Prophylactic Spinal Cord Untethering in Children with Spinal Dysraphism Undergoing Thoracolumbar Fusion for Scoliosis.

BACKGROUND: It remains unclear whether spinal cord untethering is necessary to reduce the chances of neurologic decline in children with myelomeningocele and complex closed spinal dysraphism who undergo thoracolumbar fusion for scoliosis. We sought to determine the neurologic and functional outcomes of children with spinal dysraphism undergoing spinal fusion for scoliosis with and without prophylactic spinal cord untethering. METHODS: Retrospective, single-center review of patients with spinal dysraphism treated with thoracolumbar fusion over the last 10 years (2009-2019) with or without prophylactic spinal cord untethering. RESULTS: Seventeen patients with myelomeningocele and complex closed spinal dysraphism underwent spinal fusion for scoliosis. Mean age at time of surgery was 13.9 years. Prophylactic spinal cord untethering was performed in 8 of 17 (47%) patients. The change in Cobb angle after surgery was similar between the 2 groups (19.4° untethered vs. 19.9° no untethering). The ambulatory status was similar between the groups, with 37% of the untethered cohort and 44% of the non-untethered cohort being community or household ambulators. There were no changes in intraoperative motor or sensory evoked potentials in any patient during fusion surgery. No patient had a change in motor level or ambulatory status after scoliosis surgery. CONCLUSIONS: Our data suggest that prophylactic spinal cord untethering in children with spinal dysraphism undergoing thoracolumbar fusion for scoliosis may not be necessary in patients with moderate curvatures. Our conclusions are limited by the small sample size. A larger review of registry data may yield more powerful conclusions on the necessity of prophylactic spinal cord untethering in this patient population.

Nonoperative management of adolescent idiopathic scoliosis (AIS) using braces.

This review presents the state of the art according to the current evidence on nonoperative treatment for adolescent idiopathic scoliosis, focusing on bracing. The definition of braces for the treatment of adolescent idiopathic scoliosis and a short history are provided. The analysis includes biomechanics, types, existing classifications, indications for treatment, time of brace wear and weaning, adherence, three-dimensional modeling, use of ultrasound imaging for bracing, management of treatment, issue of immediate in-brace correction, and documentation of the outcomes usually assessed for brace treatment, including the quality-of-life issues. According to the current evidence, there are two randomized control trials in favor of bracing. There are insufficient data on the superiority of one brace over another, although it is possible to classify and grade braces for efficacy from nonrigid to rigid and very rigid. Nevertheless, there is consensus on patients' management on the need for teamwork focusing on adherence to treatment, acceptability, and family and patient involvement.

Biomechanical Effects of Thoracolumbosacral Orthosis Design Features on 3D Correction in Adolescent Idiopathic Scoliosis: A Comprehensive Multicenter Study.

STUDY DESIGN: Multicenter numerical study. OBJECTIVE: To biomechanically analyze and compare various passive correction features of braces, designed by several centers with diverse practices, for three-dimensional (3D) correction of adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: A wide variety of brace designs exist, but their biomechanical effectiveness is not clearly understood. Many studies have reported brace treatment correction potential with various degrees of control, making the objective comparison of correction mechanisms difficult. A Finite Element Model simulating the immediate in-brace corrective effects has been developed and allows to comprehensively assess the biomechanics of different brace designs. METHODS: Expert clinical teams (one orthotist and one orthopedist) from six centers in five countries participated in the study. For six scoliosis cases with different curve types respecting SRS criteria, the teams designed two braces according to their treatment protocol. Finite Element Model simulations were performed to compute immediate in-brace 3D correction and skin-to-brace pressures. All braces were randomized and labeled according to 21 design features derived from Society on Scoliosis Orthopaedic and Rehabilitation Treatment proposed descriptors, including positioning of pressure points, orientation of push vectors, and sagittal design. Simulated in brace 3D corrections were compared for each design feature class using ANOVAs and linear regressions (significance P ≤ 0.05). RESULTS: Seventy-two braces were tested, with significant variety in the design approaches. Pressure points at the apical vertebra level corrected the main thoracic curve better than more caudal locations. Braces with ventral support flattened the lumbar lordosis. Lateral and ventral skin-to-brace pressures were correlated with changes in thoracolumbar/lumbar Cobb and lumbar lordosis (r =- 0.53, r = - 0.54). Upper straps positioned above T10 corrected the main thoracic Cobb better than those placed lower. CONCLUSIONS: The corrective features of various scoliosis braces were objectively compared in a systematic approach with minimal biases and variability in test parameters, providing a better biomechanical understanding of individual passive mechanisms' contribution to 3D correction.

Emergency department on-call status for pediatric orthopaedics: a survey of the POSNA membership.

