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.

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.

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.

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.

Medical complications and health-related quality of life in complex pediatric spine deformities exceeding 100 degrees or treated by 3CO.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To determine the incidence of medical complications in the pediatric population aged 10-20 years with baseline deformities exceeding 100 degrees or who had 3CO at surgery. Severe pediatric spine deformity poses a great challenge to the treating physician and carries a high complication rate. Pulmonary complications are among the most life threatening. The onus is on the treating surgeon to identify patients who are high risk and institute measures to mitigate the risk for successful outcomes. METHOD: Data of 251/311pts from FOX pediatric database from 17 international sites was queried for incidence of major medical complications. Comparative analysis was done to determine the impact of such complications on HRQoL using paired t-test. Risk factors associated with medical complications were assessed using Firth logistic regression. RESULTS: 251/311pts had min 2 year f/u. 142F/109 M, average age 14.61years (10-20). Etiologies included 96 Cong,94 Idiopathic, 14-Post TB, 12-NM,12-NF,10-syndromic,8 others. Curve types included Scoliosis-121, Kyphoscoliosis 72, Kyphosis 58. Coronal and sag cobb avg 88° ± 41.47 and 91.92° ± 39.17, respectively. Deformity apices were in the thoracic region in 88% of patients. Pre-op co-morbidities included 54 (21.5%) cardiopulmonary; 7(2.79%) Genitounrinary;13 (5.18%) GI;13 (5.18%) Anxiety/depression; neurological 24 (9.56%). HGT was utilized in 103pts (41%) at an average duration of 68 days. Mean OR time was 459 min, blood loss averaged 1465 ml. VCR was performed in 120(47.81%), PSO in 16 pts (6.37%), SPO in 145pts (57.77%), Thoracoplasty in 132 pts (52.8%). 96% had blood and other blood products transfusion (FFP and platelets). There were 35 post-op medical complications occurring in 29pts (11.6%). Event-specific cumulative incidence was 24 (9.6%) pulmonary, 5(2.0%) gastrointestinal, 3(1.2%) cardiovascular, 1(0.4%) genitourinary and 1(0.4%) other complication. There was no mortality. Osteotomy grade was found to be an independent predictor of pulmonary complication. Despite significant improvement in baseline SRS total and Domain scores at 2 year FU irrespective of medical complication, the improvement in SRS scores were blunted in the complication group. CONCLUSION: Medical complications are common among pediatric patients undergoing complex spine surgery for severe deformity. However, medical complications can be managed successfully. Although baseline HRQoL improved irrespective of medical complication status, clinical differences in the magnitude of the changes in HRQoL were observed in some domains.

Perioperative Complications and Health-related Quality of Life Outcomes in Severe Pediatric Spinal Deformity.

STUDY DESIGN: Prospective multicenter cohort study. OBJECTIVE: To evaluate perioperative complications and mid-term outcomes for severe pediatric spinal deformity. SUMMARY OF BACKGROUND DATA: Few studies have evaluated the impact of complications on health-related quality of life (HRQoL) outcomes in severe pediatric spinal deformity. METHODS: Patients from a prospective, multicenter database with severe pediatric spinal deformity (minimum of 100 degree curve in any plane or planned vertebral column resection (VCR)) with a minimum of 2-years follow-up were evaluated (n=231). SRS-22r scores were collected preoperatively and at 2-years postoperatively. Complications were categorized as intraoperative, early postoperative (within 90-days of surgery), major, or minor. Perioperative complication rate was evaluated between patients with and without VCR. Additionally, SRS-22r scores were compared between patients with and without complications. RESULTS: Perioperative complications occurred in 135 (58%) patients, and major complications occurred in 53 (23%) patients. Patients that underwent VCR had a higher incidence of early postoperative complications than patients without VCR (28.9% vs. 16.2%, P =0.02). Complications resolved in 126/135 (93.3%) patients with a mean time to resolution of 91.63 days. Unresolved major complications included motor deficit (n=4), spinal cord deficit (n=1), nerve root deficit (n=1), compartment syndrome (n=1), and motor weakness due to recurrent intradural tumor (n=1). Patients with complications, major complications, or multiple complications had equivalent postoperative SRS-22r scores. Patients with motor deficits had lower postoperative satisfaction subscore (4.32 vs. 4.51, P =0.03), but patients with resolved motor deficits had equivalent postoperative scores in all domains. Patients with unresolved complications had lower postoperative satisfaction subscore (3.94 vs. 4.47, P =0.03) and less postoperative improvement in self-image subscore (0.64 vs. 1.42, P =0.03) as compared to patients with resolved complications. CONCLUSION: Most perioperative complications for severe pediatric spinal deformity resolve within 2-years postoperatively and do not result in adverse HRQoL outcomes. However, patients with unresolved complications have decreased HRQoL outcomes.

