Use of Surgical Adjuvants Does Not Decrease Recurrence of Aneurysmal Bone Cysts in Surgical Intervention With Pediatric Patients.

BACKGROUND: Aneurysmal bone cysts (ABCs) are benign active tumors often requiring intralesional curettage with or without adjuvants. The primary aim of this study was to analyze whether recurrence is influenced by the use of surgical adjuvants in pediatric patients with ABCs. Secondary aims examined recurrence rates based on age, sex, and physeal contact. METHODS: A retrospective review was performed at a tertiary pediatric hospital from 2004 to 2020. Inclusion criteria consisted of patients treated surgically for histologically confirmed ABCs with a minimum of 6 months follow-up. Patients with treatment for a recurrent tumor or incomplete records were excluded. Patient demographics, location of the lesion, treatment technique, and incidence of recurrence were collected. Statistical analyses were performed using STATA. RESULTS: There were 129 patients (74 males and 55 females) with a mean age of 11.5 ± 4.1 years and an average follow-up of 29.0 ± 25.4 months. The most common locations for ABCs were the femur and tibia. Of the patients, 53.5% had tumors abutting the physis, 28.7% had no physeal contact, and 17.8% had insufficient imaging to evaluate physeal contact. Surgical adjuvants (high-speed burr, coagulation, liquid nitrogen, and/or hydrogen peroxide) were used in 91 of the 129 cases (70.5%). There was no significant difference in recurrence when comparing those who received an adjuvant and those who did not (25.3% vs 23.7%, P = 1.000). Physeal contact was also not significantly associated with recurrence ( P = 0.146). Finally, patients younger than 6 years old were significantly more likely to have recurrence compared with those 6 years old or older (66.7% vs 21.7%, P = 0.007). CONCLUSION: Our study found no association between the use of surgical adjuvants and the risk of recurrence after intralesional curettage for ABCs. Although our study did demonstrate that patients 6 years old or younger had an increased rate of recurrence, no significant association was found regarding physeal contact or sex. These data indicate that surgical adjuvant may not affect the recurrence rates of pediatric patients with ABCs. LEVEL OF EVIDENCE: Level III. This retrospective review compares rates of recurrence based on the choice of surgical adjuvant.

Coaching and Surgical Performance.

Surgical coaching is a form of mentoring that can improve surgical performance. While professional athletes have coaching their entire career, other professions, such as medicine, law, and education, are expected to manage their own improvement in performance over their careers. Methods of surgical coaching and the pros and cons of coaching to improve surgical performance and improve patient safety will be presented.

How and When to Transition to the Next Phase: Reflections.

With Americans living longer, many physicians and surgeons have extended their medical and surgical practice life beyond the traditional 65-year-old retirement age. As retirement is inevitable, planning for that eventuality, which in early practice years appears unnecessary, is in fact an exercise which will pay dividends at the time of retirement. Two senior orthopaedic surgeons provide insight on the 2 main issues concerning retirement: how to prepare for retirement while in active practice, and factors to consider as to the timing of that major life event.

Treatments and Sequelae of Pediatric Pathologic Proximal Femur Fractures Due to Benign Bone Cyst.

BACKGROUND: The proximal femur is a common location for pathologic fractures in children, yet there is little published information regarding this injury. The purpose of this study was to investigate the outcomes of pediatric pathologic proximal femur fractures due to benign bone tumors. METHODS: A retrospective review of patients treated for pathologic proximal femur fractures from 2004 to 2018 was conducted. Inclusion criteria were age below 18 years and pathologic proximal femur fracture secondary to a benign bone tumor. Patients were excluded if they had <1 year of follow-up. Medical charts and serial radiographs were reviewed for fracture classification, underlying pathology, treatment, complications, and time to fracture healing. RESULTS: A total of 14 patients were included. Mean age was 6±3 (3 to 11) years, and mean follow-up was 44±21 (22 to 86) months. Index treatment was spica casting in 9/14 (68%) patients, while 5/14 (32%) were treated with internal fixation. Of the 9 patients initially treated with casting, 22% (2/9) required repeat spica casting at a mean of 0.6 months after index treatment, 67% (6/9) required internal fixation at a mean of 20.3 months after index treatment, and 11% (1/9) did not require revision treatment. Eighty-eight percent (8/9) of patients treated with casting required revision treatment compared with 40% (2/5) of those treated with internal fixation (P=0.05). Nonunion occurred after 1 refracture, malunion with coxa vara occurred in 2 fractures, and the remaining 11/14 (84%) fractures had a union at a mean of 4.9±3.0 months All cases of malunion occurred in patients initially treated nonoperatively. There were 19 distinct complications in 10/14 (71%) patients. The incidence of any revision surgery was 64% (9/14). CONCLUSIONS: In this series, pediatric pathologic proximal femur fractures demonstrated prolonged time to union, high incidence of revision surgery (64%), and substantial complication rate (71%). In children with pathologic proximal femur fractures, treatment with internal fixation is recommended as this series showed a 78% failure rate of initial conservative management. LEVEL OF EVIDENCE: Level IV.