BACKGROUND: The emergency room on-call status of pediatric orthopaedic surgeons is an important factor affecting their practices and lifestyles and was last evaluated in 2006. METHODS: The entire membership of the Pediatric Orthopaedic Society of North America (POSNA) was surveyed in 2010 for information regarding their emergency room on-call status with 382 surveys returned of over 1000 e-mailed to members of POSNA. Detailed information about on-call coverage, support, and frequency was obtained in answers to 14 different questions. RESULTS: Compared with the prior survey in 2006, the 2010 survey indicated that a higher percentage of pediatric orthopaedic surgeons receive compensation for taking emergency room call; a higher percentage cover pediatric patients only when on-call; and accessibility to operating rooms in a timely manner for trauma cases, although limited, has improved for pediatric patients. Utilization of support staff to meet on-call trauma coverage demands, such as residents, physician's assistants, and nurse practitioners, is becoming more common. CONCLUSIONS: Concentration of pediatric orthopaedic trauma has increased the coverage demands on pediatric orthopaedists. This has resulted in a change in reimbursement strategies, and allocation of OR time and hospital staffing resources.

Development of a 3-Dimensional Back Contour Imaging System for Monitoring Scoliosis Progression in Children.

STUDY DESIGN: Control study. OBJECTIVES: To present a new surface topography system capable of taking 3-dimensional (3D) spine measurements, to establish baseline values for the measured parameters in a typically developing population, and to determine the intra-rater and inter-rater reproducibility of these parameters. SUMMARY OF BACKGROUND DATA: Cumulative exposure to radiation from diagnostic radiographs increases patient risk for cancer development. There is a need for noninvasive and non-radiographic tools to accurately and reproducibly measure spine deformity and track scoliosis progression. METHODS: We measured 10 typically developing subjects with the new Milwaukee Topography System, which is composed of 2 electromagnetic markers, an electronic processing unit, a handheld laser scanner, a software package, and a desktop computer. Two investigators separately scanned the same subjects multiple times, yielding a total of 4 scans per subject per investigator. We measured 17 3D back parameters in each scan. We performed a multivariate analysis of variances to test the hypothesis of no difference for all variables, measured intra-rater and inter-investigator reliability with intra-class correlation (ICC) coefficients, and calculated mean values. RESULTS: There were highly reproducible ICC values between investigators for 6 parameters (ICC > 0.75), moderate ICC values for 8 parameters (0.75 > ICC > 0.4), and poor ICC values for 3 parameters (ICC < 0.4), all at p < .05. Intra-investigator ICCs were moderate to excellent for almost all parameters. CONCLUSIONS: The Milwaukee Topography System can be used to monitor and measure 3D back contours in children. The 3D back parameters values measured in the typically developing population can be considered baseline values that can be compared with parameters measured in children with idiopathic scoliosis.

Insole-pressure distribution for normal children in different age groups.

BACKGROUND: In measuring plantar pressures during gait, earlier methods have used a platform system that does not take into account the interactions feet have with orthotics and shoe wearing. The purpose of the study was to provide normal insole plantar pressure parameter data during stance phase using the Pedar pressure insole system. METHODS: Twenty-nine normal children, age 6 to 16 years, were recruited and walked along the 25 m walkway at self-selected speeds. Patients were divided into 2 separate groups for statistical analysis--juniors (< 12 y old) and teenagers (> 13 y old). The pressure map was divided into 8 regions (masks) determined by anatomic landmarks and a total of 7 pressure parameters were analyzed of each mask. RESULTS: We did not detect significant differences in foot pressures between juniors and teenagers when regarding sex, or left and right feet for 7 parameters measured. CONCLUSIONS: This normative data will provide a basis with which to more accurately assess pediatric pathologic foot deformities and to distinguish dynamic foot deformities from anatomic foot deformities. THE LEVEL OF EVIDENCE: Level II.

MRI pathoanatomy study of congenital vertical talus.