The role of serial casting in early-onset scoliosis (EOS).

BACKGROUND: Serial casting has demonstrated efficacy for idiopathic early-onset scoliosis (EOS). Results of casting in nonidiopathic (syndromic and congenital) EOS patients have not previously been well described. METHODS: A total of 53 patients underwent serial casting for EOS from 2005 to 2010 at a single institution. Deformity was classified as idiopathic or nonidiopathic. Diagnosis, time in cast, number of casts, use of bracing, complications, and outcomes were recorded. Radiographic measures included Cobb angle and thoracic height (T1-T12). Thoracic height velocity was calculated and compared with established norms. RESULTS: A total of 36 patients, 19 idiopathic and 17 nonidiopathic (14 syndromic, 3 congenital), completed cast treatment and had >6-month follow-up and were therefore included. Of those, 17% (6/36) experienced resolution of their deformity, 53% (19/26) are currently in braces, and 31% (11/36) had undergone surgery. Surgery occurred on average at age 5.6 years and was delayed by an average of 2.1 years from time of first cast. A 19% complication was observed. There was no statistical difference in the rate of resolution of deformity between idiopathic (5/19) and nonidiopathic (1/17) patients (P=0.182), although there exists a trend toward greater curve correction in idiopathic patients. Surgery occurred in fewer patients (2/19) in the idiopathic group compared with the nonidiopathic group (9/17) (P=0.006). Significant improvements in Cobb angle was observed in the idiopathic group (12.2 degrees) during casting (P=0.003). Nonidiopathic patients did not maintain the correction gained during casting at the time of final follow-up. T1-T12 height increased across all study patients regardless of etiology during the period of casting at similar velocity to established norms of 1.4 cm/y for this age group. CONCLUSIONS: Serial casting offers modest deformity correction in idiopathic deformities compared with nonidiopathic deformities. Thoracic height growth continued throughout the casting period at normal velocity. Serial casting maintained normal longitudinal thoracic growth in all patients with EOS in this cohort. Although many required surgery, the increased thoracic height may have positive implications on ultimate pulmonary function. LEVEL OF EVIDENCE: Therapeutic level III.

A multidisciplinary approach improves infection rates in pediatric spine surgery.

BACKGROUND: Surgical site infections (SSI) associated with elective pediatric spinal surgery are a commonly reported complication, increasing hospital length of stay, readmissions, operations, and financial costs. In July 2007, a multidisciplinary task force, designated Target Zero, was created to address this issue and establish prevention protocols at our institution. METHODS: A consecutive series of 394 patient charts from April 2006 to September 2008 were retrospectively reviewed to identify patients who developed an SSI secondary to elective spinal surgery. Four cohorts were evaluated; high-risk (HR) and low-risk (LR) patients who underwent surgery before (April 2006 to June 2007) and after (July 2007 to September 2008) Target Zero initiation. The definition of HR included diagnoses of cerebral palsy, spina bifida, muscle disease, paralytic deformities, and vertebral column resections. Patients were followed for 1 year to meet The Center for Disease Control-National Health Safety Network's definition of an SSI with an implantable device. Overall infection rates were determined for each group and compared statistically. RESULTS: A total of 192 patients (70 HR and 122 LR) underwent surgery before, and 202 patients (92 HR and 110 LR) underwent surgery after Target Zero initiation. Overall infection rates were reduced from 7.8% to 4.5% (P=0.203), 12.9% to 6.5% (P=0.183), and 4.9% to 2.7% (P=0.505) for all patients, HR patients, and LR patients, respectively. The relative risk reduction was 43.0% for all patients, 49.3% for HR patients, and 44.6% for LR patients. CONCLUSIONS: Although decreases in overall infection rates were not statistically significant, the results from Target Zero were shown to be clinically meaningful with a relative risk reduction approaching 50% overall and in defined subgroups. Based on the number needed to treat analysis, 1 infection in every 16 patients within the HR group, and 1 in 30 overall, was prevented up to 1 year postoperatively. This study is the first to document the effectiveness of a multidisciplinary team implementing protocols for decreasing infection rates in pediatric spine surgery.

Ten-year follow-up of Lenke 5 curves treated with spinal fusion.

