Do Children With Medicaid Insurance Have Increased Revision Rates 5 Years After Posterior Spinal Fusions?

BACKGROUND: Socioeconomic disparities in musculoskeletal care are increasingly recognized, however, no studies to date have investigated the role of the insurance carrier on outcomes after posterior spinal fusion (PSF) with segmental spinal instrumentation for adolescent idiopathic scoliosis (AIS). METHODS: A US insurance dataset was queried using the PearlDiver Mariner software for all patients aged 10 to 18 undergoing PSF for a primary diagnosis of AIS between 2010 and 2020. Age, sex, geographic region, number of levels fused, and baseline medical comorbidities were queried. Complications occurring within 90 days of the index surgery were queried using the International Classification of Diseases, Ninth Revision (ICD-9) and International Classification of Diseases, 10th Revision (ICD-10) codes. Revision surgery was also queried up to 5 years after the index PSF. Categorical variables were compared using the Fisher χ 2 tests and continuous variables were compared using independent t tests. All-cause revision within 5 years was compared using the Kaplan-Meier analysis and a log-rank test. Significance was set at P -value <0.05. RESULTS: A total of 10,794 patients were identified with 9006 (83.4%) patients with private insurance and 1788 (16.6%) patients insured by Medicaid. The mean follow-up in the database was 5.36±3 years for patients with private insurance and 4.78±2.9 years for patients with Medicaid insurance ( P <0.001). Children with AIS and Medicaid insurance had a significantly higher prevalence of asthma, hypertension, and obesity. A larger percentage of children with Medicaid insurance (41.3%) underwent a ≥13-level PSF compared with privately insured children (34.5%) ( P <0.001). Medicaid patients did not experience higher odds of postoperative complications; in addition, revision surgeries occurred in 1.1% and 1.8% of patients with private insurance and Medicaid insurance, respectively at 5 years postoperatively ( P =0.223). CONCLUSION: Despite worse baseline comorbidities and longer fusion constructs, AIS patients insured with Medicaid did not have higher rates of complications or revisions at 5-year follow-up versus privately insured patients. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Effects of alternate wetting and drying on oxyanion-forming and cationic trace elements in rice paddy soils: impacts on arsenic, cadmium, and micronutrients in rice.

Rice is a global dietary staple and its traditional cultivation under flooded soil conditions leads to accumulation of arsenic (As) in rice grains. Alternate wetting and drying (AWD) is a widely advocated water management practice to achieve lower As concentrations in rice, water savings, and decreased methane emissions. It is not yet clear whether AWD leads to tradeoffs between concentrations of As and micronutrient elements (e.g., zinc, manganese, molybdenum) in rice grain. We analyzed pore water chemistry and rice grain composition data from a field experiment conducted in Arkansas, USA, in 2017 and 2018 to test the hypothesis that AWD will have diverging effects on oxyanion-forming (arsenic, molybdenum) vs. cationic (cadmium, zinc, manganese, copper) trace elements. This was hypothesized to occur via decreases in soil pH and/or precipitation of iron oxide minerals during oxidizing conditions under AWD. Solubility of all trace elements, except zinc, increased in more reducing conditions. Consistent with our hypothesis, AWD tended to increase grain concentrations of cationic elements while decreasing grain concentrations of oxyanionic elements. Decreases in total As in rice grains under AWD were mainly driven by changes in dimethylarsinic concentrations, with negligible changes in inorganic As. Linear mixed-effects modeling showed that effects of AWD on grain composition were more significant in 2017 compared to 2018. These differences may be related to the timing of dry-downs in the developmental stage of rice plants, with dry-downs during the heading stage of rice development leading to larger impacts on grain composition of certain elements. We also observed significant interannual variability in grain elemental composition from continuously-flooded fields and postulate the warmer temperatures in 2018 may have played a role in these differences.

A thoracoscopic anterior approach to the spine for adolescent idiopathic scoliosis does not have a detrimental effect on pulmonary function at 2 years compared to posterior-only surgery.

