Rib-on-Pelvis Deformity and Reported Pain in Neuromuscular Early-Onset Scoliosis.

BACKGROUND: Neuromuscular early-onset scoliosis (N-EOS) often presents with a long sweeping thoracolumbar scoliosis and pelvic obliquity. With severe pelvic obliquity, the ribs come into contact with the high side of the pelvis, termed rib-on-pelvis deformity (ROP). The goal of this study is to evaluate whether ROP is associated with reported pain and other health-related quality of life (HRQOL) measures. We hypothesize that ROP is associated with increased pain and negative HRQOL. METHODS: A multicenter international registry was queried for all nonambulatory patients with N-EOS from 2012 to 2022. Both surgical and nonsurgical patients were included. ROP was classified as a binary radiographic assessment of preoperative (surgical patients) and most recent follow-up (nonsurgical patients) upright radiographs. Reported pain and other HRQOL measures were assessed through the 24-Item Early Onset Scoliosis Questionnaire (EOSQ-24). Patients with nonupright radiographs or EOSQ-24 questionnaires and corresponding radiographs >4 months apart were excluded. RESULTS: Totally, 225 patients (8.4±3.1 y, 55% female) were included. The median major curve was 63.3 (IQR: 40.6 to 81.2) degrees and median pelvic obliquity was 15.5 degrees (IQR: 8.8 to 26.4). Eighty-three patients (37%) had ROP. ROP was associated with both frequency (P<0.001) and severity (P<0.001) of pain. ROP was associated with worse general health (P=0.01), increased difficulty with vocalization (P=0.02), increased frequency of shortness of breath (P=0.002), and increased difficulty sitting upright (P=0.04). Regarding overall EOSQ-24 domains, ROP was associated with worse general health, pain/discomfort, pulmonary function, and physical function (P<0.01). In a subanalysis of 76 patients who underwent surgical intervention with at least 2 years of follow-up, patients with preoperative ROP experienced significantly greater improvements in both frequency (P=0.004) and severity (P=0.001) of pain than the patients without preoperative ROP at 2 years postoperatively. CONCLUSIONS: The overall incidence of ROP in N-EOS is about 37%. ROP is associated with greater pain and worse HRQOL through the EOSQ-24 questionnaire. Furthermore, these patients experienced a greater reduction in pain after surgery. Clinicians and parents must be aware that ROP is possibly a pain generator, but responds positively to surgical intervention. LEVEL OF EVIDENCE: Level III.

Baclofen Pump Use: Complications After Growth-friendly Instrumentation for Early-onset Scoliosis.

BACKGROUND: Patients with early-onset scoliosis (EOS) and spasticity may receive treatment with an intrathecal baclofen pump. We assessed how baclofen pumps are associated with the odds of complications and secondary interventions after growth-friendly (GF) spine surgery for EOS and analyzed infectious complications within the pump cohort. METHODS: Using a prospectively maintained, international multicenter database, we studied patients with neuromuscular EOS with baclofen pumps who underwent GF spine surgery from 2002 through 2019 (n=25). Baclofen pumps were implanted before GF instrumentation in 18 patients, during in 2 patients, and after in 5 patients. Patients with existing pumps at initial GF spine surgery were matched 1:3 with 54 patients (control group) without pumps according to treatment center, year of surgery, diagnosis, surgery type, and preoperative curve magnitude. Univariate analysis and multivariate logistic regression were performed to compare complications and secondary interventions between the 2 cohorts. RESULTS: Patients with baclofen pumps had 4.8 times the odds [95% confidence interval (CI): 1.5-16] of experiencing any complication within 1 year after initial GF spine surgery compared with controls. During mean follow-up of 6.9±4.3 years, they had 4.7 times the odds (95% CI: 1.3-16) of deep surgical site infection and 5.6 times the odds (95% CI: 1.2-26) of spinal rod removal after any complication. Differences in rates of mechanical complication, such as rod migration and breakage, were nonsignificant between the 2 groups. For the 9 patients (50%) with pumps who experienced infections, the most common microorganisms were Staphylococcus aureus (4 patients) and Pseudomonas aeruginosa (2). The pump/catheter was revised or removed, in addition to antibiotic therapy or surgical irrigation and debridement, in 2 patients. CONCLUSIONS: Among patients with neuromuscular EOS, those with baclofen pumps are much more likely to experience complications within 1 year after GF spine surgery. They are also more likely to have deep surgical site infections, with S. aureus and P. aeruginosa being the most common causative organisms, and to require spinal rod removal. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Uncorrected Pelvic Obliquity Is Associated With Worse Health-related Quality of Life (HRQoL) in Children and Their Caregivers at the End of Surgical Treatment for Early Onset Scoliosis (EOS).