High Parental Anxiety Increases Narcotic Use in Adolescent Patients Following Spinal Fusion.

BACKGROUND: Parental mental status and behavior may influence postoperative recovery and the use of pain medication. The purpose of this study is to identify if parents with high anxiety are associated with prolonged narcotic use in adolescent patients following posterior spinal fusion surgery. Prolonged narcotic use in this study was defined as opioid use at their first postoperative visit. METHODS: AIS patients age 11 to 20 years undergoing posterior spinal fusion and a parent were prospectively enrolled. At the preoperative appointment, patients completed the Spence Children's Anxiety Scale and parents completed the State-Trait Anxiety Inventory. High parental anxiety was defined as 1 SD above the normative mean. At the first postoperative visit, patients were asked about medication use. RESULTS: A total of 58 patients (49 females and 9 males) were enrolled. Overall, 29% (17/58) of parents had a high general anxiety trait on the State-Trait Anxiety Inventory and 71% (41/58) had normal general anxiety. Of the patients whose parents had high general anxiety, 47% (8/17) were still taking narcotics at their first postoperative visit compared with 20% (8/41) of patients with normal anxiety parents (P=0.03). CONCLUSIONS: Patients with high general anxiety parents were more than twice as likely to still be on narcotics at their first postoperative visit. This information can be used to counsel families on the impact of anxiety on narcotic usage. LEVEL OF EVIDENCE: Level II-prognostic studies-investigating the effect of a patient characteristic on the outcome of the disease.

High Satisfaction in Adolescent Idiopathic Scoliosis Patients on Enhanced Discharge Pathway.

BACKGROUND: Recently, there have been several reports of using an enhanced discharge pathway following posterior spinal fusion (PSF) in patients with adolescent idiopathic scoliosis (AIS). No previous studies have prospectively examined patient satisfaction of patients with AIS using an enhanced discharge pathway. The purpose of this study was to evaluate patient satisfaction with an enhanced discharge pathway for PSF and whether patients felt that their length of stay was appropriate. METHODS: Patients with AIS undergoing PSF were prospectively enrolled. At their first postoperative clinic visit, patients were administered a survey regarding their experience. RESULTS: Of the 46 patients enrolled (mean age, 14 y), 1 was discharged on postoperative day (POD) 2, 33 were discharged on POD 3, 9 were discharged on POD 4, and 3 were discharged on POD 5. Eighty (37/46) of patients felt that they were discharged at an appropriate time, whereas 20% (9/46) felt they were discharged too early. Patients who felt they were discharged at an appropriate time (mean, 3.2 d) had a trend toward shorter stays than those who felt they were discharged too early (mean, 3.7 d). Overall patient satisfaction of hospital stay was high with a mean of 9 on a 10-point scale (range, 1 to 10). There was no correlation between length of stay and patient satisfaction (P=0.723). Patients who felt they were discharged early had a significantly higher mean FACES pain scores than those who felt they were discharged about right both as inpatients (mean, 4.8 vs. 3.4; P=0.0319) and at their first postoperative clinic visit (5.4 vs. 2.9; P=0.004). CONCLUSIONS: Eighty percent of patients with AIS who underwent PSF felt that the time of discharge was appropriate with an enhanced discharge pathway. There was no correlation between patient satisfaction and length of stay. LEVEL OF EVIDENCE: Level II.

Comparison of Ponte Osteotomies and 3-Column Osteotomies in the Treatment of Congenital Spinal Deformity.