PURPOSE: This study aims to examine pulmonary function outcomes in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion (PSF) with an anterior thoracoscopic release compared to those undergoing PSF alone. METHODS: A retrospective review of patients with AIS over a 9-year period at a single institution compared 2 groups: PSF with video-assisted thoracoscopic surgery (PSF/VATS) and patients undergoing a posterior spinal fusion (PSF) alone. Standard radiographs and Forced Expiratory Volume (FEV1) and Forced Vital Capacity (FVC) were obtained preoperatively and at regular follow up periods up to 2-year post-operatively. Within group and between-group comparisons were performed. RESULTS: There were 110 patients in the study: 12 in the PSF/VATS cohort and 98 in the PSF only cohort. The PSF/VATS group were younger (12.6 vs. 14.6, p = 0.003) and had larger coronal curves (80.8° vs. 60.7°, p = 0.001), and worse preoperative FVC (64.7% vs. 79.6%, p = 0.018) and FEV1 (62.3% vs. 77.6%, p = 0.003). At 2 years, the percent coronal Cobb correction was greater in the PSF/VATS group (67.9% vs. 48.4%, p < 0.001) with greater improvement in thoracic height (32.8 mm vs. 20.7 mm, p = 0.028). While the 2-year PFTs were the same for FEV1% (75.8% vs. 81.8%, p = 0.368) and FVC% (77.3% vs. 83.7%, p = 0.562), there was greater percent improvement over the 2 years in the PSF/VATS cohort: FEV1% (13.5% vs. 4.2%, p = 0.082) and FVC% (12.7% vs. 4.1%, p = 0.112). CONCLUSION: AIS patients who have a VATS approach in addition to PSF have greater coronal plane correction and improved pulmonary function compared to PSF alone despite more severe spinal deformity and worse baseline pulmonary function.

The evolving stall rate of magnetically controlled growing rods beyond 2 years follow-up.

PURPOSE: Magnetically controlled growing rods (MCGR) have become the dominant distraction-based implant for the treatment of early onset scoliosis (EOS). Recent studies, however, have demonstrated rising rates of implant failure beyond short-term follow-up. We sought to evaluate a single-center experience with MCGR for the treatment of EOS to define the rate of MCGR failure to lengthen, termed implant stall, over time. METHODS: A single-center, retrospective review was conducted identifying children with EOS undergoing primary MCGR implantation. The primary endpoint was the occurrence of implant stalling, defined as a failure of the MCGR to lengthen on three consecutive attempted lengthening sessions with minimum of 2 years follow-up. Clinical and radiographic variables were collected and compared between lengthening and stalled MCGRs. A Kaplan-Meier survival analysis was conducted to assess implant stalling over time. RESULTS: A total of 48 children met inclusion criteria (mean age 6.3 ± 1.8 years, 64.6% female). After a mean 56.9 months (range of 27 to 90 months) follow-up, 25 (48%) of children experienced implant stalling at a mean of 26.0 ± 14.1 months post-implantation. Kaplan-Meier survival analysis demonstrated that only 50% of MCGR continue to successfully lengthen at 2 years post-implantation, decreasing to < 20% at 4 years post-implantation. CONCLUSION: Only 50% of MCGR continue to successfully lengthen 2 years post-implantation, dropping dramatically to < 20% at 4 years, adding to the available knowledge regarding the long-term viability and cost-effectiveness of MCGR in the management of EOS. Further research is needed to validate these findings.

Impact of surgical treatment on parent-reported health related quality of life measures in early-onset scoliosis: stable but no improvement at 2 years.

PURPOSE: The etiology of early-onset scoliosis (EOS) has been shown to significantly influence baseline parent-reported health-related quality of life (HRQoL) measures as assessed by the Early Onset Scoliosis Questionnaire (EOSQ). We sought to assess the influence of distraction-based surgery and scoliosis etiology on EOSQ 2 years following surgical intervention remains unclear. METHODS: A retrospective review of a multi-center prospective EOS database was performed. Children untreated with distraction-based, growth friendly instrumentation for EOS with completed baseline and 2-year post-surgical EOSQ were included. Children were subdivided by curve etiology individually and in combined cohorts (congenital/idiopathic [C/I], neuromuscular/syndromic [NMS]). EOSQ domains and compositive HRQoL score at presentation and 2-year follow-up were compared across C-EOS etiologies. Minimal clinically important difference (MCID) was defined as ≥ 20% change in domain score and compared across etiologies. RESULTS: 150 children with EOS met inclusion criteria (mean 7.09 ± 2.6 years, 58.9% female). There were no differences in EOSQ domains between Congenital vs. Idiopathic nor NM vs. Syndromic etiologies at any timepoint. Combined C/I children demonstrated significantly higher EOSQ scores than combined NMS at initial and 2-years post-treatment. Etiology remained the only independent predictor of 2-year EOSQ composite HRQoL score. Overall, the vast majority of children demonstrated stable HRQoL composite scores, with a trend toward more positive MCID in NMS etiologies. CONCLUSION: EOS etiology remains the most significant influence on EOSQ scores 2 years following surgical intervention. However, the majority of patients, regardless of etiology, maintain stable HRQoL scores suggesting that surgery may only serve to stabilize HRQoL at 2 years.

Arsenic speciation in rice bran: Agronomic practices, postharvest fermentation, and human health risk assessment across the lifespan.

