Instrumented lumbar spinal fusion is common and results in biomechanical changes at adjacent spinal segments that increase facet load bearing. This can cause facet-mediated pain at levels adjacent to the surgical construct. Medial branch nerve radiofrequency ablation (RFA) exists as a treatment for some cases. It is important to acknowledge that the approach and instrumentation used during some specific lumbar fusion approaches will disrupt the medial branch nerve(s). Thus, the proceduralist must consider the fusion approach when determining which medial branch nerves are necessary to anesthetize for diagnosis and then to potentially target with RFA. This article discusses the relevant technical considerations for preparing for RFA to denervate lumbosacral facet joints adjacent to fusion constructs.

Background: Achieving and maintaining global spinal balance is a crucial goal in posterior spinal fusion for adolescent idiopathic scoliosis (AIS). Despite its substantial impact on operative success, there is a noticeable gap in the literature regarding a systematic evaluation of the trajectory and durability of this critical parameter. With this study, we aimed to characterize the evolution of global balance after posterior spinal fusion for AIS. Methods: A prospective, multicenter spinal deformity database was retrospectively queried for patients with AIS undergoing posterior spinal fusion. Standing, 2-view radiographs (anteroposterior and lateral) were obtained at the first-erect visit, 6 months, 1 year, 2 years, and 5 years, with a subset of patients having radiographs at the 10-year mark. Coronal balance was defined as the difference, in centimeters, between the C7 plumb line and the central sacral vertical line (CSVL). The sagittal vertical axis (SVA) measured sagittal balance, calculated as the difference, in centimeters, between the C7 plumb line and the posterosuperior corner of the superior end plate of S1. Results: The study included 477 patients with 5 years of follow-up and 84 patients with a decade of follow-up. The mean patient age was 14.1 years, 67.9% of the patients were White, and 81.6% of the patients were female. Preoperative assessment revealed that 50.7% of the patients demonstrated optimal global balance. The initial postoperative evaluation showed essentially no improvement, with only 55.6% achieving optimal balance (Coronal and Sagittal Harmony [CASH] A0) at the first-erect visit. Subsequent follow-up demonstrated steady improvement, with 81.8% reaching optimal balance at 5 years and 87.7% at the 10-year mark. Conclusions: This study offers a comprehensive analysis of global spinal alignment and traces the balance trajectory (in both the coronal and sagittal planes) after posterior spinal fusion in AIS. To our knowledge, it is the largest and longest follow-up study of its kind. The findings highlight a profound and steady postoperative improvement in global balance over time, advancing our understanding of postoperative spinal balance in AIS. The novel CASH classification introduced here serves as a possible tool for evaluating overall alignment and balance in patients with AIS. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction: MRI is commonly used to evaluate pelvic musculoskeletal infections. Limited “quick” MRI protocols enable timely imaging without intravenous contrast or sedation. This study examines the consistency of interpretation among pediatric orthopaedic surgeons when using quick versus full, contrast-enhanced MRI scans in cases of peripelvic musculoskeletal infection and explores these findings to inform future development and design of machine learning algorithms. Methods: Twenty-nine pediatric patients with full pelvis MRI with and without contrast and culture-positive peripelvic infection were retrospectively identified. Two deidentified files were created for each patient: one including all sequences and the other containing only the limited sequences included in our institution's quick MRI protocol. Three pediatric orthopaedic surgeons independently and sequentially evaluated the images, followed by group discussion to reach consensus on the primary diagnosis and management. Fleiss' Kappa (FK) statistic was calculated for each outcome. Results: Moderate agreement in primary diagnosis was observed among reviewers using quick MRI sequences (Kappa = 0.488), and substantial agreement was seen with full sequences (0.684; P = 0.003). Inter-rater agreement on treatment recommendations was poor with both quick (0.09) and full (0.233) MRI ( P = 0.046). No difference was found in team consensus diagnosis and final diagnosis between quick (0.523) and full (0.569) MRI ( P = 0.662). Poor agreement was found between team treatment recommendations and actual treatment for both quick (0.182) and full (0.07) MRI ( P = 0.254). Conclusion: Independent evaluation of limited, quick MRI sequences by pediatric orthopaedic surgeons showed more variability in diagnosis and treatment compared with full MRI review. When reviewed collaboratively, the diagnostic accuracy of quick MRI approached that of full MRI. Future artificial intelligence–based imaging interpretation platforms will benefit from multi-institutional collaboration to improve training data quality; use of ensemble learning techniques to reflect the diversity of multispecialist approaches; and incorporation of relevant clinical data to properly identify, triage, and direct treatment of complex pediatric musculoskeletal conditions.

Background/Objectives: The follow-up for pediatric elbow injuries often involves in-office visits to assess the range of motion (ROM). There is evidence for the use of telemedicine and digital assessments of elbow motion in adults but none in pediatrics. The aim of this study was to compare measurements of the joint range of motion and elbow alignment in children, taken in a doctor’s office, with those obtained from photographs and to evaluate the intra- and inter-observer reliability of these measurements. Methods: Fourteen children were prospectively included in this study during follow-ups after an arm fracture. Only the uninjured arm was evaluated: goniometric measurements performed in the office were compared with digital measurements obtained from photographs. For the uninjured arm, in-office goniometer measurements were compared to picture-based digital measurements. Mean digital values were compared to in-office goniometer measurements using a paired t-test, and the intra- and inter-rater reliability of the digital measurements was calculated. Results: When comparing photograph-based digital measurements to in-office goniometer measurements, the mean absolute error (average absolute difference between observer measurements and goniometer) showed differences of 4.5° for extension, 7.4° for flexion, and 4.8° for the carrying angle. The accuracy bias (average difference between observer measurements and goniometer) showed an overestimation of photographs for extension by 1.2°, an overestimation of photographs for flexion by 5.5°, and an underestimation of photographs for a carrying angle of 3.5°. Intra- and inter-rater reliability correlations were all within the good (0.75–0.9) to excellent (>0.9) ranges. The intra-rater intraclass correlation coefficient (ICC) was 0.91 for extension, 0.87 for flexion, and 0.87 for the carrying angle. The inter-rater ICC was 0.98 for extension, 0.93 for flexion, and 0.96 for the carrying angle. Conclusions: Photograph-based digital measurements appear to be an acceptable alternative compared to in-office goniometer measurements in pediatric patients.