Differences in spine growth potential for Sanders maturation stages 7A and 7B have implications for treatment of idiopathic scoliosis.

PURPOSE: This study aimed to clarify the differences in spine and total body height growth and curve progression between Sanders maturation stage (SMS) 7A and 7B in patients with adolescent idiopathic scoliosis (AIS). METHODS: This retrospective case-control study involving patients with AIS at SMS 7 evaluated the differential gains in the spine (T1-S1) and total body height and curve progression between SMS 7A and 7B. A validated formula was used to calculate the corrected height, accounting for height loss due to scoliosis. A multivariable non-linear and logistic regression model was applied to assess the distinct growth and curve progression patterns between the SMS 7 subtypes, adjusting for potential confounders. RESULTS: A total of 231 AIS patients (83% girls, mean age 13.9 ± 1.2 years) were included, with follow-up averaging 3.0 years. Patients at SMS 7A exhibited larger gains in spine height (9.9 mm vs. 6.3 mm) and total body height (19.8 mm vs. 13.4 mm) compared with SMS 7B. These findings remained consistent even after adjustments for curve magnitude. Non-linear regression models showed continued spine and total body height increases plateauing after 2 years, significantly greater in SMS 7A. More SMS 7A patients had curve progression over 10°, with an adjusted odds ratio of 3.31. CONCLUSION: This study revealed that patients staged SMS 7A exhibited more spine and total body growth and a greater incidence of substantial curve progression than those at 7B. These findings imply that delaying brace discontinuation until reaching 7B could be beneficial, particularly for those with larger curves. LEVEL OF EVIDENCE: Level III (Case-control study).

Predictors of Rod Length Gain and Sagittal Alignment Change After Magnetically Controlled Growing Rod Lengthening.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: There are preoperative characteristics that predict rod lengthening of magnetically controlled growing rods (MCGR). The lengthening of MCGR will lead to increased kyphosis. SUMMARY OF BACKGROUND DATA: The amount of length gained by MCGR is variable, and predictors are lacking. Similarly, sagittal plane changes over the MCGR lengthening period have not been investigated. MATERIALS AND METHODS: Patients with MCGR and a minimum 2-year follow-up were identified and those with previous spine surgery were excluded. Preimplantation, postimplantation, and last follow-up postlengthening radiographs were examined. Multiple linear regression analyses were used for rod length gain predictors. RESULTS: Fifty-six patients with early-onset scoliosis met inclusion criteria: nine idiopathic, five congenital, 14 neuromuscular, 20 syndromic, and eight skeletal dysplasia patients. No difference was seen between subtypes of early-onset scoliosis for rod length gain ( P =0.62). Shorter preoperative T1-T12 height and higher curve correction rate after implantation were significant predictors for rod length gain ( P <0.001). Preoperative major curve magnitude and kyphosis were not significant predictors. Flattening of the spine around the actuator and compensative increase in T1-T5 kyphosis were seen secondarily after MCGR implantation. Maximum sagittal kyphosis, T1-T5 kyphosis, and T5-T12 kyphosis did not change during lengthening. Lumbar lordosis significantly decreased postimplantation (first erect) but then increased during lengthening. Pelvic incidence and sacral slope both increased during lengthening, but this may be age related. CONCLUSION: Patients who gained the most rod length with MCGR were those with an initially shorter T1-T12 height and better initial curve correction at implantation, likely representing that implants work best in small patients with flexible curves. Diagnosis, preoperative curve magnitude, and thoracic kyphosis were not related to rod length gain. Thoracic kyphosis did not deteriorate over the lengthening phase. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

The Role of Liposomal Bupivacaine in Multimodal Pain Management Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis: Faster and Farther With Less Opioids.

STUDY DESIGN: Retrospective controlled cohort. OBJECTIVE: To evaluate the effect of intraoperative liposomal bupivacaine (LB) infiltration on postsurgical pain management in adolescent idiopathic scoliosis (AIS) patients by analyzing postoperative opioid consumption, ambulation, and length of stay (LOS). SUMMARY OF BACKGROUND DATA: Optimal postoperative pain control for AIS patients undergoing posterior spinal fusion (PSF) is challenging. Multimodal pain management protocols provide adequate analgesia while decreasing opioid consumption. LB was recently approved for pediatric patients; however, use in AIS patients is understudied. METHODS: 119 consecutive patients with AIS who underwent PSF were included. Patients were divided into 2 groups: patients who received LB as erector spinae block in addition to the standard postoperative pain management protocol (Group A), and patients who received only the standard postoperative pain protocol (Group B). Oral morphine equivalents, intravenous opioid and valium consumption, pain scores (VAS), nausea/vomiting, ambulation distance and LOS were assessed. RESULTS: Group A experienced significantly lower total opioid consumption compared to Group B (44.5 mg vs. 70.2 mg). Morphine use was lower in Group A on postoperative day (POD) 0, and oxycodone use was lower in Group A on PODs 1 and 2. There was a higher proportion of patients who used only oral opioids in Group A (81% vs. 41%). Of patients requiring any intravenous opioids, 79% did not receive LB. A significantly higher proportion of LB patients were discharged on POD 2 (55% vs. 27%); therefore, LOS was shorter for Group A. Group A ambulated further postoperatively. There were no differences in pain scores, valium requirements or nausea/vomiting. CONCLUSIONS: LB was associated with decreased total opioid use, shorter LOS, and improved ambulation in AIS patients undergoing PSF. Including LB in multimodal pain management protocols proved effective in reducing opioid use while increasing mobilization in the immediate postoperative period. LEVEL OF EVIDENCE: 3.