Arsenic (As) exposure is a global public health concern affecting millions worldwide and stems from drinking water and foods containing As. Here, we assessed how agronomic practices and postharvest fermentation techniques influence As concentrations in rice bran, and calculated health risks from consumption. A global suite of 53 rice brans were tested for total As and speciation. Targeted quantification of inorganic As (iAs) concentrations in rice bran were used to calculate Target Hazard Quotient (THQ) and Lifetime Cancer Risk (LCR) across the lifespan. Mean iAs was highest in Thailand rice bran samples (0.619 mg kg-1) and lowest in Guatemala (0.017 mg kg-1) rice bran samples. When comparing monosodium-methanearsonate (MSMA) treated and the Native-soil counterpart under the irrigation technique Alternate Wetting and Drying (AWD) management, the MSMA treatment had significantly higher total As (p = 0.022), and iAs (p = 0.016). No significant differences in As concentrations were found between conventional and organic production, nor between fermented and non-fermented rice bran. Health risk assessment calculations for the highest iAs-rice bran dosage scenario for adults, children and infants exceeded THQ and LCR thresholds, and LCR was above threshold for median iAs-rice bran. This environmental exposure investigation into rice bran provides novel information with food safety guidance for an emerging global ingredient.

Growth-Friendly Spine Surgery in Arthrogryposis Multiplex Congenita.

BACKGROUND: Arthrogryposis multiplex congenita (AMC) is a condition that describes neonates born with ≥2 distinct congenital contractures. Despite spinal deformity in 3% to 69% of patients, inadequate data exist on growth-friendly instrumentation (GFI) in AMC. Our study objectives were to describe current GFI trends in children with AMC and early-onset scoliosis (EOS) and to compare long-term outcomes with a matched idiopathic EOS (IEOS) cohort to determine whether spinal rigidity or extremity contractures influenced outcomes. METHODS: Children with AMC and spinal deformity of ≥30° who were treated with GFI for ≥24 months were identified from a multicenter EOS database (1993 to 2017). Propensity scoring matched 35 patients with AMC to 112 patients with IEOS with regard to age, sex, construct, and curve. Multivariable linear mixed modeling compared changes in spinal deformity and the 24-item Early Onset Scoliosis Questionnaire (EOSQ-24) across cohorts. Cohort complications and reoperations were analyzed using multivariable Poisson regression. RESULTS: Preoperatively, groups did not differ with regard to age (p = 0.87), sex (p = 0.96), construct (p = 0.62), rate of nonoperative treatment (p = 0.54), and major coronal curve magnitude (p = 0.96). After the index GFI, patients with AMC had reduced percentage of coronal correction (35% compared with 44%; p = 0.01), larger residual coronal curves (49° compared with 42°; p = 0.03), and comparable percentage of kyphosis correction (17% compared with 21%; p = 0.52). In GFI graduates (n = 81), final coronal curve magnitude (55° compared with 43°; p = 0.22) and final sagittal curve magnitude (47° compared with 47°; p = 0.45) were not significantly different at the latest follow-up after definitive surgery. The patients with AMC had reduced T1-S1 length (p < 0.001), comparable T1-S1 growth velocity (0.66 compared with 0.85 mm/month; p = 0.05), and poorer EOSQ-24 scores at the time of the latest follow-up (64 compared with 83 points; p < 0.001). After adjusting for ambulatory status and GFI duration, patients with AMC developed 51% more complications (incidence rate ratio, 1.51 [95% confidence interval (CI), 1.11 to 2.04]; p = 0.009) and 0.2 more complications/year (95% CI, 0.02 to 0.33 more; p = 0.03) compared with patients with IEOS. CONCLUSIONS: Patients with AMC and EOS experienced less initial deformity correction after the index surgical procedure, but final GFI curve magnitudes and total T1-S1 growth during active treatment were statistically and clinically comparable with IEOS. Nonambulatory patients with AMC with longer GFI treatment durations developed the most complications. Multidisciplinary perioperative management is necessary to optimize GFI and to improve quality of life in this complex population. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effect of Etiology, Radiographic Severity, and Comorbidities on Baseline Parent-Reported Health Measures for Children with Early-Onset Scoliosis.