BACKGROUND: While largely of concern in nonambulatory patients, pelvic obliquity (PO) can be found in many patients with early onset scoliosis (EOS) and may remain following surgery. However, its association with health-related quality of life (HRQoL) in children and their caregivers at the end of treatment is not well understood. The purpose of this study was to investigate the association between residual PO and HRQoL in children and their caregivers at the end of surgical treatment in ambulatory patients with EOS. METHODS: In this retrospective cohort study, a multicenter EOS registry was queried to identify ambulatory patients who underwent definitive posterior spinal fusion (PSF) from 2012 to 2019. Patients with fusions extending to the pelvis were excluded. PO was measured at least 1 year following PSF. HRQoL, Parental Burden, Financial Burden, and Satisfaction were assessed through the 24-Item Early Onset Scoliosis Questionnaire (EOSQ-24) also at a minimum of 1 year following PSF. RESULTS: A total of 155 patients (12.5±2.1 y, 73.5% female) were included. Etiology distribution was 30.3% congenital, 12.9% neuromuscular, 21.3% syndromic, and 35.5% idiopathic. In congenital patients, those with residual PO >8 degrees had worse Satisfaction by 23.2 points compared with those with PO ≤8 degrees. In neuromuscular patients, those with residual PO >7 degrees had worse HRQoL by 16.1 points and Parental Burden by 22.3 points compared with their counterparts. In syndromic patients, those with residual PO >8 degrees had worse HRQoL by 14.8 points, Parental Burden by 16.4 points, and Satisfaction by 21.2 points compared with their counterparts. In idiopathic patients, those with >9 degrees of residual PO had worse HRQoL by 15.0 points and Financial Burden by 26.8 points compared with their counterparts. CONCLUSIONS: Remaining PO at the end of surgical treatment is associated with worse HRQoL in ambulatory children and their caregivers. These results suggest that correction of PO should remain a primary goal of treatment in patients with EOS undergoing surgery. LEVEL OF EVIDENCE: Level II-multicenter retrospective cohort study investigating prognosis.

Best Practice Guidelines for Surgical Site Infection in High-risk Pediatric Spine Surgery: Definition, Prevention, Diagnosis, and Treatment.

BACKGROUND: Prior "best practice guidelines" (BPG) have identified strategies to reduce the risk of acute deep surgical site infection (SSI), but there still exists large variability in practice. Further, there is still no consensus on which patients are "high risk" for SSI and how SSI should be diagnosed or treated in pediatric spine surgery. We sought to develop an updated, consensus-based BPG informed by available literature and expert opinion on defining high-SSI risk in pediatric spine surgery and on prevention, diagnosis, and treatment of SSI in this high-risk population. MATERIALS AND METHODS: After a systematic review of the literature, an expert panel of 21 pediatric spine surgeons was selected from the Harms Study Group based on extensive experience in the field of pediatric spine surgery. Using the Delphi process and iterative survey rounds, the expert panel was surveyed for current practices, presented with the systematic review, given the opportunity to voice opinions through a live discussion session and asked to vote regarding preferences privately. Two survey rounds were conducted electronically, after which a live conference was held to present and discuss results. A final electronic survey was then conducted for final voting. Agreement ≥70% was considered consensus. Items near consensus were revised if feasible to achieve consensus in subsequent surveys. RESULTS: Consensus was reached for 17 items for defining high-SSI risk, 17 items for preventing, 6 for diagnosing, and 9 for treating SSI in this high-risk population. After final voting, all 21 experts agreed to the publication and implementation of these items in their practice. CONCLUSIONS: We present a set of updated consensus-based BPGs for defining high-risk and preventing, diagnosing, and treating SSI in high-risk pediatric spine surgery. We believe that this BPG can limit variability in practice and decrease the incidence of SSI in pediatric spine surgery. LEVEL OF EVIDENCE: Not applicable.

Male High School Students' Perceptions of Nursing as a Professional Career Choice: Nursing Pathway Project.

AIM: The aim of this study was to understand male high school students' perceptions of nursing as a professional career choice. BACKGROUND: Nursing is predominantly female, with male nurses accounting for less than 10 percent of the nursing workforce. METHOD: A 32-item descriptive survey that contained demography items and constructs of the theory of planned behavior was administered to 820 high school students from a large Pacific Northwest school district. RESULTS: Male students scored higher (less positive) relative to female students on all scales. When gay and bisexual male students were compared to female students, there was no statistically significant difference. Gay and bisexual male students scored significantly lower (more positive) than straight male students. CONCLUSION: Self-identified female individuals and self-identified gay and/or bisexual male individuals have a more positive perception of the nursing profession than other self-identified male individuals. Nurse educators should work with high schools, schools of nursing, and nursing professional organizations to implement strategies to recruit male high school students.

UK Higher Education staff experiences of moral injury during the COVID-19 pandemic.