BACKGROUND: Congenital spinal deformity (CSD) has traditionally been treated with 3-column osteotomies [hemivertebrectomy (HV) or vertebral column resection (VCR)] to address rigid deformities. Alternatively, multiple Ponte osteotomies (PO) may provide correction while minimizing risk. The purpose of this study was to compare safety and outcomes of patients undergoing surgical treatment for CSD with these 3 procedures. METHODS: Retrospective review of CSD patients treated with posterior spinal fusion between 1996 to 2013. Patients treated with multiple Ponte osteotomies (PO group) were compared with those managed with 3-column osteotomies (HV/VCR group). Patients with previous instrumentation, isolated cervical deformity, growing spine instrumentation, or <2 year follow-up were excluded. Deformity angular ratio (DAR) was calculated as curve magnitude divided by number of levels of the deformity. RESULTS: There were 49 patients [17 PO, 32 HV/VCR (26 HV, 6 VCR)]. For the PO group, mean age was 14 years, and they had an average of 4 ponte osteotomies and 11 levels fused. Mean total DAR was 25 and mean number of congenital anomalies was 1.8 in the PO group. The HV/VCR group had a mean age of 7 years and 5 levels fused. Mean total DAR was 28 and mean number of congenital anomalies was 2.1 in the HV/VCR group. Patients had a mean of 54.1% correction of coronal deformity in the PO group and 54.4% in the HV/VCR group (P=0.78). Signal changes were observed less frequently with PO (1/17) and HV (1/26) than with VCR (4/6), P=0.001. Revision rates were 17.6% (3/17) in the PO group and 37.5% (12/32) in the HV/VCR group (P=0.35). CONCLUSIONS: Patients with CSD and a mean total DAR of 25 treated with multiple PO and long fusions had correction comparable with the HV/VCR group. Patients treated with VCR had the highest incidence of signal changes and postoperative neurologic deficits. LEVEL OF EVIDENCE: Level III.

Sacral Alar Iliac (SAI) Screws Fail 75% Less Frequently Than Iliac Screws in Neuromuscular Scoliosis.

BACKGROUND: Despite recent popularity of sacral alar iliac (SAI) screws for fusion to the pelvis for neuromuscular scoliosis, there are little data regarding the failure rate of this technique compared with traditional modes of iliac fixation. Theoretical advantages of the SAI screws are obviating the need for a rod to iliac screw connector and a lower implant profile. The purpose of this study is to determine whether SAI screws have fewer failures than iliac screws in neuromuscular scoliosis. METHODS: Review of neuromuscular patients treated with posterior spinal fusion with pelvic fixation from 2004 to 2012 with minimum 2-year follow-up was conducted. Medical records and imaging studies were reviewed. Patients were divided into 2 groups based on the type of pelvic fixation (SAI or iliac screws), and implant failures were compared between the groups. RESULTS: A total of 101 patients were reviewed, including 55 patients with iliac screws and 46 patients with SAI screws. Implant failures included: disengagement of the rod to iliac screw connector (10%, 10/101), separation of screw head from screw shaft (4%, 4/101), and set screw disengagement (2%, 2/101). The SAI group had a lower implant failure rate (7%, 3/46) compared with the iliac screw group (24%, 13/55) (P=0.031). Rod to iliac screw connectors failed in 18% (10/55) of patients. There were significantly less surgical revisions in the SAI group (2%, 1/46) for pelvic screw prominence compared with the iliac screw group (11%, 6/55) (P=0.027). CONCLUSIONS: SAI screws had a lower rate of implant failure and revision surgery compared with iliac screws. If rod to screw connector failures are excluded, the failure rate of SAI screws of 6.5% (3/46) is similar to that of iliac screws 5.5% (3/55); therefore, the most important advantage of the SAI technique may be obviating the need for a screw to rod connector. LEVEL OF EVIDENCE: Level III.

Measurement Variability in the Evaluation of the Proximal Junction in Distraction-based Growing Rods Patients.

BACKGROUND: Proximal junctional kyphosis (PJK) is a known complication of spinal fusion and has been shown to occur in the setting of growing rod instrumentation. Previous studies have shown good reliability in measuring PJK in adolescent idiopathic scoliosis. METHODS: Four pediatric orthopaedic spine surgeons measured the proximal junction in 10 patients with growing rod instrumentation using 2 methods. In method 1, measurements were made from the inferior endplate of the upper instrumented vertebrae (UIV) to the superior endplate of 1 level above the UIV. In method 2, measurements were made from the inferior endplate 2 levels below the UIV to the superior endplate 2 levels above the UIV. These measurements were repeated 1 week later. RESULTS: Method 1 had an intraobserver variability of ±13.2 degrees and interobserver variability of ±21.6 degrees, whereas method 2 had an intraobserver variability of ±18.3 degrees and interobserver variability of ±20.7 degrees. CONCLUSIONS: Interobserver variability of PJK is >20 degrees. As PJK is commonly defined as >10 degrees of kyphosis above the UIV, measurement of PJK in patients with distraction-based growing rods on lateral radiographs has too much variability to be useful. LEVEL OF EVIDENCE: Level III-diagnostic studies.

