Vertebral body tethering for Lenke 1A curves: the lumbar modifier predicts less optimal outcomes.

INTRODUCTION: The addition of the L4 "AR" and "AL" lumbar modifier for Lenke 1A idiopathic scoliosis (IS) has been shown to direct treatment in posterior spinal fusion; however, its utility in vertebral body tethering (VBT) has yet to be evaluated. METHODS: A review of a prospective, multicenter database for VBT in IS was performed for patients with Lenke 1A deformities and a minimum of 2 years follow-up. Patients were categorized by their lumbar modifier (AR vs AL). Less optimal VBT outcome (LOVO) was defined as a final coronal curve > 35°, lumbar adding-on, or revision surgery for deformity progression or adding-on. RESULTS: Ninety-nine patients met inclusion criteria (81% female, mean 12.6 years), with 55.6% being AL curves. Overall, there were 23 instances of tether breakage (23.3%) and 20 instances of LOVO (20.2%). There was a higher rate of LOVO in AR curves (31.8% vs 10.9%, P = 0.01). Patients with LOVO had greater preoperative deformity, greater apical translation, larger coronal deformity on first erect radiographs, and less coronal deformity correction. Failure to correct the deformity < 30° on first erect was associated with LOVO, as was LIV selection short of the last touch vertebra (TV). Independent risk factors for LOVO included AR curves (OR 3.4; P = 0.04) and first erect curve magnitudes > 30 degrees (OR 6.0; P = 0.002). DISCUSSION: There is a 20.2% rate of less optimal VBT following VBT for Lenke 1A curves. AR curves are independently predictive of less optimal outcomes following VBT and require close attention to LIV selection. Surgeons should consider achieving an initial coronal correction < 30 degrees and extending the LIV to at least the TV to minimize the risk of LOVO.

Consensus-Based Best Practice Guidelines for the Management of Spinal Deformity and Associated Tumors in Pediatric Neurofibromatosis Type 1: Screening and Surveillance, Surgical Intervention, and Medical Therapy.

BACKGROUND: Spinal conditions, such as scoliosis and spinal tumors, are prevalent in neurofibromatosis type 1 (NF1). Despite the recognized importance of their early detection and treatment, there remain knowledge gaps in how to approach these manifestations. The purpose of this study was to utilize the experience of a multidisciplinary committee of experts to establish consensus-based best practice guidelines (BPGs) for spinal screening and surveillance, surgical intervention, and medical therapy in pediatric patients with NF1. METHODS: Using the results of a prior systematic review, 10 key questions that required further assessment were first identified. A committee of 20 experts across medical specialties was then chosen based on their clinical experience with spinal deformity and tumors in NF1. These were 9 orthopaedic surgeons, 4 neuro-oncologists/oncologists, 3 neurosurgeons, 2 neurologists, 1 pulmonologist, and 1 clinical geneticist. An initial online survey on current practices and opinions was conducted, followed by 2 additional surveys via a formal consensus-based modified Delphi method. The final survey involved voting on agreement or disagreement with 35 recommendations. Items reaching consensus (≥70% agreement or disagreement) were included in the final BPGs. RESULTS: Consensus was reached for 30 total recommendations on the management of spinal deformity and tumors in NF1. These were 11 recommendations on screening and surveillance, 16 on surgical intervention, and 3 on medical therapy. Five recommendations did not achieve consensus and were excluded from the BPGs. CONCLUSION: We present a set of consensus-based BPGs comprised of 30 recommendations for spinal screening and surveillance, surgical intervention, and medical therapy in pediatric NF1.

Avoiding PICU admission following PSF for neuromuscular scoliosis in non-ambulatory cerebral palsy managed with ERAS protocol.

PURPOSE: Children with neuromuscular scoliosis (NMS) undergoing posterior spinal fusion (PSF) have historically been managed post-operatively in the pediatric intensive care unit (PICU) due to institutional tendencies. This study sought to define risk factors for PICU admission when using an enhanced recovery after surgery (ERAS) pathway. METHODS: A retrospective review of children with non-ambulatory (GMFCS 4 or 5) cerebral palsy undergoing PSF for NMS performed at two institutions by 5 surgeons. Both institutions have a pre-existing ERAS pathway for NMS patients consisting of post-surgical transfer to the hospital floor with early reinstitution of feeding and mobilization. PICU admission is used at the discretion of the surgeon and anesthesiologist rather than by institutional decree. Patient and surgical factors were assessed for risk factors of PICU admission. RESULTS: A total of 103 children were included (84% GMFCS 5, mean 14.52 years (± 3.4 years)). Forty children (38.8%) required postoperative PICU admission. PICU admission was associated with seizure disorder (P = 0.09), pre-existing feeding tube (P = 0.003), tracheostomy (P = 0.03), and modified GMFCS-5 subclassification (P = 0.003). Independent predictors of PICU admission include pre-existing feeding (Odd's ratio = 2.9, P = 0.02) and length of surgery (Odd's ratio = 2.6, P < 0.001), with surgery lasting ≥ 5.0 h having an 82.5% sensitivity and 63.5% specificity (AUC 0.8, P < 0.001) for post-operative PICU admission. CONCLUSION: The majority of children with non-ambulatory cerebral palsy can be successfully managed on the hospital floor following PSF. The extent of central neuromotor impairment is significantly associated with PICU admission along with surgery lasting longer than 5 h.