Jonathan Shay argued that social, relational, and institutional contexts were central to understanding moral injury and conceptualised moral injury as a normative response to the betrayal of an individual's understanding of what is right by a more senior/authoritative "other". Using the conceptual lens of moral injury, this paper investigates academic staff experiences of HE during the COVID-19 pandemic and explores the rapid transition back to face-to-face teaching that took place in autumn 2020. To collect data, we used an online survey that opened in January 2021 and ran until the end of March 2021. A total of 663 complete questionnaires were received across the survey period. The questionnaire was comprised of ten topic-related questions, each of which included follow-up sub-questions and also invited participants to write in additional information. The majority of participants felt that during the course of the COVID-19 pandemic, they had acted in ways that put their own health and wellbeing at risk. Of those who had acted in ways that put their health and wellbeing at risk, they believed that their senior management were the most responsible for them acting in such ways, followed by the UK government. Qualitative data showed a systemic absence of leadership in the sector during the time, a sense of betrayal of staff and students by senior management and the government, and feelings of compulsion to act in ways which put lives at risk. On the basis of these results, we argue that there could be synergies between the situation facing healthcare staff and academics during the pandemic. Many of the experiences of HE academic staff during the pandemic reported to us in this research are resonant with the concepts of betrayal and moral injury and resulted in affective responses which we understand here in relation to feelings of guilt, shame, and anger, leading ultimately to poor mental health and wellbeing. This paper discusses implications for the HE sector going forward.

What Are the Indications for Spinal Fusion Surgery in Scheuermann Kyphosis?

BACKGROUND: Surgical indications for Scheuermann kyphosis are variable. We sought to evaluate the characteristics of patients undergoing operative versus nonoperative treatment of Scheuermann kyphosis to better understand current practices and the factors which contribute to the decision for surgical management. METHODS: Multicenter prospective cohort study. We evaluated consecutive patients presenting with Scheuermann kyphosis. Patients underwent either surgical or nonoperative management according to surgeon and patient discretion. Preoperative patient-reported outcome measures (Scoliosis Research Society and Spinal Appearance Questionnaire scores), demographics, and radiographic characteristics were assessed. RESULTS: Overall, 150 patients with Scheuermann kyphosis were enrolled, with 77 choosing nonoperative treatment and 73 treated operatively. Compared with the nonoperative cohort, patients treated operatively were older (16.3±2.0 vs. 15.1±2.2, P=0.0004), and had higher body mass index (26.3±7.2 vs. 22.7±6.5, P=0.003), had greater T2-T12 kyphosis (71±14 degrees vs. 61±12 degrees, P<0.001), increased pelvic incidence (46 vs. 41 degrees, P=0.03) and pelvic tilt (10 vs. 3 degrees, P=0.03). There was no detected difference in maximal sagittal Cobb angle in the operative versus nonoperative patients (73±11 vs. 70±12 degrees, P=0.11). Functionally, the operative patients had worse Scoliosis Research Society pain scores (3.7±0.9 vs. 4.1±0.7, P=0.0027) and appearance scores (2.9±0.7 vs. 3.4±0.8, P <0.0001). CONCLUSIONS: Patients undergoing surgical management of Scheuermann disease were more likely to have large body mass index and worse pain scores. Other factors beyond radiographic measurement likely contribute to the decision for surgical management of Scheuermann kyphosis. LEVEL OF EVIDENCE: Level II.

Compliance With a Comprehensive Antibiotic Protocol Improves Infection Incidence in Pediatric Spine Surgery.

BACKGROUND: A multidisciplinary task force, designated Target Zero, has developed protocols for prevention of surgical site infection (SSI) for spine surgery at our institution. The purpose of this study was to evaluate how compliance with an antibiotic bundle impacts infection incidences in pediatric spine surgery. METHODS: After institutional review board approval, a consecutive series of 511 patients (517 procedures) who underwent primary spine procedures from 2008 to 2012 were retrospectively reviewed to identify patients who developed SSI. Patients were followed for a minimum of 90 days postoperatively. Compliance data were collected prospectively in 511 consecutive patients and a total of 517 procedures. Three criteria were required for antibiotic bundle compliance: appropriate antibiotics completely administered within 1 hour before incision, antibiotics appropriately redosed intraoperatively for blood loss and time, and antibiotics discontinued within 24 hours postoperatively. A multivariable logistic regression analysis was used to test the association between compliance and the development of an infection. RESULTS: Overall antibiotic bundle compliance rate was 85%. After adjusting for risk category, estimated blood loss, and study year, the likelihood of an infection was increased in the noncompliant group compared with the compliant group (adjusted odds ratio: 3.0, 95% CI, 0.96-9.47, P=0.0587). When expressed as the number needed to treat, strict adherence to antibiotic bundle compliance prevented 1 SSI within 90 days of surgery for every 26 patients treated with the antibiotic bundle. Reasons for noncompliance included failure to infuse preoperative antibiotics 1 hour before incision (10.3%), failure to redose antibiotics intraoperatively based on time or blood loss (5.5%), and failure to discontinue antibiotics within 24 hours postoperatively (1.9%). CONCLUSIONS: Compliance with a comprehensive antibiotic protocol can lead to meaningful reductions in SSI incidences in pediatric spine surgery. Institutions should focus on improving compliance with prophylactic antibiotic protocols to decrease SSI in pediatric spine surgery. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Intrathecal Morphine Versus Extended-Release Epidural Morphine for Postoperative Pain Control in Pediatric Patients Undergoing Posterior Spinal Fusion.

