation. Lumbar-to-pelvic fixation increases the angular motion and stress at the hip joint.
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Affiliation(s)
- Takuhei Kozaki
- Department of Orthopaedic Surgery, Wakayama Medical University, Wakayama, Wakayama, Japan
| | - Hiroshi Hashizume
- Department of Orthopaedic Surgery, Wakayama Medical University, Wakayama, Wakayama, Japan
| | - Hiroyuki Oka
- Department of Medical Research and Management for Musculoskeletal Pain, Faculty of Medicine, 22nd Century Medical and Research Center, The University of Tokyo, Tokyo, Japan
| | - Satoru Ohashi
- Department of Orthopaedic Surgery, Sagamihara Hospital, National Hospital Organization, Sagamihara, Kanagawa, Japan
| | - Yoh Kumano
- Department of Spine Surgery, Tokyo Yamate Medical Center, Japan Community Healthcare Organization, Tokyo, Japan
| | - Ei Yamamoto
- Department of Biomedical Engineering, Faculty of Biology-Oriented Science and Technology, KinDai University, Kinokawa, Wakayama, Japan
| | - Akihito Minamide
- Department of Orthopaedic Surgery, Wakayama Medical University, Wakayama, Wakayama, Japan
| | - Yasutsugu Yukawa
- Department of Orthopaedic Surgery, Wakayama Medical University, Wakayama, Wakayama, Japan
| | - Hiroshi Iwasaki
- Department of Orthopaedic Surgery, Wakayama Medical University, Wakayama, Wakayama, Japan
| | - Shunji Tsutsui
- Department of Orthopaedic Surgery, Wakayama Medical University, Wakayama, Wakayama, Japan
| | - Masanari Takami
- Department of Orthopaedic Surgery, Wakayama Medical University, Wakayama, Wakayama, Japan
| | - Keiji Nakata
- Department of Orthopaedic Surgery, Wakayama Medical University, Wakayama, Wakayama, Japan
| | - Takaya Taniguchi
- Department of Orthopaedic Surgery, Wakayama Medical University, Wakayama, Wakayama, Japan
| | - Daisuke Fukui
- Department of Orthopaedic Surgery, Wakayama Medical University, Wakayama, Wakayama, Japan
| | - Daisuke Nishiyama
- Department of Orthopaedic Surgery, Wakayama Medical University, Wakayama, Wakayama, Japan
| | - Manabu Yamanaka
- Department of Orthopaedic Surgery, Wakayama Medical University, Wakayama, Wakayama, Japan
| | - Hidenobu Tamai
- Department of Orthopaedic Surgery, Wakayama Medical University, Wakayama, Wakayama, Japan
| | - Ryo Taiji
- Department of Orthopaedic Surgery, Wakayama Medical University, Wakayama, Wakayama, Japan
| | - Shizumasa Murata
- Department of Orthopaedic Surgery, Wakayama Medical University, Wakayama, Wakayama, Japan
| | - Akimasa Murata
- Department of Orthopaedic Surgery, Wakayama Medical University, Wakayama, Wakayama, Japan
| | - Hiroshi Yamada
- Department of Orthopaedic Surgery, Wakayama Medical University, Wakayama, Wakayama, Japan
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19
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Kim HS, Kwon JW, Park KB. Clinical Issues in Indication, Correction, and Outcomes of the Surgery for Neuromuscular Scoliosis: Narrative Review in Pedicle Screw Era. Neurospine 2022; 19:177-187. [PMID: 35130428 PMCID: PMC8987549 DOI: 10.14245/ns.2143246.623] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 01/29/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Hak Sun Kim
- Department of Orthopaedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Won Kwon
- Department of Orthopaedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kun-Bo Park
- Division of Pediatric Orthopedic Surgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
- Corresponding Author Kun-Bo Park https://orcid.org/0000-0002-8839-4870 Division of Pediatric Orthopedic Surgery, Severance Children’s Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea ,
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20
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Luo Y, Li Y, He L, Yi C. S2-Alar-Iliac Screw Fixation versus Iliac Screw Fixation in the Treatment of Sacral Fractures. J INVEST SURG 2022; 35:1224-1230. [PMID: 34974780 DOI: 10.1080/08941939.2021.2022253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE To compare the short-term therapeutic effects of S2-alar-iliac (S2AI) screw fixation and iliac screw fixation techniques in managing sacral fractures. METHODS From September 2015 to May 2020, 42 patients with sacral fractures who underwent lumbopelvic fixation by a single surgeon were analyzed. The patients were divided into the S2AI screw group (19 patients) and the iliac screw group (23 patients). Operative data, reduction quality, postoperative complications, and functional outcomes were evaluated. RESULTS The incidence of unplanned reoperation was significantly different between patients treated with S2AI screws than in those treated with iliac screws (0 versus 6, p = 0.02). The mean intraoperative estimated blood loss was 405.26 ± 229.67 mL in the S2AI screw group and 539.13 ± 246.32 mL in the iliac screw group (P = 0.08). No significant difference was observed in either group regarding the quality of reduction, functional outcome, or low back pain. The reduction quality based on the Matta criteria and excellent/good outcomes were 21/2 in the iliac screw group and 17/2 in the S2AI screw group. The functional outcomes based on the Majeed score and excellent/good/fair outcomes were 17/3/3 in the iliac screw group and 17/1/1 in the S2AI screw group. No complications, including implant breakage, loosening of the implant, or loss of reduction were found in either group during follow-up. CONCLUSION Both S2AI screws and iliac screws were effective in the treatment of sacral fractures. The use of S2AI screws, however, was independently associated with fewer unplanned reoperations for surgical site infection, wound dehiscence, and symptoms of screw protrusion than the use of iliac screws.
