Study Design.: Retrospective cohort study. Objective.: This study aimed to identify risk factors that predict lumbar curve adding-on in patients who had selective thoracic fusion. Summary of Background Data.: Selective thoracic fusion offers deformity correction of Lenke 1 and 2 thoracic curves and maintains lumbar range of movement. However, some patients may develop postoperative lumbar adding-on. Methods.: This study included patients 18 years or younger that underwent spinal instrumentation for Lenke 1 and 2 curves. Results.: A total of 161 patients were included (147 females, 14 males). The mean age was 14.0 ± 2.1 years: 103 patients were Lenke 1, and 58 patients were Lenke 2 curves. Ninety-seven patients underwent posterior approach surgery, whereas 64 via anterior approach. In the posterior approach group, 79(81.4%) patients underwent selective fusion. Ten patients (6.2%) had lumbar curve adding-on, with nine females and one male. There were seven Lenke 1 and three Lenke 2 patients. All 10 patients were lumbar modifier (a), with 5 hypokyphotic patients. Selective fusion was done in nine patients. Lumbar adding-on was seen most commonly between 6 months to 1 year postoperative period (five patients). Two patients had adding-on because of incorrect distal fusion level, six were due to 1A-R curve, one due to the inadvertent fusion from the excessive long rod at the subjacent level. In multivariate analysis, hypokyphotic patients were at higher risk of lumbar adding-on (odds ratio = 9.2). Patients with Risser classification 0, 1, 2, 3 were also at higher risk of lumbar adding-on (odds ratio =6.1). Conclusion.: The incidence of lumbar curve adding-on was 6.2%. Patients who were hypokyphotic and skeletally immature are nine times and six times more likely to have lumbar adding-on, respectively. This article examines adding-on in patients who had either anterior or posterior approach scoliosis surgeries, with follow-up stretching up to 10 years. This offers the rare opportunity to examine the natural history of the adding-on phenomenon. Level of Evidence: 3

Background: Delays in the diagnosis and treatment of metastatic epidural spinal cord compression (MESCC) can potentially result in serious, deleterious effects on patient outcomes and postoperative morbidity. Delays may occur any at any step in the chain of care, increasing the risk of preventable complications. Objectives: This study, thus, aims to identify patterns of treatment delays and determine the predictive factors of postoperative ambulatory function in patients with symptomatic MESCC. Methods: Adult patients, aged >18 years, who underwent surgical treatment for MESCC between 2015 and 2022, were included for analysis in this retrospective study. Results: A total of 177 patients were included. The most significant delay contributing to total delay was patient delay (mean duration 41 days) followed by diagnostic delay (mean duration 16 days). Patients presenting acutely to the Emergency Department and patients with neurological deficits were found to have significantly shorter delays. Preoperative neurological deficits (p = 0.001) and preoperative red flag symptoms of cord compression (p = 0.008) were significant factors that were predictive of postoperative functional independence. Referral delay was also a significant predictive factor (p = 0.013); surgical delay approached statistical significance (p = 0.075). Conclusions: The results of this study highlight the need for increasing patient education, enhancing physician management of patients with MESCC, and improving diagnostic efficiency to reduce delays and maximize patient outcomes.

Background: Delay in diagnosing metastatic epidural spinal cord compression (MESCC) adversely impacts clinical outcomes. High-grade MESCC is frequently overlooked on routine staging CT scans. We aim to assess the potential of our deep learning model (DLM) in detecting high-grade MESCC and reducing diagnostic delays. Methods: This retrospective review analyzed 140 patients with surgically treated MESCC between C7 and L2 during 2015–2022. An experienced radiologist (serving as the reference standard), a consultant spine surgeon, and the DLM independently classified staging CT scans into high-grade MESCC or not. The findings were compared to original radiologist (OR) reports; inter-rater agreement was assessed. Diagnostic delay referred to the number of days elapsed from CT to diagnostic MRI scan. Results: Overall, 95/140 (67.8%) patients had preoperative CT scans. High-grade MESCC was identified in 84/95 (88.4%) of the scans by the radiologist (reference standard), but in only 32/95 (33.7%) of the preoperative scans reported by the OR. There was almost perfect agreement between the radiologist and the surgeon (kappa = 0.947, 95% CI = 0.893–1.000) (p < 0.001), and between the radiologist and the DLM (kappa = 0.891, 95% CI = 0.816–0.967) (p < 0.001). In contrast, inter-observer agreement between the OR and all other readers was slight (kappa range = 0.022–0.125). Diagnostic delay was potentially reduced by 20 ± 28 (range = 1–131) days. Conclusions: The original radiologist reports frequently missed high-grade MESCC in staging CT. Our DLM for CT diagnosis of high-grade MESCC showed almost perfect inter-rater agreement with two experienced reviewers. This study is the first to demonstrate that the DLM could help reduce diagnostic delays. Further prospective research is required to understand its precise role in improving the early diagnosis/treatment of MESCC.