Socioeconomic, Racial, and Insurance Disparities in Clinical Outcomes After Surgery Among Patients With Idiopathic Scoliosis.

BACKGROUND: Socioeconomic status (SES), race, and insurance type correlate with initial curve severity for patients with idiopathic scoliosis, but less is known regarding how these variables impact surgical outcomes. The objectives of this study were to determine the influence of SES, race, and insurance on preoperative appointment attendance, likelihood of obtaining a preoperative second opinion, brace prescription, missed 6 or 12-month postsurgical appointments, incidence of emergency department visits 0 to 90 days after surgery, and major complications within a year of surgery. METHODS: A review of 421 patients diagnosed with idiopathic scoliosis who underwent surgery at a single high-volume pediatric spinal deformity institution between May 2015 and October 2021 was conducted. Area Deprivation Index, a quantitative measure of SES, was collected. Scores were stratified by quartile; higher scores indicated a lower SES. χ 2 tests for correlation were performed to determine whether clinical outcomes were dependent upon Area Deprivation Index, race, or insurance type; P ≤0.05 was significant. RESULTS: The sample was 313 Caucasian (74%), 69 (16%) black, and 39 (9.3%) other patients. More patients had private versus public insurance (80% vs 20%) and were of higher SES. The likelihood of missing preoperative appointments was higher for black patients ( P = 0.037). Those with lower SES missed more postoperative appointments and received less bracing and second opinions ( P = 0.038, P = 0.017, P = 0.008, respectively). Being black and publicly insured correlated with fewer brace prescriptions ( P < 0.001, P = 0.050) and decreased rates of obtaining second opinions ( P = 0.004,  P = 0.001). CONCLUSION: Patients with idiopathic scoliosis surgery who were Caucasian, privately insured, and of higher SES were more likely to seek preoperative second opinions, be prescribed a brace, and attend postoperative appointments. Recognition of the inherent health care disparities prevalent within each pediatric spine surgery referral region is imperative to better inform local and national institutional level programs to educate and assist patients and families most at risk for disparate access to scoliosis care. LEVEL OF EVIDENCE: Level III; retrospective case-control study.

Do Pedicle Screws That Terminate in the Costovertebral Joint Compromise Proximal Anchor Fixation in a Dual Growing Rod Construct?

INTRODUCTION: Growing rods (GRs) are used to treat early-onset scoliosis (EOS) recalcitrant to bracing and casting. Proximal anchor pullout, a known complication of GR constructs, can result in spinal cord injury if pedicle screw anchors are placed with a lateral-to-medial trajectory. To mitigate this risk, a more straightforward and potentially safer trajectory may result in screws that terminate within the costovertebral joint (CVJ). We asked, how often does CVJ placement occur and does this technique increase the rate of failure in GR constructs? METHODS: We retrospectively reviewed 35 patients with EOS treated with dual GR with >2-year follow-up excluding patients with skeletal dysplasia or history of previous posterior instrumentation. Patient demographics, radiographic parameters, and implant constructs were assessed. RESULTS: Of patients meeting the inclusion criteria, 18/35 (51%) were females with an average age of 7.96 (range: 4.0 to 15.2) years at surgery with a follow-up of 3.7 (range: 2.0 to 7.7) years. Five (14%) patients had idiopathic EOS, 5 (14%) had congenital EOS, 12 (34%) had neuromuscular EOS, 10 (29%) had syndromic scoliosis, and 3 (9%) had another etiology for EOS. Among 195 proximal pedicle screws placed, 19 (10%) terminated within the CVJ, and 13 patients (37%) had at least 1 CVJ screw. Two patients (6%) experienced unilateral proximal pullout. In both patients, the anchors on the affected side included 1 of 2 screws within the CVJ. Both patients had constructs that included 2 screws on the side that pulled out and 3 screws on the side that did not. None of the remaining 17 CVJ screws led to implant failure. CONCLUSION: Pedicle screw placement within the CVJ is common and does not appear to significantly contribute to proximal screw pullout; however, it may contribute to unilateral implant failure in constructs employing only 2 proximal screws, where 1 of those 2 screws terminates within the CVJ. Construct modifications should be considered in this scenario. LEVEL OF EVIDENCE: Level III.

Subclassification of Sanders Maturation Stage 3 Demonstrates Differences in Spine and Total Height Velocity Between 3A and 3B in Patients with Idiopathic Scoliosis.