BACKGROUND: Posterior spinal fusion for scoliosis is one of the most painful elective pediatric surgeries. Good postoperative pain control allows early ambulation and return of ability to tolerate oral intake. Options for analgesia in this patient population are suboptimal. We hypothesized that extended-release epidural morphine (EREM) would provide better pain control and less adverse effects compared to intrathecal (IT) morphine. METHODS: The primary outcome was total IV morphine consumption during 0-48 hours postoperatively. Secondary outcomes included time until first patient-controlled analgesia (PCA) demand, pain scores, and adverse opioid effects. After institutional review board approval, 71 subjects undergoing posterior spinal fusion for idiopathic scoliosis completed the study. The subjects were randomly allocated to 7.5 µg/kg IT morphine or 150 µg/kg EREM. The final IT morphine and EREM groups contained 37 and 34 subjects, respectively. Postoperative pain was treated with morphine PCA, ketorolac, oral oxycodone, and acetaminophen. Morphine consumption, pain scores, nausea and vomiting, pruritus, and respiratory depression were measured every 4 hours. Parents completed a caregiver questionnaire about their child's pain control regimen after the first postoperative day. RESULTS: There was no difference in total morphine consumption over the first 48 hours between subjects in the EREM and IT morphine groups: median (range) 42.2 (5.5-123.0) and 34.0 (4.5-128.8) mg, respectively (P = .27). EREM and IT morphine groups had no difference in time until first PCA demand. Pain scores were no different between the groups from 8 to 24 hours after surgery. Compared to IT morphine, EREM subjects had lower pain scores from 28 to 36 hours after surgery. The reported incidence of pruritus was lower in the EREM subjects. CONCLUSIONS: There was no difference in total morphine consumption or time until first PCA demand between the EREM and IT morphine groups. EREM provides a longer duration of analgesia after posterior spinal fusion for scoliosis and may be associated with less opioid-induced pruritus.

Variation in 60-day Readmission for Surgical-site Infections (SSIs) and Reoperation Following Spinal Fusion Operations for Neuromuscular Scoliosis.

BACKGROUND: Readmission for surgical-site infection (SSIs) following spinal fusion for NMS impacts costs, patient risk, and family burden; however, it may be preventable. The purpose of this study was to examine variation in hospital performance based on risk-standardized 60-day readmission rates for SSI and reoperation across 39 US Children's Hospitals. METHODS: Retrospective cohort study using the Pediatric Health Information Systems (PHIS) database involving children aged 10 to 18 years with ICD9 codes indicating spinal fusion, scoliosis, and neuromuscular disease discharged from 39 US children's hospitals between January 1, 2007 and September 1, 2012. Readmissions within 60 days for SSI were identified based on the presence of ICD9 codes for (1) infectious complication of device or procedure, or (2) sepsis or specific bacterial infection with an accompanying reoperation. Logistic regression models accounting for patient-level risk factors for SSI were used to estimate expected (patient-level risk across all hospitals) and predicted (weighted average of hospital-specific and all-hospital estimates) outcomes. Relative performance was determined using the hospital-specific predicted versus expected (pe) ratios. RESULTS: Average volume across hospitals ranged from 2 to 23 fusions/quarter and was not associated with readmissions. Of the 7560 children in the cohort, 534 (7%) were readmitted for reoperation and 451 (6%) were readmitted for SSI within 60 days of discharge. Reoperations were associated with an SSI in 70% of cases. Across hospitals, SSI and reoperation rates ranged from 1% to 11% and 1% to 12%, respectively. After adjusting for age, sex, insurance, presence of a gastric tube, ventriculoperitoneal shunt, tracheostomy, prior admissions, number of chronic conditions, procedure type (anterior/posterior), and level (>9 or <9 vertebrae), pe ratios indicating hospital performance varied by 2-fold for each outcome. CONCLUSIONS: After standardizing outcomes using patient-level factors and relative case mix, several hospitals in this cohort were more successful at preventing readmissions for SSIs and reoperations. Closer examination of the organization and implementation of strategies for SSI prevention at high-performing centers may offer valuable clues for improving care at lower performing institutions. LEVEL OF EVIDENCE: Level III.

Do Intraoperative LIV-Tilt and Disk Angle Remain Stable at 2-year Follow-up Compared With Upright Radiographs in Patients With Idiopathic Scoliosis?: A Retrospective Cohort Study.