BACKGROUND: The Classification of Early-Onset Scoliosis (C-EOS) allows providers to differentiate patients, for clinical and research purposes, on the basis of the etiology of their disease as well as radiographic parameters. The Early Onset Scoliosis Questionnaire (EOSQ) is the first disease-specific, parent-reported HRQOL (health-related quality-of-life) outcome measure for this condition. We sought to determine the influence of the C-EOS etiology designation, radiographic parameters, and medical comorbidities on EOSQ scores to differentiate quality of life in this heterogeneous patient population. We hypothesized that baseline EOSQ scores for patients with EOS would be strongly affected by the C-EOS etiology designation. METHODS: The analysis included prospectively enrolled patients with EOSQ scores recorded in a multicenter EOS database prior to intervention for the EOS. EOSQ scores were compared across C-EOS etiologies, severity of disease based on radiographic measurements, and patient comorbidities prior to scoliosis intervention. RESULTS: Six hundred and ten patients with EOS were available for analysis; 119 had congenital, 201 had idiopathic, 156 had neuromuscular, and 134 had syndromic EOS. In multivariate analysis, neuromuscular and syndromic etiologies were associated with lower scores than congenital and idiopathic etiologies in many EOSQ domains including general health, transfer, daily living, fatigue/energy level, and emotion. Patients with neuromuscular EOS had the lowest EOSQ scores in general. Congenital and idiopathic EOS did not differ from each other in any EOSQ domain. Coronal Cobb and kyphosis angles had significant inverse but generally weak correlations with EOSQ domains. Individual medical comorbidities had a minor effect on certain domains while American Society of Anesthesiologists (ASA) class and total number of comorbidities had inverse correlations with most domains. CONCLUSIONS: The underlying etiology of EOS appears to have a significant influence on the parent-reported HRQOL outcomes of the disease. Specifically, syndromic and neuromuscular C-EOS diagnoses are associated with lower EOSQ scores before treatment compared with congenital and idiopathic diagnoses. Radiographic measurements of severity have a relatively small influence on EOSQ scores. These baseline differences in C-EOS-designated etiology should be accounted for in studies comparing outcomes of treatment for this heterogeneous patient population. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The growth-friendly surgical treatment of scoliosis in children with osteogenesis imperfecta using distraction-based instrumentation.

PURPOSE: The study was undertaken to determine the feasibility of growth-friendly distraction-based surgery in children with OI. METHODS: Two multi-center databases were queried for children with OI who had undergone GR or VEPTR surgery. Inclusion criteria were a minimum 2-year follow-up and three lengthening procedures following the initial implantation. Details of the surgical techniques, surgical complications, and radiographic measurements of deformity correction, T1-T12 and T1-S1 elongation and growth were recorded. RESULTS: Five patients were identified. There was one patient with type I OI and two patients each with type III and type IV. Four patients had GR constructs and one a VEPTR construct. The initial scoliosis deformity averaged 80° (70°-103°), and the subsequent corrections averaged 32% for initial correction, 48% at last follow-up, and 54% for the two patients that had a final fusion. The T1-T12 and T1-S1 growth averaged 31 mm and 44 mm respectively, and yearly growth averaged 4 mm and 6 mm, respectively. Growth was notably much less in those with more severe disease. There were 13 complications in 4 patients. Nine of the 10 surgical complications were anchor failures which were corrected in 7 planned and 2 un-planned procedures. Significant migration occurred in one patient with severe OI type III. CONCLUSION: The results varied in this heterogeneous population. In general, satisfactory deformity corrections were obtained and maintained, modest growth was obtained, and complications were similar to those reported in other series of growth-friendly surgery. Limited growth and significant anchor migration are to be anticipated in this population. LEVEL OF EVIDENCE: IV.

Growth-preserving instrumentation in early-onset scoliosis patients with multi-level congenital anomalies.

STUDY DESIGN: Retrospective. OBJECTIVES: To assess final outcomes in patients with early-onset scoliosis (EOS) who underwent growth-preserving instrumentation (GPI). Various types of growth-preserving instrumentation (GPI) are frequently employed, but until recently had not been utilized long enough to assess final outcomes. METHODS: GPI "graduates" with multi-level congenital curves were identified. Graduation was defined as a final fusion or 5 years of follow-up without planned future surgeries. Outcomes included radiographic parameters and complications. RESULTS: 26 patients were included. 11 had associated diagnoses; eight had fused ribs. 17 were treated with traditional growing rods, seven with vertically expandable prosthetic ribs, and two with Shilla procedures. The mean GPI spanned 12.3 levels including 10.7 motion segments, age at index surgery was 5.5 years, treatment spanned 7.5 years, and follow-up was 9.2 years. 24 patients underwent final fusion. Mean major curve decreased from 73° to 49° with index surgery (p < 0.01) and remained unchanged through a final follow-up. Final major curve was < 40° in 9 patients (35%), 40°-60° in 11 patients (42%), and > 60° in 6 patients (23%). None worsened throughout treatment. Mean T1-T12 height increased 2.4 cm with index surgery (p = 0.02) and 5.4 cm total (p < 0.01). T1-T12 height increased in all patients and was ultimately < 18 cm in 10 patients (38%), 18-22 cm in 10 patients (38%), and > 22 cm in 6 patients (23%). On average, there were 2.6 complications per patient, including 1.7 implant failures. 12 patients (46%) experienced ≥ 3 complications; four patients (15%) experienced none. CONCLUSION: We observed successful prevention of deformity progression but substantial residual deformity among GPI graduates with multi-level congenital EOS. Most coronal curve correction was attained during GPI implantation; thoracic height improved throughout treatment. While some favorable results were found, treatment strategies allowing improved deformity correction would be valuable for this challenging population. LEVEL OF EVIDENCE: Therapeutic-III.