STUDY DESIGN: A single-center retrospective case-control study. OBJECTIVE: To compare the spine and total height velocity between Sanders maturation stage (SMS) 3A and 3B. SUMMARY OF BACKGROUND DATA: Identifying SMS 3 is critical for treating growing children because it represents the early phase of rapid adolescent growth. However, there is limited literature available that clearly describes the growth differences between 3A and 3B. METHODS: The current study included consecutive patients with idiopathic scoliosis staged SMS 3 from January 2012 to December 2021. T1-S1 spine height, total body height, and curve magnitude were measured at the initial and follow-up visits. In addition to the spine and total height velocity calculated per month, corrected height velocity was estimated for curve magnitude using a validated formula. Mann-Whitney U test was used to compare SMS 3A and 3B outcomes, followed by a multiple linear regression model to evaluate the association of the SMS subclassifications to growth velocity adjusted for confounding factors. RESULTS: A total of 204 patients (66% girls, mean age: 12.3±1.3 y) met the inclusion criteria. Patients staged SMS 3A had higher spine height velocity (mm/month) in both girls (2.3 vs. 1.5, P<0.001) and boys (2.6 vs. 1.7, P<0.001), as well as total height velocity (mm/month; (5.8 vs. 4.3, P<0.001 for girls; 6.6 vs. 4.5, P<0.001 for boys). Corrected velocity showed similar results with greater spine and total height velocity in SMS 3A. Multivariate analysis indicated a significant association of the SMS subclassification to the spine and total height velocity. The scoliosis curve progression was comparable between SMS 3A and 3B. CONCLUSION: SMS 3A and 3B had differential growth velocity in the spine and total body height. These results advocated the significance of SMS 3 subclassification for managing scoliosis treatment, including observation, bracing, and surgical interventions with fusion and growth modulation. LEVEL OF EVIDENCE: Level III (Case-control study).

Increased medial pedicle angulation of the lumbar spine as a function of the posterior osseous defect in patients with myelomeningocele.

PURPOSE: Bony anatomy in patients with immature spines has been previously characterized. Alterations in lumbosacral morphology in patients with myelodysplasia, demonstrating increasing medial pedicle angulation (MPA) from L1-S1, have been examined; however, MPA related to size of the defect in myelomeningocele patients has not been defined. We aimed to establish that magnitude of posterior vertebral arch defects determines the extent of MPA in the lumbar spine, with larger posterior defects associated with increased MPA. METHODS: This retrospective case-control study compared lumbar morphometric measurements of patients with and without myelomeningocele. Eighteen patients with myelomeningocele underwent computed tomography with three-dimensional reconstruction; there was no concurrent pathology. Advanced imaging software was utilized to manipulate the axial, sagittal, and coronal axes at each lumbar level, and obtain accurate measurements of pedicle width, height, length, MPA, and posterior laminar defect. RESULTS: In lumbar vertebrae with a posterior arch defect (PAD), increased magnitude was associated with a concurrent increase in MPA between 16.2° (43.4%) and 28.1° (299.4%) depending on lumbar level. At levels without a PAD, increases in MPA were between 0.8° (4.3%) and 5.7° (60.6%) depending on lumbar level. Although the actual degree of medial angulation increases from cephalad to caudal levels, the percentage of deviation from normal is higher at the more cephalad levels compared with controls. CONCLUSION: In patients with myelomeningocele, larger posterior vertebral arch defects were associated with increased MPA in the lumbar spine. Lumbar levels without a PAD also demonstrated increases in MPA compared with normal values.

Modified Clavien-Dindo-sink classification system for adolescent idiopathic scoliosis.

PURPOSE: The Clavien-Dindosink (CDS) classification system provides more treatment-focused granularity than subjective methods of describing surgical complications; however, it has not been validated in posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). The purpose of this study was to modify the CDS system for application in patients with AIS undergoing PSF to assess its inter- and intra-rater reliability for describing complications faced by this population. METHODS: A review of all complications specific to patients with AIS captured in a large multicenter international database was performed. All complications were classified according to CDS, modified by addition of "prolonged initial hospital stay" as a criterion for Grade II. A survey of this complication list and an additional 20 clinical vignettes (sent out on two occasions) was sent to nine spinal deformity surgeons. Weighted kappa values were used to determine inter- and intra-rater reliability. RESULTS: The Fleiss κ value for interrater reliability among 5 respondents grading all AIS complications was 0.8 (very good). For each grade, interrater reliability was very good, with an overall range of 0.8-1. The overall kappa value for intrarater reliability among eight respondents grading 20 vignettes was between 0.6 (good) and 0.9 (very good). CONCLUSION: The modified CDS classification system has very good interrater and intrarater reliability in describing complications following PSF in patients with AIS. This system may be of greater utility for reporting outcomes than a "major" versus "minor" complication system and can serve as a valuable tool for improving surgical practices and patient outcomes in this population. LEVEL OF EVIDENCE: IV case series.