STUDY DESIGN: This study was a retrospective chart and radiographic review. OBJECTIVE: The aim of this study was to determine if lowest instrumented vertebra (LIV) tilt and disk wedging measured intraoperatively correlated to their respective values on standing radiographs at intermediate follow-up. SUMMARY OF BACKGROUND DATA: No guidelines exist regarding an acceptable intraoperative LIV-tilt. MATERIALS AND METHODS: After IRB approval, a consecutive series of patients with adolescent idiopathic scoliosis (AIS) and structural lumbar curves treated with posterior spinal fusion (PSF) at a single institution between 2007 and 2010 was identified. A total of 163 patients with AIS underwent PSF during this time period. Seventeen patients had fusion of structural lumbar curves with adequate imaging and a minimum 2-year follow-up. The LIV-tilt and disk angle below the LIV was measured on the preoperative standing, intraoperative supine fluoroscopy and postoperative standing radiographs, and coronal balance was measured on the preoperative and postoperative standing radiographs using a standardized method separately by 2 authors. RESULTS: The curve distribution was as follows: Lenke 3 (29%), Lenke 5 (47%), and Lenke 6 (24%). There was agreement on radiographic measurements between the 2 authors with a correlation coefficient of 0.98 for coronal balance, 0.91 for LIV-tilt, and 0.65 for disk angle. LIV-tilt improved from 19.4 degrees preoperatively to 3.6 degrees intraoperatively. At minimum 2-year follow-up, LIV had on average progressed to 8.6 degrees. The disk angle improved from 5.4 degrees preoperatively to 2.5 degrees intraoperatively. This improvement was maintained at 2 years (2.8 degrees). Coronal balance also improved during the postoperative period from 17.9 mm immediately following surgery to 11.1 mm at the last follow-up. CONCLUSIONS: Compared with prone intraoperative fluoroscopic images, disk wedging below LIV remains stable at 2 years postsurgery on standing radiographs in patients with AISundergoing PSF, including structural lumbar curves, whereas LIV-tilt improvement is not maintained. Intraoperative fluoroscopy provides a reliable prediction of disk wedging below LIV, 2 years after surgery on standing radiographs.

Are routine postoperative radiographs necessary during the first year after posterior spinal fusion for idiopathic scoliosis? A retrospective cohort analysis of implant failure and surgery revision rates.

BACKGROUND: Radiographs are routinely obtained at postoperative visits during the first year after posterior spinal fusion (PSF) for idiopathic scoliosis (IS). The goal of this study was to determine how often radiographic findings change postoperative care. METHODS: A total of 227 consecutive patients aged 10 to 21 years who underwent surgery for IS at our institution from 2004 to 2010 were identified. Charts were reviewed to determine the frequency of the following clinical symptoms during the first year after surgery: pain greater than expected, implant prominence, and sensory/motor disturbance. Radiographs were reviewed to identify implant failure and curve change. Logistic regression analysis was used to identify clinical symptoms associated with treatment deviation. RESULTS: During the first year after surgery, an average of 6 (range, 2 to 12) radiographs were obtained from patients during an average of 3 (range, 2 to 10) follow-up visits. Pain (14%) was the most common symptom. Neurologic symptoms (13%) and implant prominence (4%) were less common. Implant failure was identified in 4 subjects (2%), of which 3 required revision surgery. The incidence of revision surgery was 2.9/1000 radiographs (95% confidence interval, 0.6-8.3). Curve progression >5 degrees in the uninstrumented curve occurred in 2 patients (0.9%). Curve progression did not result in a change in treatment for any of the patients. Pain was the only clinical symptom associated with implant failure (P=0.0047). 169/227 patients did not have any symptoms and only one of these underwent revision surgery. The sensitivity of a clinical test, which uses the presence of pain to guide the need for radiographic evaluation and rule out implant failure, was 75%, specificity 87%, positive predictive value 10%, and negative predictive value 99.5%. CONCLUSIONS: After obtaining baseline postoperative radiographs, additional radiographs during the first year after surgery for IS may not be required in the absence of clinical symptoms. Reducing the number of radiographs taken during the first year after surgery for IS in patients without symptoms can reduce radiation exposure to patients and health care costs without affecting treatment. LEVEL OF EVIDENCE: Level II, Diagnostic Study.

Management of late (>1 y) deep infection after spinal fusion: a retrospective cohort study.