Simple steps to minimize spine infections in adolescent idiopathic scoliosis.

BACKGROUND: To examine the surgical site infection (SSI) rates in patients undergoing posterior spinal fusion surgery for adolescent idiopathic scoliosis (AIS) after implementation of a change in antibiotic prophylaxis and intraoperative irrigation. METHODS: A retrospective review of all consecutive spinal fusions for AIS from 1996 to 2008 was performed. In 2003, 2 changes in our protocol were implemented: (1) routine antibiotic prophylaxis was changed from cefazolin alone to vancomycin and ceftazidime; (2) intraoperative irrigation technique was changed from bulb syringe to pulse lavage irrigation. We compared the rates of deep SSI requiring irrigation and debridement before institution of these changes (1996 to 2002) to the rates after these changes (2003 to 2008). RESULTS: Before the change in the antibiotic and lavage regimen, 261 spinal fusions were performed. Of these, 28/261 (11%) patients underwent irrigation and debridement for SSI. The most common infecting pathogen was coagulase-negative Staphylococcus aureus (47%). Between the years 2003 and 2008, 263 spinal fusions were performed. Only 2/263 (0.7%) patients underwent irrigation and debridement for SSI. This decrease in infection rate is highly significant (P<0.001). CONCLUSIONS: Routine use of vancomycin and ceftazidime and pulsatile lavage for posterior spinal fusion in AIS patients decreased the rates of postoperative infection by 10 fold. As 2 variables were changed, it is impossible to know the relative effect of each. However, as spine infections can be so devastating, and the potential risks of these changes are small, we recommend both the new antibiotic and irrigation protocol. LEVEL OF EVIDENCE: Level III.

Spinal Manifestations of Skeletal Dysplasia: A Practical Guide for Clinical Diagnosis.

Skeletal dysplasias are a group of genetic conditions defined by atypical bone or cartilage growth and development. Skeletal abnormalities include short stature, limb deformity, joint contracture, and spinal deformity. Over 90% of disorders have a known genetic mutation that can definitively determine the diagnosis. As patients may present with a primary spinal concern, a careful clinical and radiographic evaluation can allow the physician to develop a working diagnosis to guide additional evaluation. Spinal manifestations include scoliosis and kyphoscoliosis, cervical instability, cervical kyphosis, thoracolumbar kyphosis, spinal stenosis, and atypical vertebral body morphology. An understanding of the affected conditions, prevalence, and natural history of these radiographic findings aids the orthopaedic surgeon in establishing a diagnosis and guides appropriate orthopaedic care.

High long-term local control with sacrectomy for primary high-grade bone sarcoma in children.

BACKGROUND: Sacrectomy may offer curative potential for primary sarcomas of the sacrum. However, it is unclear whether and to what extent sacrectomies achieve local control. QUESTIONS/PURPOSE: We therefore determined the curative potential, walking ability, continence control, and quality of life for children after sacrectomy for primary bone sarcoma. METHODS: We retrospectively reviewed eight children with high-grade primary bone sarcomas treated with sacrectomy. The average age of the patients was 14 years (range, 4-18 years). There were six Ewing sarcomas and two osteosarcomas. Five patients underwent partial and three underwent total sacrectomies with all resection margins free of tumor. We recorded local and distant recurrences, functional (Musculoskeletal Tumor Society [MSTS] score) and oncologic outcome (survival), walking ability, bladder and bowel control, independence, and reintegration in society. The average followup was 80 months (range, 54-204 months). RESULTS: Six patients were alive without evidence of disease at last followup. Three patients had metastases develop and two died of disease 3 and 25 months postoperative. MSTS scores among survivors averaged 17.5 points (range, 5-25 points). Seven of the eight patients were able to ambulate, two independently. All initially were incontinent, but at last followup, two were continent and two were incontinent only under stress. Complications occurred in seven of eight, five of whom required additional surgery. CONCLUSION: Despite the high incidence of neurologic deficits and complications, sacrectomy achieved local control in patients with high-grade bone sarcomas. Our observations suggest long-term survival and adequate quality of life are possible in the pediatric population. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Spine problems in young athletes.