Spinal Deformity in Sotos Syndrome: First Results of Growth-friendly Spine Surgery.

BACKGROUND: Sotos syndrome (SS), or cerebral gigantism, describes children with macrocephaly, craniofacial abnormalities, general overgrowth, ligamentous laxity, developmental delay, and neurological disabilities. Fewer than 500 cases have been reported since Sotos and colleagues described the condition in 1964 and no literature exists on the management of spinal deformity in children under 10 years old.The aims of this study were: (1) to characterize the presentation of spinal deformities in patients with SS; and (2) to provide preliminary results of growth-friendly instrumentation (GFI) in these children. METHODS: Thirteen children (9 boys) with SS and minimum of 2-year follow-up were identified from 2 multicenter early-onset scoliosis (EOS) databases (1997-2017). Mean age at index surgery and follow-up duration were 5.0 years (range, 1.8 to 10 y) and 7.2 years (range, 2.1 to 14.9 y), respectively. Patients underwent GFI for a mean of 5.7 years (range, 2 to 10.2 y), with an average of 9 lengthenings (range, 2 to 18). Definitive spinal fusion was performed in 4 patients (31%). Major curve magnitude, T1-T12 and T1-S1 lengths, thoracic kyphosis, and lumbar lordosis were evaluated preindex, postindex, latest GFI, and postfusion, when possible. RESULTS: Five thoracolumbar (38%), 4 double major (31%), 2 main thoracic (15%), and 2 double thoracic curves (15%) were seen that spanned a mean of 6.8 levels (5 to 9). Major curves improved 36% (range, 5% to 71%), from a mean of 71 degrees (range, 48 to 90 degrees) to 46 degrees (range, 20 to 73 degrees) postindex surgery (P<0.001). Major curves remained stable at a mean of 52 degrees (range, 20 to 87 degrees) at latest GFI (P=0.36). True T1-T12 and T1-S1 growth velocities during GFI were 0.5 mm/mo (range, 0.4 to 0.8 mm/mo) and 0.8 mm/mo (range, 0.1 to 2.1 mm/mo), respectively. Twenty-six complications occurred in 9 patients (69%) averaging 2 complications per patient (range, 0 to 7). CONCLUSIONS: This is the first study to evaluate the outcomes of GFI in children with SS and EOS. Compared with published data for outcomes of GFI in EOS, children with SS may have less major curve correction. Growth-friendly surgery remains an effective treatment method for EOS in patients with SS. LEVELS OF EVIDENCE: Level IV-retrospective case-series.

MRI utilization and rates of abnormal pretreatment MRI findings in early-onset scoliosis: review of a global cohort.

STUDY DESIGN: Retrospective review OBJECTIVES: To report the frequency of pretreatment magnetic resonance imaging (MRI) utilization and rates and types of intra-spinal abnormalities identified on MRI in patients with early-onset scoliosis (EOS). MRI can help identify spinal cord abnormalities in patients with EOS. METHODS: We reviewed data from patients enrolled from 1993-2018 in an international EOS registry. Patients with incomplete/unverifiable data and those with spinal deformities secondary to infection or tumor were excluded, leaving 1343 patients for analysis. Demographic characteristics, pretreatment major curve magnitude, treatment type, and MRI findings were analyzed. Patients were categorized by EOS type (congenital, idiopathic, neuromuscular, syndromic), pretreatment MRI utilization, and presence of intra-spinal abnormality on MRI. Univariate testing and multivariate logistic regression were performed to identify demographic, radiographic, and clinical predictors of MRI utilization and abnormal MRI findings. RESULTS: MRI was used in 836 patients (62%). Pretreatment MRI utilization rates ranged from 42% in neuromuscular EOS to 74% in congenital EOS. Prevalence of abnormal MRI findings was 24% overall, ranging from 13% in patients with idiopathic EOS to 39% in neuromuscular EOS. Compared with white/Caucasian patients, Asian/Asian-American patients had higher odds of MRI utilization and abnormal MRI findings. Treatment type, pretreatment major curve magnitude, age at MRI, and age at treatment were not associated with abnormal MRI findings. Overall, 249 abnormalities were identified in 197 patients. The most common findings were syrinx and tethered cord. Syrinx with Chiari malformation was the most frequent combination of abnormal findings. CONCLUSION: In the two-thirds of patients who underwent MRI before EOS treatment, findings were abnormal in 24%. EOS type and race/ethnicity were associated with both MRI utilization and abnormal findings. The most frequent abnormalities were syrinx and tethered cord, and the type of abnormalities appeared to differ by EOS type. LEVEL OF EVIDENCE: Prognostic, Level III.