BACKGROUND: The incidence of late infection published in the literature varies from 1% to 12% with varying definition of late infection (range, 3 mo to 1 y). Current evidence suggests implant removal and antibiotic therapy is necessary to clear these infections. A high incidence of late (>1 y) deep infection after instrumented spinal fusion was identified at our institution. We sought to evaluate the efficacy of our management of these patients. METHODS: A total of 1390 patients underwent instrumented spinal fusion from 2000 to 2009. Forty-two patients developed deep infection >1 year after index procedure (3%) and had surgical debridement. Clinical records and microbiology reports were reviewed for details of operative and postoperative management. RESULTS: Advanced imaging was only obtained in 6 patients (5 computed tomography, 1 magnetic resonance imaging). Offending organisms were identified in 39/42 patients, 27 of these grew Propionibacterium acnes. P. acnes grew in culture at a median of 6 days (range, 3 to 10 d), significantly longer than all other organisms, which grew in a median of 1 day (range, 0 to 8 d) (P<0.001). Implants were removed at the index hospitalization in 41 patients. Implant retention was attempted in 1 patient and failed. Primary closure was carried out in 37 patients; the remainder had undergone multiple debridements (4 planned, 1 unplanned). VAC closure was utilized in 2 patients. All patients were treated with organism-specific intravenous antibiotics and transitioned to oral antibiotics on average in 34 days (range, 2 to 186 d). Total length of antibiotic therapy was an average of 141 days (range, 34 to 413 d). CONCLUSIONS: P. acnes was the most common organism identified and took nearly 1 week to grow in culture. Treatment is generally successful with thorough debridement, removal of implants, and antibiotic treatment. LEVEL III: retrospective comparative study.

Analysis of 5,070 consecutive pedicle screws placed utilizing robotically assisted surgical navigation in 334 patients by experienced pediatric spine deformity surgeons: surgical safety and early perioperative complications in pediatric posterior spinal fusion.

PURPOSE: This study evaluates the intraoperative and short-term complications associated with robotically assisted pedicle screw placement in pediatric posterior spinal fusion (PSF) from three surgeons at two different institutions. METHODS: We retrospectively reviewed 334 pediatric patients who underwent PSF with robotic-assisted navigation at 2 institutions over 3 years (2020-2022). Five thousand seventy robotically placed screws were evaluated. Data collection focused on intraoperative and early postoperative complications with minimum 30-day follow-up. Patients undergoing revision procedures were excluded. RESULTS: Intraoperative complications included 1 durotomy, 6 patients with neuromonitoring alerts not related to screw placement, and 62 screws (1.2%) with documented pedicle breaches, all of which were revised at time of surgery. By quartile, pedicle breaches statistically declined from first quartile to fourth quartile (1.8% vs. 0.56%, p < 0.05). No breach was associated with neuromonitoring changes or neurological sequelae. No spinal cord or vascular injuries occurred. Seventeen postoperative complications occurred in eleven (3.3%) of patients. There were five (1.5%) patients with unplanned return to the operating room. CONCLUSION: Robotically assisted pedicle screw placement was safely and reliably performed on pediatric spinal deformity by three surgeons across two centers, demonstrating an acceptable safety profile and low incidence of unplanned return to the operating room.

What Do We C in Children With Scurvy? A Case Series Focused on Musculoskeletal Symptoms.

OBJECTIVES: Vitamin C deficiency in children commonly presents with musculoskeletal symptoms such as gait disturbance, refusal to bear weight, and bone or joint pain. We aimed to identify features that could facilitate early diagnosis of scurvy and estimate the cost of care for patients with musculoskeletal symptoms related to scurvy. METHODS: We conducted a retrospective chart review of patients at a single site with diagnostic codes for vitamin C deficiency, ascorbic acid deficiency, or scurvy. Medical records were reviewed to identify characteristics including presenting symptoms, medical history, and diagnostic workup. The Pediatric Health Information System was used to estimate diagnostic and hospitalization costs for each patient. RESULTS: We identified 47 patients with a diagnosis of scurvy, 49% of whom had a neurodevelopmental disorder. Sixteen of the 47 had musculoskeletal symptoms and were the focus of the cost analysis. Three of the 16 had moderate or severe malnutrition, and 3 had overweight or obesity. Six patients presented to an emergency department for care, 11 were managed inpatient, and 3 required critical care. Diagnostic workups included MRI, computed tomography, echocardiogram, endoscopy, lumbar puncture, and/or EEG. Across all patients evaluated, the cost of emergency department utilization, imaging studies, diagnostic procedures, and hospitalization totaled $470 144 (median $14 137 per patient). CONCLUSIONS: Children across the BMI spectrum, particularly those with neurodevelopmental disorders, can develop vitamin C deficiency. Increased awareness of scurvy and its signs and symptoms, particularly musculoskeletal manifestations, may reduce severe disease, limit adverse effects related to unnecessary tests/treatments, and facilitate high-value care.

Intraoperative neuromonitoring predicts postoperative deficits in severe pediatric spinal deformity patients.