Analysis of Shoulder Complex Function After Posterior Spinal Fusion in Adolescents With Idiopathic Scoliosis.

BACKGROUND: Nonsurgically treated patients with AIS demonstrate altered scapular kinematics and decreased patient-reported shoulder function compared with typically developing adolescents. It is unknown whether surgical correction of the spine deformity has beneficial or detrimental effects on scapulothoracic joint function, as previous assessments of shoulder function following surgery have only focused on humerothoracic motion. The objective of this study was to perform a comprehensive analysis of scapular kinematics before and after PSF and compare postoperative scapular kinematics in AIS to those of a typically developing cohort. METHODS: Typically developing adolescents (n=33) and patients with AIS (n=20) with a planned PSF surgery were recruited. Motion capture was used to analyze scapular kinematics at rest and in full abduction. AIS subjects were evaluated before surgery and at a 6-month follow-up. Individual changes following surgery were assessed, and postoperative scapular kinematics were compared with the typically developing subjects. RESULTS: Patients with AIS patients in this study demonstrated significant losses of scapulothoracic range of motion for the convex side shoulder and gains of scapulothoracic range of motion for the concave side shoulder following PSF. When compared with typically developing adolescents, the resting scapular position of the postoperative AIS group seemed normalized, but the AIS group still exhibited altered scapular motion, particularly along the upward rotation and tilt axes. CONCLUSIONS: Patients with AIS demonstrated significant changes at the scapulothoracic joint following PSF. Compared with typically developing adolescents, scapular resting position normalized, but the AIS group still demonstrated altered scapular kinematics, including patterns associated with shoulder pathology. The results of this study will inform the course of short-term postoperative rehabilitation by addressing the upper extremity implications of PSF for individuals with AIS. LEVEL OF EVIDENCE: Level III.

Intraoperative CT Scan Verification of Pedicle Screw Placement in AIS to Prevent Malpositioned Screws: Safety Benefit and Cost.

STUDY DESIGN: Prospective database review. OBJECTIVES: Determine if use of intraoperative 3D imaging of pedicle screw position provides clinical and cost benefit. SUMMARY OF BACKGROUND: Injury or reoperation from malpositioned pedicle screws in adolescent idiopathic scoliosis (AIS) surgery occurs but is increasingly considered to be a never-event. To avoid complications, intraoperative 3D imaging of screw position may be obtained. METHODS: A prospective, consecutive AIS database at a high-volume pediatric spine center was examined three years before and after implementation of an intraoperative low-dose computed tomographic (CT) scan protocol. All screws were placed via freehand technique and corrected if found to be outside optimal trajectory on the postplacement CT scan. Demographic and outcome data were compared between cohorts, along with number, location, and reason for screw change. Cost analysis was based on the average cost of revision surgery for screw malposition versus intraoperative CT use. RESULTS: There were 153 patients in the pre-CT and 153 in the post-CT cohorts with a minimum 2-year follow-up. Two reoperations were needed for revision of improper screw placement in the pre-CT group and none in the post-CT group. Number of patients needed to harm was 76 (absolute risk increase = 1.31% [-0.49%, 3.11%]). Of those who had intraoperative CT scans, 80 (52.3%) needed on average 1.75 screw trajectories/lengths changed. Forty-three percent were medial breaches; of these, 39% were in the concavity. There were no differences between patients who did and did not need screw repositioning with regard to body mass index (BMI), age, curve size, surgeon/trainee side, screw density, or preoperative and one-year postoperative Scoliosis Research Society-22 patient questionnaire (SRS-22) scores. The average cost of reoperation for malposition was $4,900, whereas the cost of a single intraoperative CT was $232. CONCLUSION: Intraoperative CT is an effective tool to prevent reoperation in AIS surgery for incorrect screw placement. Despite high volume, experience, and specialty training, incorrect trajectories occur and systems should be in place for preventable error. LEVEL OF EVIDENCE: Level II.

Shoulder Complex Mechanics in Adolescent Idiopathic Scoliosis and Their Relation to Patient-perceived Function.

BACKGROUND: Proper contribution of the scapulothoracic joint is necessary for adequate shoulder complex function. Associations between trunk shape and abnormal scapular kinematics and subsequent shoulder dysfunction have been established; however, the extent of shoulder dysfunction in adolescent idiopathic scoliosis (AIS) is still poorly understood. The purpose of this study was to perform a comprehensive analysis of scapular kinematics during multiplanar arm motion in patients with AIS and compare kinematics and patient-reported function with that of a typically developing cohort. METHODS: Typically developing adolescents (n=33) and patients with AIS (n=26) with no history of spine or shoulder surgery were recruited for this study. A 3-dimensional optoelectronic motion capture system was used to analyze scapular kinematics in 4 positions: rest, full abduction, forward reach, and hand to spine. Subjects in each group also completed the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire as a measure of patient-reported function. RESULTS: The convex shoulders of the patients with AIS exhibited deficits in scapular upward rotation and posterior tilt in all positions and reduced protraction range of motion during reaching. The AIS group also reported worse patient-perceived shoulder function than the typically developing group; however, this dysfunction was not related to specific scapular kinematic patterns. CONCLUSIONS: Patients with AIS show alterations in scapular kinematics that are associated with shoulder pathology. Despite displaying an unaffected ability to place the hand in space, the underlying joint mechanics place these adolescents at risk for future pathology. Accordingly, consideration of scapulothoracic and glenohumeral joint function is warranted in the treatment of AIS. LEVEL OF EVIDENCE: Level III-cross-sectional comparison.