Idiopathic Early-onset Scoliosis: Growing Rods Versus Vertically Expandable Prosthetic Titanium Ribs at 5-year Follow-up.

BACKGROUND: Distraction-based techniques allow spinal growth until skeletal maturity while preventing curve progression. METHODS: Two multicenter early-onset scoliosis databases were used to identify patients with idiopathic spine abnormalities treated with traditional growing rods (TGR) or vertically expandable titanium ribs (VEPTR). Patients underwent at least 4 lengthenings and had at least 5-year follow-up. Significance was set at P<0.05. RESULTS: In total, 50 patients treated with TGR and 22 treated with VEPTR were included. Mean (±SD) age at surgery was 5.5 (±2.0) years for the TGR group versus 4.3 (±1.9) years for the VEPTR group (P=0.044); other demographic parameters were similar. VEPTR patients had more procedures (mean 15±4.2) than TGR patients (mean 10±4.0) (P=0.001). Unilateral constructs were present in 18% (4 of 22) of VEPTR and 16% (8 of 50) of TGR patients. Bilateral constructs spanned a mean 2.1 additional surgical levels and exposed patients to 1.6 fewer procedures than unilateral constructs. Curve correction was similar between bilateral and unilateral constructs. TGR patients experienced greater curve correction (50%) than VEPTR patients (27%) (P<0.001) and achieved a greater percentage of thoracic height gain (24%) than VEPTR patients (12%) (P=0.024). At latest follow-up, TGR patients had better maintenance of curve correction, less kyphosis, and 15% greater absolute gain in thoracic height versus VEPTR patients. TGR patients had a lower rate of wound complications (14%) than VEPTR patients (41%) (P=0.011). CONCLUSIONS: In patients with idiopathic early-onset scoliosis, TGRs produced greater initial curve correction, greater thoracic height gains, less kyphosis, and lower incidence of wound complications compared with VEPTR. LEVEL OF EVIDENCE: Level III.

Results of growth-friendly management of early-onset scoliosis in children with and without skeletal dysplasias: a matched comparison.

AIMS: The aim of this study was to compare the surgical and quality-of-life outcomes of children with skeletal dysplasia to those in children with idiopathic early-onset scoliosis (EOS) undergoing growth-friendly management. PATIENTS AND METHODS: A retrospective review of two prospective multicentre EOS databases identified 33 children with skeletal dysplasia and EOS (major curve ≥ 30°) who were treated with growth-friendly instrumentation at younger than ten years of age, had a minimum two years of postoperative follow-up, and had undergone three or more lengthening procedures. From the same registries, 33 matched controls with idiopathic EOS were identified. A total of 20 children in both groups were treated with growing rods and 13 children were treated with vertical expandable prosthetic titanium rib (VEPTR) instrumentation. RESULTS: Mean preoperative major curves were 76° (34° to 115°) in the skeletal dysplasia group and 75° (51° to 113°) in the idiopathic group (p = 0.55), which were corrected at final follow-up to 49° (13° to 113°) and 46° (12° to 112°; p = 0.68), respectively. T1-S1 height increased by a mean of 36 mm (0 to 105) in the skeletal dysplasia group and 38 mm (7 to 104) in the idiopathic group at the index surgery (p = 0.40), and by 21 mm (1 to 68) and 46 mm (7 to 157), respectively, during the distraction period (p = 0.0085). The skeletal dysplasia group had significantly worse scores in the physical function, daily living, financial impact, and parent satisfaction preoperatively, as well as on financial impact and child satisfaction at final follow-up, than the idiopathic group (all p < 0.05). The domains of the 24-Item Early-Onset Scoliosis Questionnaire (EOSQ24) remained at the same level from preoperative to final follow-up in the skeletal dysplasia group (all p > 0.10). CONCLUSION: Children with skeletal dysplasia gained significantly less spinal growth during growth-friendly management of their EOS and their health-related quality of life was significantly lower both preoperatively and at final follow-up than in children with idiopathic EOS. Cite this article: Bone Joint J 2019;101-B:1563-1569.

Superior Extension of Upper Instrumented Vertebrae in Distraction-based Surgery: A Surrogate for Clinically Significant Proximal Junctional Kyphosis.