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Affiliation(s)
- Yangxing Luo
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yue Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Li He
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chengla Yi
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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21
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Choi HY, Jo DJ. Utilization of S1 Foraminal Hooks for Augmentation of S1 Screws in Adult Spinal Deformity Surgery: Comparative Study With Iliac Screws. Neurospine 2021; 18:554-561. [PMID: 34610686 PMCID: PMC8497253 DOI: 10.14245/ns.2142148.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 06/02/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To compare the outcomes of S1 foraminal hooks and iliac screws regarding fusion rate at the lumbosacral junction and protective effects on S1 screws. METHODS From January 2017 to December 2019, consecutive patients who underwent long fusions (uppermost instrumented vertebra at or above L1) to the sacrum for adult spinal deformity were enrolled. Patients were divided into S1 foraminal hook group and iliac screw group. Radiographic parameters and the incidence of pseudarthrosis and instrument failure at the lumbosacral junction were compared between the groups. RESULTS Twenty-nine patients (male:female = 1:28) with a mean age of 73.6 ± 6.8 years were evaluated. Sixteen patients (55.2%) had S1 foraminal hook fixation and 13 patients (44.8%) had iliac screw fixation. Lumbar lordosis, sacral slope, and sagittal vertical axis did not differ between the groups preoperatively and postoperatively. The rate of L5/S1 pseudarthrosis was significantly higher in S1 foraminal hook group (5 of 16, 31.3%), compared to iliac screw group (0 of 13, 0%; p = 0.048). Instrument failure at the lumbosacral junction trended toward a higher rate in S1 foraminal hook group (6 of 16, 37.5%) than in iliac screw group (1 of 13, 7.7%), without statistical significance (p = 0.09). Proximal junctional kyphosis/failure occurred less often in S1 foraminal hook group (2 of 16, 12.5%) than in iliac screw group (3 of 13, 30.8%) without statistical significance (p = 0.36). CONCLUSION Treatment with S1 foraminal hooks achieved equivalent satisfactory sagittal correction with proportioned alignment compared to that with iliac screws. However, S1 foraminal hooks did not provide enough structural support to the lumbosacral junction in long fusions to the sacrum.
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Affiliation(s)
- Ho Yong Choi
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea.,Department of Neurosurgery, College of Medicine, Kangwon National University, Chuncheon, Korea
| | - Dae Jean Jo
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
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22
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Noureldine MHA, Pressman E, Kumar JI, Zavadskiy G, Tran ND, Greenberg MS, Alikhani P. Sacroiliac joint arthropathy in adult spinal deformity patients with long constructs to the pelvis. Clin Neurol Neurosurg 2021; 203:106593. [PMID: 33706061 DOI: 10.1016/j.clineuro.2021.106593] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/16/2021] [Accepted: 02/27/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Sacroiliac joint (SIJ) arthropathy is an increasingly recognized problem in adult spinal deformity patients undergoing long construct surgery. S2-alar-iliac (S2AI) screw instrumentation is thought to reduce morbidity from pelvic fixation in these patients. The goal of this study is to assess the overall incidence of SIJ arthropathy in patients with long constructs to the pelvis as well as compare SIJ outcomes of partially threaded (PT) versus fully threaded (FT) S2AI screws. METHODS Data of eligible patients were collected from a prospectively maintained database with retrospective review of electronic records at an academic institution between 2016 and 2019. RESULTS 65 consecutive patients who underwent S2AI screw instrumentation (40 in PT group, 25 in FT group) were enrolled. The rate of postoperative SIJ pain was higher in the PT (52.5 %) compared to FT (32 %) group. There was a significantly shorter time-to-pain development in the PT compared to FT group (11.8 versus 20.1 months, respectively). Of those who developed SIJ pain in the PT group, the pain worsened in 80.9 % versus only 25 % of those in the FT group despite conservative treatment. Cox regression found the PT group more likely to develop SIJ pain at any point during follow-up compared to the FT group (Hazard Ratio = 7.308). SIJ fusion was not detected on imaging of any patient during follow-up. CONCLUSION FT S2AI screws are associated with better SIJ outcomes compared to PT screws. However, our data suggest that S2AI screw instrumentation is not sufficient to achieve fusion or prevent development of SIJ pain. Concurrent SIJ fusion may be necessary in patients with long constructs to prevent SIJ arthropathy.
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Affiliation(s)
| | - Elliot Pressman
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Jay I Kumar
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Gleb Zavadskiy
- Muma College of Business, University of South Florida, Tampa, FL, USA
| | - Nam D Tran
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Mark S Greenberg
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Puya Alikhani
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
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