Are We Prescribing Our Patients Too Much Pain Medication? Best Predictors of Narcotic Usage After Spinal Surgery for Scoliosis.

BACKGROUND: Physicians play a role in the current prescription drug-abuse epidemic. Surgeons often prescribe more postoperative narcotic pain medication than patients routinely need. Although narcotics are effective for severe, acute, postoperative pain, few evidence-based guidelines exist regarding the routinely required amount and duration of use post-hospital discharge. METHODS: Patients in a prospective cohort undergoing posterior spinal fusion for idiopathic scoliosis were asked preoperatively to rate their pain level, the level of pain expected each week postoperatively, and their pain tolerance. Post-discharge pain scores and narcotic use were reported at weekly intervals for 4 weeks postoperatively. Demographic data, preoperative Scoliosis Research Society (SRS)-22 scores, operative details, perioperative data, and self-reported pain levels were analyzed with respect to their association with total medication use and refills received. Disposal plans were also assessed. RESULTS: Seventy-two patients were enrolled, and 85% completed the surveys. The mean patient age was 14.9 years; 69% of the patients were female. The cohort was divided into 3 groups on the basis of total medication usage. The mean number of pills used in the middle (average-use) group was 49 pills. In postoperative week 4, narcotic usage was minimal (a mean of 2.9 pills by the highest-use group). Also by this time point, pain scores had, on average, returned to preoperative levels. Older age, male sex, a higher body mass index, and a higher preoperative pain score were associated with increased narcotic use. Sixty-seven percent of the patients planned to dispose of their unused medication, although only 59% of those patients planned on doing so in a manner recommended by the U.S. Food and Drug Administration. CONCLUSIONS: Postoperative narcotic dosing may be improved by considering patient age, weight, sex, and preoperative pain score. The precise estimation of individual narcotic needs is complex. Patient and family education on the importance and proper method of narcotic disposal is an essential component of minimizing the availability of unused postoperative medication. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Prediction of Curve Progression in Idiopathic Scoliosis: Validation of the Sanders Skeletal Maturity Staging System.

STUDY DESIGN: Retrospective case series. OBJECTIVE: This study aimed to validate the Sanders Skeletal Maturity Staging System and to assess its correlation to curve progression in idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: The Sanders Skeletal Maturity Staging System has been used to predict curve progression in idiopathic scoliosis. This study intended to validate that initial study with a larger sample size. METHODS: We retrospectively reviewed 1100 consecutive patients with idiopathic scoliosis between 2005 and 2011. Girls aged 8 to 14 years (<2 yr postmenarche) and boys aged 10 to 16 years who had obtained at least 1 hand and spine radiograph on the same day for evaluation of skeletal age and scoliosis curve magnitude were followed to skeletal maturity (Risser stage 5 or fully capped Risser stage 4), curve progression to 50° or greater, or spinal fusion. Patients with nonidiopathic curves were excluded. RESULTS: There were 161 patients: 131 girls (12.3 ± 1.2 yr) and 30 boys (13.9 ± 1.1 yr). The distribution of patients within Sanders stage (SS) 1 through 7 was 7, 28, 41, 45, 7, 31, and 2 patients, respectively; modified Lenke curve types 1 to 6 were 26, 12, 63, 5, 38, and 17 patients, respectively. All patients in SS2 with initial Cobb angles of 25° or greater progressed, and patients in SS1 and SS3 with initial Cobb angles of 35° or greater progressed. Similarly, all patients with initial Cobb angles of 40° or greater progressed except those in SS7. Conversely, none of the patients with initial Cobb angles of 15° or less or those in SS5, SS6, and SS7 with initial Cobb angles of 30° or less progressed. Predictive progression of 67%, 50%, 43%, 27%, and 60% was observed for subgroups SS1/30°, SS2/20°, SS3/30°, SS4/30°, and SS6/35° respectively. CONCLUSION: This larger cohort shows a strong predictive correlation between SS and initial Cobb angle for probability of curve progression in idiopathic scoliosis. LEVEL OF EVIDENCE: 3.

Effectiveness of cross-linking posterior segmental instrumentation in adolescent idiopathic scoliosis: a 2-year follow-up comparative study.