PURPOSE: To evaluate intraoperative monitoring (IOM) alerts and neurologic deficits during severe pediatric spinal deformity surgery. METHODS: Patients with a minimum Cobb angle of 100° in any plane or a scheduled vertebral column resection (VCR) with minimum 2-year follow-up were prospectively evaluated (n = 243). Preoperative, immediate postoperative, and 2-year postoperative neurologic status were reported. Radiographic data included preoperative and 2-year postoperative coronal and sagittal Cobb angles and deformity angular ratios (DAR). IOM alert type and triggering event were recorded. SRS-22r scores were collected preoperatively and 2-years postoperatively. RESULTS: IOM alerts occurred in 37% of procedures with three-column osteotomy (n = 36) and correction maneuver (n = 32) as most common triggering events. Patients with IOM alerts had greater maximum kyphosis (101.4° vs. 87.5°) and sagittal DAR (16.8 vs. 12.7) (p < 0.01). Multivariate regression demonstrated that sagittal DAR independently predicted IOM alerts (OR 1.05, 95% CI 1.02-1.08) with moderate sensitivity (60.2%) and specificity (64.8%) using a threshold value of 14.3 (p < 0.01). IOM alerts occurred more frequently in procedures with new postoperative neurologic deficits (17/24), and alerts with both SSEP and TCeMEP signals were associated with new postoperative deficits (p < 0.01). Most patients with new deficits experienced resolution at 2 years (16/20) and had equivalent postoperative SRS-22r scores. However, patients with persistent deficits had worse SRS-22r total score (3.8 vs. 4.2), self-image subscore (3.5 vs. 4.1), and function subscore (3.8 vs. 4.3) (p ≤ 0.04). CONCLUSION: Multimodal IOM alerts are associated with sagittal kyphosis, and predict postoperative neurologic deficits. Most patients with new deficits experience resolution of their symptoms and have equivalent 2-year outcomes. LEVEL OF EVIDENCE: II.

Timing of intraoperative neurophysiological monitoring (IONM) recovery and clinical recovery after termination of pediatric spinal deformity surgery due to loss of IONM signals.

BACKGROUND CONTEXT: Intraoperative neurophysiological monitoring (IONM) is used to reduce the risk of spinal cord injury during pediatric spinal deformity surgery. Significant reduction and/or loss of IONM signals without immediate recovery may lead the surgeon to acutely abort the case. The timing of when monitorable signals return remains largely unknown. PURPOSE: The goal of this study was to investigate the correlation between IONM signal loss, clinical examination, and subsequent normalization of IONM signals after aborted pediatric spinal deformity surgery to help determine when it is safe to return to the operating room. STUDY DESIGN/SETTING: This is a multicenter, multidisciplinary, retrospective study of pediatric patients (<18 years old) undergoing spinal deformity surgery whose surgery was aborted due to a significant reduction or loss of IONM potentials. PATIENT SAMPLE: Sixty-six patients less than 18 years old who underwent spinal deformity surgery that was aborted due to IONM signal loss were enrolled into the study. OUTCOME MEASURES: IONM data, operative reports, and clinical examinations were investigated to determine the relationship between IONM loss, clinical examination, recovery of IONM signals, and clinical outcome. METHODS: Information regarding patient demographics, deformity type, clinical history, neurologic and ambulation status, operative details, IONM information (eg, quality of loss [SSEPs, MEPs], laterality, any recovery of signals, etc.), intraoperative wake-up test, postoperative neurologic exam, postoperative imaging, and time to return to the operating were all collected. All factors were analyzed and compared with univariate and multivariate analysis using appropriate statistical analysis. RESULTS: Sixty-six patients were enrolled with a median age of 13 years [IQR 11-14], and the most common sex was female (42/66, 63.6%). Most patients had idiopathic scoliosis (33/66, 50%). The most common causes of IONM loss were screw placement (27/66, 40.9%) followed by rod correction (19/66, 28.8%). All patients had either complete bilateral (39/66, 59.0%), partial bilateral (10/66, 15.2%) or unilateral (17/66, 25.8%) MEP loss leading to termination of the case. Overall, when patients were returned to the operating room 2 weeks postoperatively, nearly 75% (40/55) had monitorable IONM signals. Univariate analysis demonstrated that bilateral SSEP loss (p=.019), bilateral SSEP and MEP loss (p=.022) and delayed clinical neurologic recovery (p=.008) were significantly associated with having unmonitorable IONM signals at repeat surgery. Multivariate regression analysis demonstrated that delayed clinical neurologic recovery (> 72 hours) was significantly associated with unmonitorable IONM signals when returned to the operating room (p=.006). All patients ultimately made a full neurologic recovery. CONCLUSIONS: In children whose spinal deformity surgery was aborted due to intraoperative IONM loss, there was a strong correlation between combined intraoperative SSEP/MEP loss, the magnitude of IONM loss, the timing of clinical recovery, and the time of electrophysiological IONM recovery. The highest likelihood of having a prolonged postoperative neurological deficit and undetectable IONM signals upon return to the OR occurs with bilateral complete loss of SSEPs and MEPs.

The Effect of Implant Density on Adolescent Idiopathic Scoliosis Fusion: Results of the Minimize Implants Maximize Outcomes Randomized Clinical Trial.