BACKGROUND: Proximal junctional kyphosis (PJK) is a reported complication of distraction-based growth-friendly surgery for early-onset scoliosis (EOS). A potential consequence of PJK is revision surgery with superior extension of the upper instrument vertebrae (UIV). The purpose of this study was to determine the risk of radiographic and clinically significant PJK during growth-friendly surgery. METHODS: This is a retrospective review of children treated with distraction-based growth-friendly surgeries from two EOS registries with minimum two-year follow-up. PJK is defined as clinically significant in this study if surgery with superior extension of the UIV was performed. RESULTS: Of 419 total patients, there was a 20% risk of developing clinically significant PJK (24% rib vs. 15% spine-based anchors, p = .03). These patients had a mean preoperative age of 5.6 years (5.2-year rib vs. 6.0-year spine, p < .001), scoliosis of 73° (69° rib vs. 77° spine, p < .001), and kyphosis of 51° (47° rib vs. 56° spine, p < .01). Regression analysis demonstrated that these differences in age, scoliosis, and kyphosis between anchor type did not account for a significant proportion of the measured variance. CONCLUSIONS: There was a 20% risk of developing clinically significant PJK, with a slightly higher risk for patients treated with rib-based proximal anchors (24%) than for those patients treated with spine-based proximal anchors (15%). LEVEL OF EVIDENCE: Level III.

Surgical and Health-related Quality-of-Life Outcomes of Growing Rod "Graduates" With Severe versus Moderate Early-onset Scoliosis.

STUDY DESIGN: A retrospective review of a prospective, multicenter database. OBJECTIVE: The aim of this study was to compare surgical and quality-of-life outcomes at the end of growing rod treatment in patients with severe versus moderate early-onset scoliosis (EOS). SUMMARY OF BACKGROUND DATA: Knowledge of the outcomes of severe EOS after growth-friendly treatment is limited because this condition is uncommon. METHODS: We identified 40 children with severe EOS (major curve ≥90°) treated with growing rods before age 10 with minimum 2-year follow-up after last lengthening or final fusion. From the same registry, we matched 40 patients with moderate EOS (major curve < 90°). Twenty-seven patients in the severe group and 12 in the moderate group underwent final fusion (P < 0.001). RESULTS: Mean preoperative curves were 102° (range, 90°-139°) in the severe group and 63° (range, 33°-88°) in the moderate group (P < 0.001). At final follow-up, mean curves were 56° (range, 10°-91°) and 36° (range, 12°-89°), respectively (P < 0.001). Fourteen (35%) children in the severe group and 32 (80%) in the moderate group had scoliosis of < 45° at final follow-up [risk ratio (RR), 0.44; 95% confidence interval (95% CI), 0.20-0.57]. At final follow-up, 30 (75%) children in the severe group and 35 (88%) in the moderate group had achieved T1-T12 length of ≥18 cm (RR, 0.86; 95% CI, 0.70-1.09). Thirty-five children in the severe group and 26 in the moderate group had at least one complication (RR, 1.35; 95% CI, 1.05-1.73). Mean 24-Item Early-Onset Scoliosis Questionnaire scores were similar between groups at final follow-up. CONCLUSION: Delaying surgery until the major curve has progressed beyond 90° is associated with larger residual deformity and more complications than treating at a lesser curve magnitude. Quality-of-life outcomes were similar between those with severe and moderate EOS. LEVEL OF EVIDENCE: 3.

Radiographic Outcome Differences in Distraction-Based Growing Rod Constructs Using Tandem Versus Wedding Band Connectors.

STUDY DESIGN: Comparative cohort study. OBJECTIVE: To compare coronal deformity control, lengthening efficacy, and sagittal alignment between distraction-based growing rod constructs utilizing tandem versus wedding band connectors. SUMMARY OF BACKGROUND DATA: Different construct designs exist for growing rod treatment of early-onset scoliosis. All use a version of a rod connector, with the two main types being tandem and wedding band. Little data exist to quantify the impact of connector choice on radiographic outcomes of treatment. METHODS: A multicenter database of prospectively and retrospectively collected data on early-onset scoliosis patients was reviewed. Patients of any thoracic or thoracolumbar coronal plane deformity whose initial growing rod treatment was initiated before age 10 years and underwent at least 3 years of dual growing rod treatment with either tandem or wedding band connectors were included. Preoperative, immediate postoperative, and prefinal radiographs were reviewed and compared in regard to major curve magnitude, T1-T12 and T1-S1 spinal length, length of instrumentation, and sagittal plane measures. RESULTS: A total of 209 patients were included. The overall percent change from preoperative to prefinal in all radiographic parameters was not different between the two groups indicating similar efficacy in treatment. After controlling for institutional variation, the improvement of the major coronal Cobb angle from preoperative to prefinal was statistically improved for the tandem group (34° vs. 29°, p = .002) and the difference in T5-T12 kyphosis from preoperative to prefinal was significantly different between the groups (-6° vs. +1.3°, p = .008). CONCLUSION: We identified little difference in the effects of connector type on radiographic outcomes of patients treated with traditional growing rod, which indicates that both wedding band and tandem connectors function similarly. The small differences detected suggest that tandem connectors may improve major Cobb correction, and wedding band connectors may maintain thoracic kyphosis over time. LEVEL OF EVIDENCE: Level III.

