Structured Online Support to Inform and Assist Antidepressant Deprescribing in Primary Care (WiserAD Tool): Protocol for a Pragmatic Randomized Controlled Trial.

Adolescent idiopathic scoliosis (AIS) is a complex 3-dimensional (3D) spinal deformity characterized by lateral deviation and axial rotation of the vertebrae []. In severe cases, surgical correction is indicated to restore trunk balance by correcting the 3D curve and prevent long-term sequelae caused by the deformed spinal curve and thorax [,]. Posterior spinal fusion (PSF) remains the mainstay of surgical treatment for curves exceeding 45° in the thoracolumbar region or 50° in the thoracic region []. However, conventional open scoliosis surgery (COSS) necessitates one long skin incision with extensive soft tissue dissection, which leads to substantial morbidity, cosmetic dissatisfaction, and psychological distress [-]. Minimally invasive scoliosis surgery (MISS) has been introduced to address these limitations of COSS in AIS. This encompasses vertebral body tethering via an anterior approach for motion preservation, and posterior MISS, which performs PSF through 2 or 3 small (3–4 cm) skin incisions [,]. Posterior MISS, in particular, offers advantages over COSS by minimizing soft tissue dissection and skin incisions while allowing for the application of established perioperative planning principles, such as the determination of the lowest instrumented vertebra (LIV) []. Previous studies have demonstrated that in flexible AIS with moderate-to-severe curves, posterior MISS achieves radiological outcomes comparable to COSS, along with benefits in perioperative management and cosmetic satisfaction []. However, limitations associated with the restricted surgical vision and space of mini-incisions—such as wound disruption, skipped pedicle screws even on the concave side, and technical difficulties in very severe curves—have been raised as concerns with posterior MISS []. The coin-hole technique of posterior MISS was devised to mitigate these risks []. By utilizing a tubular retractor at the miniincision site to protect soft tissues and expose targeted facet joints, this technique allows for pedicle screw insertion at all functional segments, thereby reducing the risk of complications such as wound disruption, surgical site infection, and rod dislodgement []. While this coin-hole technique has yielded complication rates comparable to COSS, its current indication is generally limited to moderate-to-severe curves (<80°) []. Nevertheless, in very severe cases of AIS where the curve remains flexible, posterior MISS may still be a feasible option as additional osteotomies are not required. However, it remains unclear whether this approach yields outcomes equivalent to those observed in flexible AIS with moderate-to-severe curves. Therefore, this study aims to investigate the feasibility and effectiveness of posterior MISS in patients with flexible AIS presenting with very severe curves exceeding 80°.