INTRODUCTION: Patients with surgically treated Lenke 5 curves require at least partial fusion of the lumbar spine. The implications of lumbar fusion remain unknown as long-term follow-up is sparse. METHODS: A retrospective review of a prospectively collected registry of patients with Lenke 5 curves treated with spinal fusion was performed. Clinical and radiographic outcomes as well as SRS-22 scores were collected at 2- and 10-year follow-up. RESULTS: 54 of 247 available patients met all inclusion criteria [26 treated with posterior spinal fusion (PSF) and 28 with anterior spinal fusion (ASF)]. Preoperative lumbar curve magnitude was 45.1 ± 8.4° and corrected to 14.0 ± 7.2° (p < 0.001). A 3.3 ± 7.3° increase in curve size was noted at final follow-up (p < 0.008) with 20.3% of patients having a loss of correction (LOC)of 10° or more. Thoracic curve correction and kyphosis were stable at 10-year follow-up. End vertebrae angulation improved from 11.2 ± 23.2° to 0.96 ± 6.4° (p = 0.004) and translation improved from 2.5 ± 2.9 to 0.92 ± 1.5 cm (p = 0.008) with no LOC. Disc wedging below the lower instrumented vertebrae increased from 0.3 ± 4.9° to 2.8 ± 4.4° (p < 0.001) with no change at 10 years. SRS-22 self-image and satisfaction improved from post-operative to final follow-up. No patient required a second operation. CONCLUSIONS: Both ASF and PSF showed durable results at 10-year follow-up with no obvious difference between approaches. 20% of patients had a LOC > 10°; this did not correlate with pain or need for revision surgery. Disc wedging was stable. Selection of LIV did not correlate with pain scores. LEVEL OF EVIDENCE: Level III.

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.

Pathways that distinguish simple from complex scoliosis repair and their outcomes.

PURPOSE OF REVIEW: Surgical management of spinal deformities in patients with neuromuscular diseases or other underlying comorbidities is often challenging, as this population is at an increased risk of experiencing complications. Identifying these patients early on in the preoperative planning process is imperative in order to improve patient outcomes. RECENT FINDINGS: Many recent studies have identified risk factors associated with perioperative and postoperative complications, including neuromuscular diseases, genetic syndromes, traumatic nerve/muscle injuries, seizure disorders, decreased cognitive ability, poor pulmonary status, restrictive lung disease, history of frequent pneumonias, sleep apnea, malnutrition, cardiac disease, immune-compromised patients, social status, ambulatory status, and the complexity of the procedure itself. SUMMARY: Management of spinal deformities in patients with neuromuscular diseases or other underlying comorbidities must be approached cautiously and in a multidisciplinary manner. Identifying these comorbidities early on, understanding their influence on patient outcomes after spinal surgery and managing high-risk patients through a common therapeutic and clinical pathway can help to improve patient outcomes.

Lowest instrumented vertebra selection in AIS.

Appropriate selection of the lowest instrumented vertebra (LIV) is crucial to ensure positive outcomes after surgical management of patients with adolescent idiopathic scoliosis. Failure to do so can lead to curve decompensation and "adding on" of additional vertebrae to the deformity. Correct identification of the stable, end, and neutral vertebra, whether the curve(s) is structural or nonstructural, and classifying the type of curve are essential aspects of preoperative planning. Evaluating curve flexibility using fulcrum, side bending, push-prone, and traction can be used to predict the amount of observed postoperative correction for both fused and unfused curves. In addition, these measures can be used to foresee potential residual LIV-tilt and disc wedging postoperatively. Intraoperative techniques such as fine tuning, derotation, wide release, and in situ contouring and instrumentation type used all influence the LIV selection and therefore, must be taken into account preoperatively. Surgical goals when treating adolescent idiopathic scoliosis include achieving a well-balanced spine in all planes while working to preserve segments and therefore, maintain mobility.

New neurologic deficit and recovery rates in the treatment of complex pediatric spine deformities exceeding 100 degrees or treated by vertebral column resection (VCR).