As the number of young people involved in sports activities increases, acute and chronic back pain has become more common. With a careful medical history and physical examination, along with the judicious use of imaging modalities, the causes of back pain can be correctly diagnosed and treated so that young athletes can quickly return to sports participation. Although most back pain in these young patients is muscular in origin, findings that should trigger increased concern include night pain, marked hamstring tightness, pain with lumbar spine hyperextension, or any neurologic finding. When recently developed vague back pain is present, a delay in radiographic imaging is warranted. With new back pain after trauma, AP and lateral radiographs of the symptomatic spinal area are indicated. CT, bone scans, and MRI should be reserved for special circumstances. Spondylolysis is the most common bony cause of back pain in young athletes. Spondylolysis can be treated with activity limitation, a specific exercise program, a thoracolumbar orthosis, and/or surgery. Treatment should be based on the amount of pain as well as the desire of the young athlete to continue in the sports activity that caused the pain. Other significant causes of back pain that require more extensive treatment in these young athletes include spondylolisthesis, lumbar disk disorders, and sacral stress fractures. It is anticipated that nearly all young athletes can return to sports activity after successful treatment. Even if surgical treatment is needed, return to all sports is expected, with the occasional exception of collision sports.

Surgical technique for balancing posterior spinal fusions to the pelvis using the T square of Tolo.

BACKGROUND: Correcting pelvic obliquity and improving sitting balance in neuromuscular scoliosis often requires fixation to the pelvis. We describe the use of a T square instrument to assist intraoperatively in evaluating the alignment of these curves and achieving balance in the coronal plane. METHODS: The T square instrument was constructed with a vertical limb perpendicular to 2 horizontal limbs in a T formation. At the conclusion of the instrumentation and preliminary reduction maneuvers, the T square was positioned with the horizontal limbs parallel to the pelvis and the vertical limb in line with the central sacral line. If the spine and pelvis were well balanced, fluoroscopic images demonstrated that the superior aspect of the vertical limb of the T square was crossing the vertebral body of T1. If this was not shown, then some combination of compression, distraction, or a change in the contouring of the rods was performed until this balance was achieved. RESULTS: In this series, we describe case examples in which the T square has been successfully used to aid in achieving balance in the coronal plane. This technique helps to overcome the challenges with positioning and imaging often encountered in managing these long, rigid curves. The T square is a useful adjunct in balancing posterior spinal fusions and evaluating the correction of pelvic obliquity in cases of neuromuscular scoliosis. CONCLUSIONS: This novel, yet simple, T square technique can be used for any method of posterior spinal fusion with lumbopelvic fixation to assist in the intraoperative evaluation and achievement of balance in the coronal plane and has become routine at our institution. LEVEL OF EVIDENCE: IV.

Pediatric Chance fractures: a multicenter perspective.

BACKGROUND: Chance fractures or flexion-distraction injuries of the spine are uncommon in children. Previous reports have been limited to isolated case reports or very small retrospective series. This is the largest series reported in the English literature. METHODS: This was a multicenter retrospective review of pediatric Chance fractures treated at 3 large level-1 pediatric trauma centers. We analyzed the demographics, causes, circumstances, treatment, complications, and clinical outcome of 35 patients younger than 18 years old with a Chance fracture. We hypothesize that surgical treatment provides the best results. RESULTS: There were 20 females and 15 males, with an average age of 9 years (range, 1.6 to 17 y). The most common level of injury was at L2 and L3 (20/35). Fifteen children (43%) had a neurological deficit at the time of injury and only 8 fully recovered. One patient deceased before formal orthopaedic treatment. Patients were treated at the discretion of the surgeon and the surgically treated group (20/34) had greater initial kyphotic deformity (22 degrees) than those treated nonoperatively (14/34; 11.4 degrees) and less posttreatment residual kyphotic deformity (3.5 vs. 20 degrees, respectively). The complication rate related to treatment was 26% (9/34) and most complications in the nonoperative group were related to progression of kyphosis whereas in the surgical group most complications are related to discomfort over the hardware (4 patients). Fifteen children (43%) had neurological deficit at presentation, 7 did not fully recover, for an incidence of permanent neurologic deficit of 10% among restrained patients versus 42% for unrestrained patients. Twenty-one patients (62%) had a good final clinical outcome defined by no chronic pain or neurologic deficit, this represented 45% good outcome in the nonoperative group compared with 84% in the operative group (NS). CONCLUSIONS: In this multicenter retrospective study, surgical treatment of Chance fractures in children seems to produce better clinical outcome, the appropriate use of restraints reduce the incidence of definitive neurologic deficit. LEVEL OF EVIDENCE: Level 3, comparative study.