BACKGROUND CONTEXT: Surgeons continue to debate the need for a cross-link (CL) in posterior spinal instrumentation constructs with segmental pedicle screws in adolescent idiopathic scoliosis (AIS). Advantage of CLs is increased stiffness of the construct, and disadvantages include added expense and risk of late operative-site pain and pseudarthrosis. PURPOSE: To compare the effectiveness of using CLs versus using no cross-links (NCLs) in posterior segmental instrumentation in AIS. STUDY DESIGN: Retrospective comparative study, level of evidence 3. PATIENT SAMPLE: Seventy-five AIS patients less than 21 years of age, who underwent posterior spinal instrumentation with segmental pedicle screws (25 with CLs and 50 with NCLs) at a single institution with 2-year follow-up, are described. OUTCOME MEASURES: Physiologic measures include imaging: thoracic and lumbar Cobb angles, correction rate, apical vertebral translation (AVT), and apical vertebral rotation (AVR); self-report measures include Scoliosis Research Society (SRS) domain outcome scores. METHODS: Preoperative (pre-op) and postoperative first erect, 1-year, and 2-year follow-up radiographs were measured. Instrumentation-related complications and normalized SRS scores were recorded. Independent sample t test, χ(2) test, and repeated-measures analysis of variance were used for analyses. RESULTS: The average age at surgery was 14 years, the mean pre-op Cobb angle was 57°, and the mean number of levels fused was 10.9. The groups were similar preoperatively with respect to age, sex, Lenke curve, Cobb angle, AVT, and Risser grade and were similar intraoperatively for levels fused and anchor density. There was no difference in AVR, Cobb angle, correction rate, or AVT between the groups (p>.05). Complications included one wound infection in the CL group and one painful scar in the NCL group. There were no differences in SRS domain scores. CONCLUSION: We observed no differences in maintenance of correction, SRS scores, and complications with or without cross-linking posterior segmental instrumentation in AIS patients over 2-year follow-up. Further follow-up is necessary.

Ponte Osteotomies With Pedicle Screw Instrumentation in the Treatment of Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Review of prospective database. OBJECTIVES: To report the results of Ponte osteotomy with pedicle screw instrumentation for major thoracic adolescent idiopathic (AIS) curves. SUMMARY OF BACKGROUND DATA: Ponte osteotomy for achieving coronal and sagittal correction of major thoracic curves in AIS with pedicle screw instrumentation is a widespread technique, but results have not been well described. METHODS: Review of 87 consecutive AIS patients with Lenke 1-4 curves who underwent Ponte osteotomies and pedicle screw instrumentation by 2 surgeons at a single institution. Surgical details, blood loss, and complications were recorded. We evaluated coronal and sagittal radiological measurements and Scoliosis Research Society-22 (SRS-22) questionnaire scores over 2-year follow-up. RESULTS: The mean preoperative thoracic coronal Cobb angle was 57° ± 9.7°, fulcrum flexibility was 47.2%, and lateral Cobb angle was 17.8° ± 4°. The mean estimated blood loss (EBL), expressed as percent estimated blood volume, was 35.8 ± 20.5 mL. There was significant improvement in coronal thoracic Cobb angle, percent correction, and apical vertebral translation over 2-year follow-up (p < .05). In hypokyphotic curves, there was a significant increase in lateral thoracic T5-T12 kyphosis from 8.1° to 18.3° (p < .001). In hyperkyphotic curves, mean lateral thoracic T5-T12 kyphosis improved from 45° to 26° (p < .001). Median SRS-22 domains were higher after treatment (p < .05). Complications included significant hypotension (1), EBL greater than 75% estimated blood volume (2), and wound infection needing drainage (2). There were neuromonitoring signal changes in 7 patients but no significant neurological complications. CONCLUSIONS: In this case series of major thoracic AIS curves treated with segmental pedicle screw instrumentation and Ponte osteotomies, there was an improvement in the coronal and sagittal radiological parameters. A prospective controlled study is needed to determine whether pedicle screw instrumentation and Ponte osteotomies influence outcomes and complications.

Sagittal Spinopelvic Parameters of Young Children With Scoliosis.

STUDY DESIGN: Retrospective, multicenter review of the spinopelvic parameters in young children with scoliosis. OBJECTIVES: To describe sagittal alignment of the spine and pelvis in young children with scoliosis. SUMMARY OF BACKGROUND DATA: The natural history of spinopelvic parameters has been defined for the first 10 years of life in normal children; however, they have not been described for children with scoliosis. Such information is important because these values can be used as a baseline for the assessment of radiographic outcomes after surgical intervention. METHODS: Seven measures of sagittal alignment were taken from standing lateral radiographs of 80 children with scoliosis (coronal Cobb angle greater than 50°) and compared with age-matched normal children described in the literature. Statistical analysis was performed using 2-tailed Student t tests (level of significance = .05) and Pearson correlation coefficient. RESULTS: Patients had a mean age of 4.8 years (range, 1-10 years) and a mean Cobb angle of 72.0° ± 16°. Mean sagittal spine parameters were sagittal balance (2.2 ± 4 cm), thoracic kyphosis (38.0° ± 20.8°), and lumbar lordosis (49.0° ± 16.6°). These values were similar to those of children without scoliosis. Mean sagittal pelvic parameters were: pelvic incidence (46.5° ± 15.8°), pelvic tilt (10.7° ± 13.6°), sacral slope (35.5° ± 12.1°), and pelvic radius (55.7° ± 21.3°). Pelvic incidence was not significantly different from that of age-matched normal children; however, pelvic tilt was significantly higher and sacral slope was significantly lower in children with scoliosis. CONCLUSIONS: Sagittal plane spine parameters and some pelvic parameters were similar for young children with scoliosis versus age-matched normal children; however, children with scoliosis showed signs of increased pelvic tilt and decreased sacral slope. These values can be used as a baseline for both the natural history and the assessment of radiographic outcomes after surgical intervention.