STUDY DESIGN: Prospective multicenter international observational study. OBJECTIVE: To investigate incidence of new neurologic deficit (NND) and the long-term recovery patterns following complex pediatric spine deformity surgery. The SRS M&M reports identify pediatric patients as having higher rate of new neurologic deficit compared with adults, while congenital and neuromuscular deformities are associated with higher new neurologic risks. Very few studies have had the large numbers of pediatric patients with curves exceeding 100 deg to ascertain the new neurologic deficit (NND) rates and recovery patterns as it relates to curve laterality and diagnosis. METHOD: The FOX pediatric database from 17 international sites was queried for New Neurologic Deficit (NND) as characterized by change in American Spinal Injury Association (ASIA) Lower or Upper Extremity Motor Score. Recovery rates at specific intervals were recorded and related to the curve type and etiology. RESULTS: Data of 286 consecutive patients with normal pre-operative neurologic exams were reviewed. There were 160 females vs 125 males with an average age of 14.6 years. NND occurred in 27 patients (9.4%) in the immediate post-operative period. Diagnostic categories included idiopathic scoliosis (3 patients); idiopathic kyphoscoliosis(5 patients); congenital scoliosis (7 patients); congenital kyphoscoliosis (4 patients); congenital kyphosis (6 patients), other kyphosis (1 patient) and syndromic (1 patient). 1 patient was lost to follow-up (f/u) after discharge; 1 had chronic deficits at the first post-operative erect visit (from discharge to 9 months f/u) and was subsequently lost to follow-up; 2 patients were improving at 1-year f/u but lost to subsequent f/u. 16 patients had normal neurologic function by the time of the first post-operative erect visit, 21 patients at 1-year f/u and 21 patients at the 2-year f/u. 2 patients (0.69%) had improved NND at 2-year mark. CONCLUSION: A significant proportion of patients with complex spine deformity experience NND. However, significant improvement in neurologic function can be expected over time as seen in this study without additional surgical intervention in most cases. Congenital deformities accounted for 63% of the patients experiencing NND.

Does thoracoplasty adversely affect lung function in complex pediatric spine deformity? A 2-year follow-up review.

STUDY DESIGN: Retrospective review of prospective multi-center cohort. OBJECTIVE: To investigate the impact of thoracoplasty on pulmonary function at 2-year follow-up among complex pediatric spine deformity patients. Complex pediatric spine deformities may be associated with significant rib prominence causing body image concerns. Surgical correction of spine deformity may include thoracoplasty to correct the rotational prominence. Some surgeons refrain from performing thoracoplasty due to its purported negative effect on pulmonary function. There is paucity of literature on the effect of thoracoplasty on pulmonary function at 2-year follow-up in pediatric patients with complex spine deformity. METHODS: We reviewed data of 312 patients (> 100°, with or without vertebral column resection (VCR)) or (< 100° with VCR)) from an international multicenter database. Data of 106 patients with complete radiographic and pulmonary function test (PFT) assessment with a minimum of 2-year follow-up was analyzed. Paired t test was performed to compare pre-op and 2-year PFT results. PFT comparison was stratified based on thoracoplasty status (thoracoplasty: Group 1 vs. no thoracoplasty: Group 2). RESULTS: 106 patients (61 patients Group 1 vs. 45 in Group 2). The average age and gender ratio were similar in both groups (p > 0.05). Group 1 had significantly lower body mass index (BMI) compared to Group 2 (18.4 kg m-2 ± 2.8 vs. 19.9 kg m-2 ± 4.8, p = 0.0351). The average baseline coronal and sagittal Cobbs were larger for Group 1 relative to Group 2 (p  < 0.05). The distribution of deformity etiology and curve types, and apices were similar between the two groups (p  >  0.05). The rate of pre-op utilization of halo gravity traction (HGT) was 52.5% vs. 26.7% (p  =  0.008), at an average duration of 103 days vs. 47 days, p  =  0.0001. The rate of surgical osteotomies was similar in both groups. Estimated blood volume (EBV) loss was greater in Group 1 (63.1% vs. 43.1%, p  =  0.0012). Post-op coronal and sagittal Cobb correction was similar in both groups. The incidence of post-op pulmonary complication was similar in both groups (8.2% vs. 8.9%, p  =  0.899). Baseline and 2-year follow-up PFT did not differ significantly between and within the groups. Vertebral column resection (VCR) did not negatively affect PFT in both groups. CONCLUSION: Despite higher curve magnitudes in patients undergoing surgical correction and thoracoplasty for complex pediatric spine deformity, our findings revealed that thoracoplasty does not negatively affect pulmonary function at 2-year follow-up.

Evaluation of high-risk patients undergoing spinal surgery: a matched case series.

BACKGROUND: Neuromuscular (NM) spinal deformities necessitating surgical intervention present a difficult challenge to the medical community. Underlying comorbidities lead to extended hospital stays, significant complications, and social challenges in the extensive perioperative period. In response to this problem, a therapeutic algorithm, the Care Pathway for Spinal Surgery (CAPSS) has been developed at our institution to address this complex medical issue. METHODS: In 1999, a multidisciplinary team developed a treatment protocol, CAPSS, that emphasized perioperative work up and operative scheduling under the direction of a dedicated care coordinator. A case series analysis was conducted to compare the surgical outcomes from before and after CAPSS implementation. Statistical analyses were performed on a carefully paired subset of NM patients (N=9). Outcome measures were hospital length of stay (LOS), pediatric intensive care unit LOS, number of days intubated, surgical estimated blood loss, postoperative curve magnitude, percent curve correction, and perioperative complications. RESULTS: Statistical analyses indicated that the use of CAPSS provided significant reduction in overall LOS, pediatric intensive care unit LOS, and perioperative complication rate within this patient group. CONCLUSIONS: CAPSS is an effective method to improve perisurgical care within the NM patients with spinal deformity necessitating operative stabilization. LEVEL OF EVIDENCE: III-Retrospective comparative study.