In Vitro Fermentation Patterns of Rice Bran Components by Human Gut Microbiota.

Whole grain rice is a rich source of fiber, nutrients, and phytochemicals that may promote gastrointestinal health, but such beneficial components are typically removed with the bran during polishing. Soluble feruloylated arabinoxylan oligosaccharides (FAXO) and polyphenols (RBPP) isolated from rice bran are hypothesized to have positive impacts on human gut microbiota through a prebiotic function. Using an in vitro human fecal fermentation bioassay, FAXO and RBPP treatments were assessed for short-chain fatty acids (SCFA) production patterns and by evaluating their impacts on the phylogentic composition of human gut microbiota by 16S rRNA gene sequencing. Fresh fecal samples collected from healthy adults (n = 10, 5 males, 5 females) were diluted with anaerobic medium. Each sample received five treatments: CTRL (no substrates), FOS (fructooligosaccharides), FAXO, RBPP, and MIX (FAXO with RBPP). Samples were incubated at 37 °C and an aliquot was withdrawn at 0, 4, 8, 12, and 24 h Results showed that SCFA production was significantly increased with FAXO and was comparable to fermentation with FOS, a well-established prebiotic. RBPP did not increase SCFA productions, and no significant differences in total SCFA production were observed between FAXO and MIX, indicating that RBPP does not modify FAXO fermentation. Changes in microbiota population were found in FAXO treatment, especially in Bacteroides, Prevotella, and Dorea populations, indicating that FAXO might modulate microbiota profiles. RBPP and MIX increased Faecalibacterium, specifically F. prausnitzii. Combined FAXO and RBPP fermentation increased abundance of butyrogenic bacteria, Coprococcus and Roseburia, suggesting some interactive activity. Results from this study support the potential for FAXO and RBPP from rice bran to promote colon health through a prebiotic function.

Functional and Radiographic Outcomes Following Growth-Sparing Management of Early-Onset Scoliosis.

BACKGROUND: In this study, we sought to evaluate radiographic, functional, and quality-of-life outcomes of patients who have completed growth-sparing management of early-onset scoliosis. METHODS: This prospective study involved patients with early-onset scoliosis who underwent growth-sparing treatment and either "final" fusion or observation for ≥2 years since the last lengthening procedure. Demographics, radiographic parameters, pulmonary function test (PFT) values, and scores of patient-reported assessments (Early-Onset Scoliosis Questionnaire [EOSQ] and Scoliosis Research Society [SRS]-30) were obtained. At the most recent follow-up, patients performed 2 additional functional outcome tests: step-activity monitoring and a treadmill exercise-tolerance test. RESULTS: Twelve patients were evaluated as "graduates" of growth-sparing management of early-onset scoliosis (mean of 37 months since the most recent surgery). The major scoliosis curve measurement averaged 88° before treatment and 47° at the most recent follow-up. T1-S1 height increased from a mean of 22.3 cm to 34.7 cm and T1-T12 height, from 13.3 to 22.3 cm. At the most recent follow-up, the mean forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) as a percentage of the predicted volume were 52.1% and 55.3%, respectively, and were essentially unchanged from the earliest PFT that patients could perform (FEV1 = 53.8% of predicted and FVC = 53.5% of predicted). There was no difference between graduates and controls with respect to activity time or total steps in step-activity monitoring, and in the exercise-tolerance test, graduates walked at the same speed but at a higher heart rate and at a significantly higher (p <0.001) VO2 cost (rate of oxygen consumed per distance traveled). The EOSQ mean score was 102.2 of a possible 120 points, and the SRS mean score was 4.1 of a possible 5 points. CONCLUSIONS: A realistic long-term goal for the management of early-onset scoliosis appears to be spine elongation and maintenance of pulmonary function at a level that is no less than the percentage of normal at initial presentation. Functional testing and patient-reported outcomes at a mean of 3 years from the last surgery suggest that activity levels were generally equal to those of controls but required greater physiologic demand. General health and physical function outcomes revealed continued impairment in these domains. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Paper #20: Vertebral Column Resection for Early-Onset Scoliosis: Indications, Utilization and Outcomes.

EOS treated with VCR were predominantly congenital or myelomeningocele with 84% performed at index surgery and 70% definitive fusion. Correction of major curve was 69% and increases in spinal and thoracic height. Complication rate was 33% with 57% being IONM/neuro related.