Comparative analysis of hook, hybrid, and pedicle screw instrumentation in the posterior treatment of adolescent idiopathic scoliosis.

BACKGROUND: Spinal instrumentation in adolescent idiopathic scoliosis (AIS) aims to correct spinal deformity and maintain long-term spinal stability until bony healing is ensured. The purpose of this study was to compare the minimum 2-year postoperative radiographic and clinical results of posterior spine correction and fusion with all-hook instrumentation versus hybrid segmental instrumentation versus pedicle screw instrumentation for AIS from a single institution. METHODS: A total of 105 patients with AIS who underwent a posterior spinal fusion with segmental pedicle screw (35), hook (35), or hybrid (35) instrumentation were sorted and matched according to the following criteria: similar age at surgery, identical Lenke curve types, curve magnitude, and Risser grade. Patients were evaluated before, immediately after, and at 2 years after surgery for radiographic parameters, complications, and outcome, as well as on the basis of the Scoliosis Research Society (SRS) questionnaire. RESULTS: The age and Risser grade, major curve Cobb angle, apical vertebral rotation (AVR), apical vertebral translation (AVT), lowest instrumented vertebral tilt, global coronal and sagittal balance, lumbar lordosis, and thoracic kyphosis were determined as part of preoperative evaluation. All 3 groups showed significant differences between the preoperative and postoperative major curve Cobb angle, lowest instrumented vertebral tilt, AVT, and AVR. At the latest follow-up, lumbar lordosis, thoracic kyphosis, and global coronal and sagittal balance remained similar among the 3 groups. Major curve Cobb angle, AVT, and AVR were significantly different--the hook group's measurements were significantly higher than the other groups, but there was no difference between the pedicle screw and hybrid groups. Major curve correction rate was significantly different among all groups (screw=71.9%±13.8%, hybrid=61.4%±16.6%, hook=48.1%±19.7%) (P<0.001). The pedicle screw group had the least amount of correction loss but there was no statistically significant difference between groups (screw=2.6±6.7 degrees, hybrid=4.5±7.4 degrees, hook=4.4±6.2 degrees) (P=0.35). The hook group had the least amount of AVT correction, but the screw group and the hybrid groups were similar (pedicle=67.3%±15.5%, hybrid=57.5%±22.4%, hook=39.9%±32.5%) (P<0.001). Surgery time and blood loss were higher in the screw group. No differences in global SRS-22 scores were demonstrated between the patients treated with pedicle screw, hybrid, and hook constructs; however, the satisfaction domain was higher in the screw group at the latest follow-up. CONCLUSIONS: Pedicle screw and hybrid instrumentations offer significantly better spinal deformity correction than hook constructs in major curve coronal correction, AVT, and AVR. Patients with pedicle screw instrumentation had the greatest curve correction percentage, maintenance of this correction in the coronal and sagittal planes, and higher patient satisfaction by the SRS outcome scores. Global SRS-22 scores were similar at 2-year follow-up in all groups. LEVEL OF EVIDENCE: Therapeutic level III retrospective comparative study.

Spinal fusion for scoliosis in Rett syndrome with an emphasis on early postoperative complications.

STUDY DESIGN: Retrospective case-control study. OBJECTIVE: To examine the postoperative complications of posterior spinal fusion in a population of patients with Rett syndrome (RS). SUMMARY OF BACKGROUND DATA: Scoliosis is a common feature of RS, a progressive neurologic disorder affecting almost exclusively females. Despite this, there is little published information regarding the surgical treatment of scoliosis in this disorder. METHODS: Sixteen consecutive female patients with RS treated by posterior spinal fusion and unit rod instrumentation for progressive scoliosis between 1995 and 2003 were evaluated. Only patients with a minimum of 2-year follow-up were included. Preoperative medical conditions and postoperative complications were recorded. As a control group, we randomly selected 32 spastic quadriplegic patients who underwent the identical procedure during the same time period, selected from our database and matched according to age, level of neurologic impairment, and medical complexity. RESULTS: There was a high rate of early medical complications in the RS patients, with 28 major and 37 minor complications. Only 1 patient did not have a major medical complication, and every patient had at least 1 minor gastrointestinal and/or respiratory complication. Major respiratory complications occurred in 10 patients (63%) and comprised 61% of all major complications. Major gastrointestinal complications occurred in 6 patients (37%) and comprised 21% of all major complications. Other major complications included disseminated intravascular coagulopathy (1 patient), subacute bacterial endocarditis (1 patient), sacral decubiti requiring surgical debridement (2 patients), and extensive bilateral heterotopic ossification of the hips (1 patient). There were no cases of instrumentation failure, pseudarthrosis, deep infection, or need for rod revision. Postoperative complication scores were similar to those in patients with spastic quadriplegic pattern cerebral palsy. CONCLUSION: Spinal fusion for scoliosis in RS can give a satisfactory technical result, but a high rate of early postoperative medical problems should be anticipated.