Willingness to enroll in a surgical randomized controlled trial: patient and parent preferences regarding implant density for adolescent idiopathic scoliosis fusion.

STUDY DESIGN: Prospective survey of adolescent idiopathic scoliosis (AIS) patients/parents with surgical magnitude curves. OBJECTIVE: We hypothesized that patients and families considering fusion surgery would be willing to enroll in a randomized controlled trial (RCT) evaluating the effect of number of implants on curve correction. Surgical RCTs are infrequently performed, particularly in a pediatric population. Parental willingness to enroll affects both study design and trial feasibility. The Minimize Implants Maximize Outcomes (MIMO) Clinical Trial proposes to randomize patients to more versus fewer screws (high or low density) for Lenke 1A curve patterns, but it is unclear whether families and patients are willing to enroll in such a trial. METHODS: This study was undertaken at 4 of the 14 sites participating in the MIMO Clinical Trial. AIS patients with Cobb > 45° were included. Implant density is defined as screws per level fused. Patients and families reviewed the MIMO education module describing proposed advantages and disadvantages of high (> 1.8) vs. low (< 1.4) density screw constructs and completed a custom survey regarding their preferences about the trial. RESULTS: 159 individuals were surveyed (78 families), including 82 parents/guardians, and 77 patients. Of those surveyed, 95% mostly or completely understood the trial (range 47-78%), and 63% agreed to enroll. Parents and patients who completely understood the trial were significantly more likely to enroll. CONCLUSION: Randomization in the MIMO Trial was acceptable to the majority (63%) of patients and parents. Clear patient and parent education materials and access to the surgeon may facilitate enrollment in the trial. Parents afforded the child much autonomy when considering enrollment, although most families agree both child and parent should be in agreement before entering the trial. LEVEL OF EVIDENCE: II.

Expression profile of nerve growth factor after muscle incision in the rat.

BACKGROUND: Previous studies have demonstrated that nerve growth factor (NGF) is an important mediator of pathologic pain. Many studies have focused on cutaneous mechanisms for NGF-induced hyperalgesia; few have examined its contribution in deeper tissues like muscle. This study examined pain behaviors and the expression of NGF in incised hind paw flexor digitorum brevis muscle. METHODS: Adult Sprague-Dawley rats were pretreated with anti-NGF peptibody and underwent skin or skin plus deep fascia and muscle incision. Guarding pain behaviors were measured. Muscle NGF messenger RNA (mRNA) was measured by reverse-transcriptase polymerase chain reaction. Changes in NGF protein expression were measured using Western blot, enzyme-linked immunosorbent assay, and immunohistochemistry. In situ hybridization for NGF mRNA was also performed. RESULTS: Pretreatment with anti-NGF peptibody (100 mg/kg) decreased the guarding behavior caused by deep fascia and muscle incision. Muscle NGF mRNA increased abruptly 2 h after incision and was the same as control by postoperative day 1. NGF protein increased from 4 h after incision and was sustained for several days. NGF was localized in many calcitonin gene-related peptide-positive axons, few N52-positive axons, but not isolectin B4-positive axons in incised muscle. The sources of NGF mRNA included keratinocytes in epidermis and fibroblasts in deeper tissues. CONCLUSION: Fibroblasts adjacent to the injury are sources of NGF in incised muscle. NGF is upregulated by incision of muscle and contributes to guarding pain behavior.

3 case reports of edema associated with quetiapine.

BACKGROUND: Edema associated with quetiapine has been described in only one case report to date and represents a potentially serious adverse reaction. METHODS: We present a case series of 3 patients who developed bilateral leg edema following initiation of quetiapine. RESULTS: One of these patients had a recurrence of edema with subsequent rechallenge. Another patient developed quetiapine-induced edema following a prior episode of olanzapine-induced edema. All 3 cases present a compelling temporal relationship between the drug challenge and the adverse event. CONCLUSION: Prompt recognition and intervention with discontinuation of the offending agent is important for this potentially serious, seemingly idiosyncratic vascular complication.