BACKGROUND: Prior reports regarding the pathologic anatomy for congenital vertical talus have noted some disagreement as to which elements of the pathologic anatomy are consistently present. The purpose of his study is to evaluate the 3-dimensional morphologic changes and pathoanatomy of the congenital vertical talus using magnetic resonance imaging. METHODS: Nine patients with congenital vertical talus (ranging from 5 mo-11 y) underwent magnetic resonance imaging of both feet. A foot and ankle coil was used for the 1.5 T system. The protocol consisted of T1-weighted spin echo sequence image and T2-weighted fast spin echo sequence image in the sagittal, coronal, and axial planes. Slice thickness ranged from 3 to 4 mm with 0 to 1.0 mm interspace thickness. A descriptive analysis was performed based upon the T1-weighted image by physicians. RESULTS: At the level of the talonavicular joint, the navicular was seen significantly subluxed dorsally with associated wedging of the navicular. At the level of the calcaneocuboid joint, often there was a significant dorsal subluxation of the cuboid in relation to the calcaneus. Lateral obliquity of the calcaneocuboid joint could be present to varying degrees. The anterior calcaneus was significantly laterally displaced in relation to the talar head with an element of lateral translation and eversion of the calcaneus at the subtalar joint. Distal cavus at the cuneiform-first metatarsal joint was observed in 5 patients. CONCLUSIONS: This study suggests that there is significant pathology at the level of subtalar joint in congenital vertical talus. In addition to satisfactory reduction of the talonavicular joint, methods to ensure realignment of the calcaneus under the talus may be a crucial component of deformity correction and to prevent recurrence of deformity. LEVEL OF EVIDENCE: A Level III diagnostic study using normal pediatric foot anatomy in magnetic resonance imaging as a reference.

Gabapentin use in pediatric spinal fusion patients: a randomized, double-blind, controlled trial.

BACKGROUND: Gabapentin has opioid-sparing effects in adult surgical patients, but no reported studies have involved children and adolescents. In a double-blind, randomized, controlled trial, we examined whether gabapentin decreases postoperative opioid consumption for pediatric spinal fusion patients with idiopathic scoliosis. METHODS: Patients, aged 9 to 18 years, received preoperative gabapentin (15 mg/kg, treatment) or placebo. Anesthesia was standardized. After surgery, all patients received standardized patient-controlled analgesia opioid and continued on either gabapentin (5 mg/kg) or placebo 3 times per day for 5 days. Opioid use was calculated in mg/kg/time intervals. Pain scores and opioid side effects were recorded. RESULTS: Data from 59 patients (30 placebo and 29 gabapentin) did not differ in demographics. Total morphine consumption (mg/kg/h +/- SD) was significantly lower in the gabapentin group in the recovery room (0.044 +/- 0.017 vs 0.064 +/- 0.031, P = 0.003), postoperative day 1 (0.046 +/- 0.016 vs 0.055 +/- 0.017, P = 0.051), and postoperative day 2 (0.036 +/- 0.016 vs 0.047 +/- 0.019, P = 0.018). In addition, gabapentin significantly reduced first pain scores in the recovery room (2.5 +/- 2.8 vs 6.0 +/- 2.4, P < 0.001) and the morning after surgery (3.2 +/- 2.6 vs 5.0 +/- 2.2, P < 0.05), but otherwise pain scores were not significantly different. There were no differences in opioid-related side effects over the course of the study. CONCLUSION: Perioperative oral gabapentin reduced the amount of morphine used for postoperative pain after spinal fusion surgery, but not overall opioid-related side effects. Initial pain scores were lower in the treatment group. Perioperative use of gabapentin seems to be an effective adjunct to improve pain control in the early stages of recovery in children and adolescents undergoing spinal fusion.

Reliability of a functional classification system in the monitoring of patients with idiopathic scoliosis.

STUDY DESIGN: Patients with scoliosis from 1999 to 2001 were monitored using radiographs and the Quantec Spinal Imaging System (Quantec) to validate the Functional Classification System (FCS) developed at Children's Hospital of Wisconsin (CHW). OBJECTIVE: To determine the accuracy of the FCS. SUMMARY OF BACKGROUND DATA: The authors evaluated different noninvasive ways of evaluating the scoliotic spine. The FCS was developed as a means to predict the degree of scoliotic curve. METHODS: Consecutive scoliosis visits (543) seen at CHW between 1999 and 2001 for initial or follow-up examination were investigated; of them, 157 had an radiograph within 6 months of Quantec. Subjects were placed into groups based on Cobb Angles. FCS classifications were compared to Cobb angle groupings and calculated sensitivity and specificity. Pearson's correlation coefficient was calculated for 39 subjects. RESULTS: Sensitivity of the FCS for single curve groups ranged from 0.50 to 0.63 and specificity from 0.64 to 0.86. For double curve, both sensitivity and specificity ranged from 0.48 to 0.81. Pearson's correlation was statistically significant (r = 0.45, P < 0.05). CONCLUSIONS: Sensitivity, specificity, and Pearson's correlation coefficient reflect the reliability of the Quantec method. Therefore, the FCS can be considered as a reliable tool for monitoring the progression of scoliosis with reduced need of radiographs.

Severe osteomyelitis caused by Myceliophthora thermophila after a pitchfork injury.