Are antifibrinolytics helpful in decreasing blood loss and transfusions during spinal fusion surgery in children with cerebral palsy scoliosis?

STUDY DESIGN: Therapeutic comparative study. OBJECTIVE: To evaluate the safety and efficacy of antifibrinolytic (AF) agents in reducing blood loss and transfusions during posterior spinal fusion (PSF) in children with cerebral palsy (CP) scoliosis. SUMMARY OF BACKGROUND DATA: Scoliosis surgery in CP children is associated with substantial blood loss. Few reports on the role of AFs exist. METHODS: A multicenter, retrospective review of a prospectively collected database of 84 consecutively enrolled patients with CF (age < 18 years) with spinal deformity who underwent PSF and instrumentation. The use of AFs, tranexamic acid (TXA), epsilon-aminocaproic acid (EACA), or none was based on the surgeon preference. Estimated blood loss (EBL), transfusion requirements, and length of stay were recorded. Analysis was performed with the independent-samples t test and 1-way analysis of variance with post hoc Bonferroni analysis. RESULTS: The average age at the time of surgery was 14.4 ± 2.6 years. The groups were well matched in preoperative major deformity, age, levels fused, and operating time. Forty-four patients received AFs (30 TXA and 14 EACA), and 40 received no antifibrinolytics (NAF). The EBL averaged 1684 mL for the AFs group and 2685 mL for the NAF group (P = 0.002). There was more cell salvage transfusion in the NAF group. No significant differences were found in total transfusion requirements. There was a trend for decreased hospital stay in the AFs group. No adverse effects were seen. On comparison of the 3 groups (NAF, TXA, and EACA), a significant difference was observed between the TXA and the other groups with respect to EBL and cell salvage transfusion. CONCLUSION: AFs significantly reduced intraoperative EBL associated with PSF, with no adverse effects; however, we could not demonstrate significant differences in total transfusion, except in cell salvage. TXA was more effective than EACA in decreasing the EBL and cell salvage transfusion.

Reliability and necessity of computerized tomography in distal tibial physeal injuries.

OBJECTIVE: Complex distal tibial physeal fractures can be difficult to characterize on plain radiographs. The role of computed tomography (CT) scans in the evaluation and treatment decision of these injuries is unclear. We aimed to determine whether or not the addition of CT would improve the reliability of fracture classification and treatment decision. METHODS: Five independent observers evaluated 50 distal tibial physeal fractures on 2 separate occasions for Salter Harris (SH) classification and treatment decision (surgical/nonsurgical) using plain radiographs (round 1) and combination of radiographs and CT (round 2). During round 1, observers were asked if they would order a CT, and during round 2, they were asked if the CT was useful. These rounds were repeated at 2 to 4 weeks to assess intraobserver reliability. Statistical analyses were performed to assess inter and intraobserver reliability using Kappa coefficient (κ). RESULTS: Intraobserver reliability for SH classification showed substantial agreement, κ=0.76 and κ=0.80, respectively, during round 1 and 2. Interobserver agreement on the SH class was lower during round 1 and 2 (κ=0.67 and κ=0.57, respectively). There also was almost perfect intraobserver and interobserver agreement in the measurement of displacement at the fracture site during both rounds 1 and 2. Intraobserver reliability for treatment decision was substantial, κ=0.74 and κ=0.80, respectively, during round 1 and 2. However, interobserver agreement for treatment decision was moderate (κ=0.48) and fair (κ=0.36), respectively, during round 1 and 2. Surgeons indicated that they would like to order CT scans for 66% of the time in round 1, but the interobserver agreement as to who would best benefit from the CT was only fair (κ=-0.23). The main purpose of ordering the CT was to delineate fracture anatomy (55% of the time) and the observers felt CT would add to their treatment decision only 26% of the time. During round 2, 75% of time surgeons felt that CT scan was useful. CT was thought to be most useful in guiding screw placement (56% of the time) and not as useful (28% of time) for treatment decision making. CONCLUSIONS: Addition of CT in complex distal tibial physeal fractures did not increase interobserver reliability to classify the fracture or the treatment decision. Surgeons reported that the CT was most useful to plan screw placement and changed their treatment decision in about a fifth of the cases.