Using a dedicated spine radiology technologist is associated with reduced fluoroscopy time, radiation dose, and surgical time in pediatric spinal deformity surgery.

STUDY DESIGN: Retrospective comparative study OBJECTIVES: The goal of this study was to investigate fluoroscopy time and radiation exposure during pediatric spine surgery using a dedicated radiology technologist with extensive experience in spine operating rooms. Repetitive use of intraoperative fluoroscopy during posterior spinal fusion (PSF) exposes the patient, surgeon, and staff to radiation. METHODS: Retrospective review was conducted on patients with posterior spinal fusion (PSF) of ≥ 7 levels for adolescent idiopathic scoliosis (AIS) at a pediatric hospital from 2015 to 2019. Cases covered by the dedicated radiology technologist (dedicated group) were compared to all other cases (non-dedicated group). Surgical and radiologic variables were compared between groups. RESULTS: 230 patients were included. 112/230 (49%) were in the dedicated group and 118/230 (51%) were in the non-dedicated group. Total fluoroscopy time was significantly reduced in cases with the dedicated technologist (46 s) compared to those without (69 s) (p = 0.001). Radiation dose area product (DAP) and air kerma (AK) were reduced by 43% (p < 0.001) and 42% (p < 0.001) in the dedicated group, respectively. The dedicated group also had reduced total surgical time (4.1 vs. 3.5 h; p < 0.001) and estimated blood loss (447 vs. 378 cc (; p = 0.02). Multivariate regression revealed that using a dedicated radiology technologist was independently associated with decreased fluoroscopy time (p = 0.001), DAP (p < 0.001), AK (p < 0.001), surgical time (p < 0.001), and EBL (p = 0.02). CONCLUSIONS: In AIS patients undergoing PSF, using a dedicated radiology technologist was independently associated with significant reductions in fluoroscopy time, radiation exposure, surgical time, and EBL. This adds to the growing body of research demonstrating that the experience level of the team-not just that of the surgeon-is necessary for optimal outcomes. LEVEL OF EVIDENCE: III.

Scoliosis-specific exercises: A state of the Art Review.

Scoliosis-specific exercises are prescribed and used by many centers either primarily or as an adjunct to other treatment methods for adolescent idiopathic scoliosis of mild to moderate severity. These methods are often used in Europe and are being used in the United States with increasing frequency. There are few publications about these methods in the spine or orthopedic literature. We have performed a review of the relevant literature from the PubMed database to evaluate the evidence for effectiveness of these treatments. We found no studies that provide valid evidence that an exercise method prevents progression of AIS (adolescent idiopathic scoliosis) in patients during their peak growth period. We report our review of selected relevant efforts and provide a description of many of the available treatment programs.

Side Plank Pose Exercises for Adolescent Idiopathic Scoliosis Patients.

BACKGROUND: Fishman et al. reported that side plank poses asymmetrically strengthened the convex side of the curve and decreased primary Cobb angle by 49% among compliant patients with adolescent idiopathic scoliosis (AIS). METHODS: AIS patients with curves of 10° to 45° were randomized into the front plank (control) or side plank group. The side plank was performed with their curve convex down. A weekly survey monitored compliance, defined by completing poses 4 or more times a week. RESULTS: A total of 64 patients were enrolled; 34% (22 of 64) of patients (mean age = 13 years) were compliant. In the control group, there were 11 compliant patients with 6 undergoing brace treatment. At enrollment, they had a mean Cobb angle of 30° (range: 14°-40°) and mean scoliometer reading of 13°. At 6 months, they had a mean Cobb angle of 30° (range: 14°-42°) and mean scoliometer of 12°. In the side plank group, there were 11 compliant patients with 5 undergoing brace treatment. At enrollment, they had a mean Cobb angle of 32° (range: 21°-44°) and mean scoliometer reading of 12°. At 6 months, they had a mean Cobb angle of 31° (range: 17°-48°) and a mean scoliometer reading of 13°. There were no significant changes in either the control or side plank group in regards to primary Cobb angle (control: P = .53, side plank: P = .67) or scoliometer (control: P = .22, side plank: P = .45). CONCLUSION: There were no significant changes in primary Cobb angle or scoliometer after 6 months of side plank exercises. In contrast to a prior study, there was no improvement in curve magnitude in AIS patients performing side plank exercises.