BACKGROUND: Traumatic injuries occurring in agricultural settings are often associated with infections caused by unusual organisms. Such agents may be difficult to isolate, identify, and treat effectively. CASE REPORT: A 4-year-old boy developed an extensive infection of his knee and distal femur following a barnyard pitchfork injury. Ultimately the primary infecting agent was determined to be Myceliophthora thermophila, a thermophilic melanized hyphomycete, rarely associated with human infection, found in animal excreta. Because of resistance to standard antifungal agents including amphotericin B and caspofungin, therapy was instituted with a prolonged course of terbinafine and voriconazole. Voriconazole blood levels demonstrated that the patient required a drug dosage (13.4 mg/kg) several fold greater than that recommended for adults in order to attain therapeutic blood levels. CONCLUSION: Unusual pathogens should be sought following traumatic farm injuries. Pharmacokinetic studies may be of critical importance when utilizing antifungal therapy with agents for which little information exists regarding drug metabolism in children.

Correlation of foot radiographs with foot function as analyzed by plantar pressure distribution.

The goal of this study was to correlate radiographic measurements to the dynamic plantar pressure of the residual clubfoot. This was done by comparing radiographs and EMED plantar pressure results in 61 idiopathic clubfeet in 39 children at an average of 8 years after complete subtalar release. Radiographic measures were obtained using the standard method outlined by Simons, and pressure data were collected for eight regions of the foot. Pearson correlation analysis was performed and the most significant correlation was found between the calcaneal/first metatarsal angle in the lateral radiographic view (r = 0.72) and the midfoot contact area. In the anteroposterior view there was mild correlation between the talus/first metatarsal angle and both the peak pressure and plantar contact area. The results of this study indicate that radiographs used in concert with dynamic plantar pressure analysis will provide a more complete assessment of the corrected clubfoot.

Dynamic plantar pressure measurement for the normal subject: Free-mapping model for the analysis of pediatric foot deformities.

In measuring plantar pressures during gait, prior methods have divided the foot into five regions and neglected forefoot alignment as it is involved in intoeing and outtoeing. The authors' proposed free-mapping method divides the foot into nine regions and incorporates a pedobarograph foot progression angle. The purpose of the study was to provide normal pressure parameter data during stance phase using a free-mapping model. Sixty-six normal children, ages 6 to 16 years, were recruited and walked along the 5-m walkway at self-selected speeds. The mean and standard deviation for the plantar contact area, contact time, peak pressure, maximal mean pressure, pressure-time integral, force-time integral, instant of peak pressure, and instant of maximum force in nine foot regions are reported. These normative data will provide a basis with which assessment of foot deformities involved in clubfoot, pes planus, and cavus foot will be more accurately defined.

Reproducibility of spinal back-contour measurements taken with raster stereography in adolescent idiopathic scoliosis.

200 children with a mean age of 12.7 years were measured with the Quantec Spinal Image System (QSIS), which uses computerized raster stereography technology. The aim of the study was to assess the intraobserver reproducibility of QSIS metrics in scoliosis patients and to quantify the effect of postural sway on the measurements. Children were randomly assigned to 1 of 2 groups: Group 1 contained 198 subjects, having 3 digitized measurements of 1 scan; Group 2 contained 200 subjects, undergoing 3 separate QSIS scans with 1 measurenent of each scan. Random-effects variance components models were fit to each outcome variable of interest (subject, scan or measurement) separately for the single scan dataset and the 3 scan dataset. They revealed that data from Group 2 contained greater reliability than data from Group 1 (reliability > or = 80%). The reliability of these parameters was perfect if one performed 3 scans and 3 measurements per scan. Results demonstrate that the QSIS with 3 scans and 1 measurement yields reproducible data from mild idiopathic scoliosis patients and that postural sway has minimal effect on data reproducibility.

Effects of trunk position on back surface-contour measured by raster stereophotography.

A study of the contour of the surface of the back was conducted using the Quantec spinal image system (QSIS; raster stereophotography) and the Vicon 3-dimensional (3-D) motion analysis system with a plaster model of the scoliotic spine. With postural changes in 3 dimensions came alterations in the surface shape of the back. Most changes in QSIS parameters occurred in the coronal plane. The study showed that model 1, with 9 degrees of Q angle (similar to Cobb angle in the coronal plane) in right thoracolumbar scoliosis, altered 3-D metrics less than model 2 did, with 54 degrees of Q angle in scoliosis. The change in the position of the trunk in the transverse plane had a more significant impact on the QSIS parameters. Raster stereophotography has been used clinically to monitor curve progression. Changes in transverse rotation of the trunk correlate significantly with variations in Q angle and axial rotation. Clinicians using a raster stereophotograph system to assess scoliotic deformity need to control postural sway, as doing so results in more stable and reproducible measurements that can be used for clinical follow-up.