BACKGROUND: Severe adolescent idiopathic scoliosis (AIS) can be treated with instrumented fusion, but the number of anchors needed for optimal correction is controversial. METHODS: We conducted a multicenter, randomized study that included patients undergoing spinal fusion for single thoracic curves between 45° and 65°, the most common form of operatively treated AIS. Of the 211 patients randomized, 108 were assigned to a high-density screw pattern and 103, to a low-density screw pattern. Surgeons were instructed to use ≥1.8 implants per spinal level fused for patients in the high-implant-density group or ≤1.4 implants per spinal level fused for patients in the low-implant-density group. The primary outcome measure was the percent correction of the coronal curve at the 2-year follow-up. The power analysis for this trial required 174 patients to show equivalence, defined as a 95% confidence interval (CI) within a ±10% correction margin with a probability of 90%. RESULTS: In the intention-to-treat analysis, the mean percent correction of the coronal curve was equivalent between the high-density and low-density groups at the 2-year follow-up (67.6% versus 65.7%; difference, -1.9% [95% CI: -6.1%, 2.2%]). In the per-protocol cohorts, the mean percent correction of the coronal curve was also equivalent between the 2 groups at the 2-year follow-up (65.0% versus 66.1%; difference, 1.1% [95% CI: -3.0%, 5.2%]). A total of 6 patients in the low-density group and 5 patients in the high-density group required reoperation (p = 1.0). CONCLUSIONS: In the setting of spinal fusion for primary thoracic AIS curves between 45° and 65°, the percent coronal curve correction obtained with use of a low-implant-density construct and that obtained with use of a high-implant-density construct were equivalent. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

The use of barbed sutures during scoliosis fusion wound closure: a quality improvement analysis.

BACKGROUND: Growing evidence in the orthopaedic arthroplasty literature supports the use of running bidirectional barbed suture (barbed suture) for closure of knee arthrotomies. More rapid wound closure and suture line integrity are described as its major advantages. No studies of barbed suture for the closure of posterior spinal wounds exist. The purpose of this project is to compare wound closure times and hospital charges using traditional closure versus barbed suture closure of posterior spine wounds created during scoliosis surgery. METHODS: A quality improvement project was initiated at a single tertiary-referral children's hospital spine program evaluating traditional layered interrupted suture closure (group 1) and running bidirectional barbed suture closure (Quill SRS) (group 2). Data regarding wound closure time, length of incision, fusion levels, suture cost, and hospital charges were prospectively collected over a 1-month period. RESULTS: Ten incisions comprised group 1 and 15 comprised group 2. The average wound closure times were 29.5 and 17 minutes, respectively, P=0.006. The wound lengths between the groups were statistically comparable (P=0.15). Taking into account the wound length, the average closure time in group 1 was 1.29 cm/min compared with 1.97 cm/min in group 2 (P<0.01). When accounting for the extra cost associated with the use of barbed sutures ($62.54; P<0.0001), the impact of a more rapid closure resulted in a difference in hospital charges of $884.60 per case (P=0.0013). CONCLUSIONS: Barbed suture closure of spinal fusion incisions results in a 40% reduction in closure time, resulting in an $884.60 decrease in hospital charges related to operating room time. This may represent significant yearly cost savings in a high-volume spine fusion center and warrants further investigation comparing patient-related outcomes. SIGNIFICANCE: This quality improvement analysis provides preliminary economic justification for using barbed suture for scoliosis fusion wound closure resulting in decreased operating room times and subsequent hospital charges. LEVEL OF EVIDENCE: Level II-therapeutic study, prospective nonrandomized cohort.

Variability in spinal surgery outcomes among children's hospitals in the United States.

BACKGROUND: We performed a retrospective cohort study of 7637 spinal fusion surgical cases from 2004 to 2006 at 38 children's hospitals participating in the Pediatric Health Information System database to evaluate the variability of in-hospital outcomes by patient factors and between facilities in children who underwent spinal surgery. METHODS: Outcomes were stratified by whether children did or did not have neurological impairment. Multilevel multivariate logistic regression models were used to determine patient and hospital factors associated with in-hospital infections, surgical complications, and length of stay (LOS)≥10 days. RESULTS: Neurologically impaired (NI) children (N=2117 out of 7637) represented 28% of the cases. The interhospital interquartile range of LOS for NI children was 6 to 8 days (median 7 d) and for non-neurologically impaired (NNI) children was 5 to 6 days (median 5 d). Children with NI had roughly 6 times higher rates of in-hospital infection and 3 times higher complication rates: major interhospital variation was seen for both of these outcomes. Hospital rates of infection ranged from 0% to 27% (median 10%) for NI and from 0% to 14% (median 2%) for NNI children. Complication rates ranged from 0% to 89% (median 33%) for NI and from 3% to 68% (median 9%) for NNI children. The following factors were associated with a LOS≥10 days: in-hospital infection (P<0.0001), surgical complication (P<0.0001), and anterior/posterior versus posterior-only surgery (P<0.0001). Hospital case volume was not associated with infection, surgical complication, or LOS≥10 days. CONCLUSIONS: Substantial variation exists in reported outcomes for children undergoing spinal surgery in children's hospitals within the United States. Further study is needed to characterize hospital-level factors related to surgical outcome to direct future quality improvement.