Aprotinin in pediatric neuromuscular scoliosis surgery.

Reduction of blood transfusions in patients with neuromuscular scoliosis can decrease potential complications such as immune suppression, infection, hemolytic reaction and viral transmission. Aprotinin (Trasylol), Bayer), an antifibrinolytic, has proven to be effective in reducing blood loss in cardiac and liver surgery, but little data exists in patients undergoing spinal fusion for neuromuscular scoliosis. The purpose of this study was to evaluate the safety and efficacy of aprotinin in pediatric neuromuscular scoliosis patients undergoing spinal fusion. The medical records of all patients undergoing initial spinal fusions for neuromuscular scoliosis between January 1999 and March 2003 were reviewed to determine demographic data, perioperative data, wound drainage and number of transfusion required. Cases were compared to a matched group of historical controls. We had 14 patients in the aprotinin group and 17 in the control group. Total blood loss in the aprotinin group was significantly lower compared to the control group (715 vs. 2,110 ml; P = 0.007). Significantly less blood loss occurred in the aprotinin group when blood loss per kilogram was evaluated as well (23 vs. 60 ml/kg, respectively; P = 0.002). Intra-operative packed red blood cell (PRBC) transfusions were also significantly lower in the aprotinin group (1.25 vs. 3.16 units; P = 0.001). No clinical evidence of anaphylaxis, deep vein thrombosis (DVT) or renal failure was observed in the aprotinin group. After considering the price of drug therapy, operating room time, and the cost of blood products, the use of aprotinin saved an average of $8,577 per patient. In our series, the use of aprotinin resulted in decreased blood loss and a decreased rate of transfusions in children with neuromuscular scoliosis undergoing extensive spinal fusion. At out institution, the use of aprotinin is safe and cost effective for patients with neuromuscular scoliosis.

Preventing Distal Junctional Kyphosis by Applying the Stable Sagittal Vertebra Concept to Selective Thoracic Fusion in Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Multicenter retrospective review. OBJECTIVE: To assess the effectiveness of using the stable sagittal vertebra (SSV) for selecting the lowest instrumented vertebrae (LIV) to prevent distal junctional kyphosis (DJK) in selective thoracic fusions. SUMMARY OF BACKGROUND DATA: Cho et al. reported that including the SSV in a fusion decreased the rate of DJK in thoracic hyperkyphosis. METHODS: A retrospective review was performed of patients from two pediatric hospitals with adolescent idiopathic scoliosis who underwent selective posterior thoracic fusion with the LIV at L2 or above from 2000 to 2012. Patients with less than 2 years' follow-up were excluded. The primary outcome measure was DJK, defined radiographically as ≥10° between the superior end plate of the LIV and the inferior end plate of the vertebra below on a standing lateral radiograph. We investigated the SSV, which was defined as the vertebral level at which 50% of the vertebral body was in front of the posterior sacral vertical line (PSVL) on a standing lateral radiograph. This particular definition was referred to as SSV. RESULTS: A total of 113 patients met the inclusion criteria. Mean age was 14.4 years. Mean Cobb angle was 58°. The overall rate of DJK was 7% (8/113). When the LIV was superior to SSV, the rate of DJK was 17% (8/46) versus 0% (0/67) when the LIV was at or inferior to SSV (p=.01). The rates of DJK for patients with the LIV one, two, and three levels above SSV were 17% (4/24), 7% (1/14), and 43% (3/7), respectively. There was no significant association between preoperative or postoperative maximum kyphosis, thoracic kyphosis, thoracolumbar kyphosis, pelvic incidence, sagittal balance or coronal balance, and development of DJK. CONCLUSION: Although LIV selection is complex, choosing the LIV at or below the SSV is a simple rule that minimizes the risk of DJK. LEVEL OF EVIDENCE: Level IV.