Continued Increase in Cost of Care Despite Decrease in Stay After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

INTRODUCTION: Previous studies have demonstrated decreased hospital length of stay (LOS) for children undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). METHODS: Hospitalization event data from the Kids Inpatient Database were queried for all PSF events for AIS performed in 2009, 2012, and 2016 using diagnosis and surgical codes. Data were subdivided into two groups: pre-enhanced recovery after surgery (ERAS) (2009 and 2012) and post-ERAS (2016). The primary outcome variables were LOS and total treatment charge (adjusted for 2020 inflation). Univariate and multivariate analysis were performed to identify differences in outcome variables. RESULTS: A total of 12,010 unique hospitalization events were identified, 74% female, mean 14.3 years. There was a decrease in LOS (pre-ERAS: 5.4 ± 4.0 versus 4.3 ± 3.2 days, P < 0.0001) with an increase in adjusted total treatment charge (pre-ERAS $193,544.4 ± $108,116.1 versus $200,469.1 ± $110,112.6; P = 0.0013). Pre-ERAS, male sex, smaller hospital, and non-Medicaid insurance were predictive of longer LOS, whereas pre-ERAS, older age, non-White race, male sex, hospital outside the Northeast, and non-Medicaid insurance were predictive of higher treatment costs. DISCUSSION: There continues to be a significant decrease in LOS for PSF hospitalization events for AIS; however, total treatment charges continue to rise. Future research should investigate potential factors influencing total treatment charges after PSF for AIS.

Application of a Halo Fixator for the Treatment of Pediatric Spinal Deformity.

BACKGROUND: In spine surgery, the halo fixator was initially utilized to stabilize cervical fusions in patients with poliomyelitis. More recently, the indications for halo fixation have evolved to include stabilization and definitive treatment for upper cervical spine injuries (Jefferson fractures, atlanto-occipital dissociations, odontoid fractures, etc.), treatment of atlantoaxial rotatory subluxation, stabilization of long cervical fusions, and preoperative traction. In the realm of pediatric spinal deformity, halo fixation has proved to be a valuable resource for severe or neglected spinal deformities. In this video article, we demonstrate the application of a halo fixator in a pediatric patient with severe scoliosis. DESCRIPTION: The procedure includes appropriate pin placement in the safe zones of the skull performed under either general anesthesia or local anesthesia. Pins are secured to a halo frame that is sized to be 2 cm larger than the circumference of the skull and are tightened according to age-specific torque guidelines. ALTERNATIVES: Alternative treatments vary from cervical spine immobilization to definitive surgical treatment in the spine, or even spinal osteotomies, depending on the underlying spinal pathology. RATIONALE: The halo fixator works by limiting motion of the cervical spine in flexion, extension, and axial rotation. The halo is also able to control and correct translational injuries of the cervical spine. In the setting of spinal deformity, the halo fixator can also be utilized to overcome the effects of gravity and lengthen the spine. EXPECTED OUTCOMES: For spinal deformities, the halo fixator can be expected to lengthen the spine and increase deformity flexibility prior to definitive surgical treatment in the spine or growth-friendly spinal instrumentation. IMPORTANT TIPS: Correct identification of safe zones for pin placement is vital to correct pin placement.For pediatric patients, it is important to obtain fixation with a minimum of 6 to 8 pins.Pins should be tightened with use of a torque-limiting wrench, up to no more than 1 in/lb (55.9 mm/kg) per year of age, up to a maximum of 8 in/lb (447.9 mm/kg).Applied traction should be a maximum of 50% of the body weight of the patient.Neurovascular examination is vital following application of weight.

In-hospital opioid usage following posterior spinal fusion for adolescent idiopathic scoliosis: Does methadone offer an advantage when used with an ERAS pathway?

PURPOSE: Intraoperative methadone has been shown to decrease opioid medication requirement following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). No study to date has investigated the effect of methadone on opioid medication requirement when used in conjunction with an enhanced recovery after surgery (ERAS) protocol following PSF. METHODS: A retrospective cohort study was performed at a single, tertiary care pediatric hospital. Patients with AIS undergoing PSF were consecutively given a single intra-operative methadone dose and matched 1:2 to a AIS control group without methadone. Patients were matched for age, curve magnitude, levels fused, blood loss, and operating time. All children followed a standard ERAS protocol with methadone being the only change in the post-operative regimen. In-hospital data for opioid and non-opioid medication use, surgical, and patient variables were recorded and compared between cohorts. RESULTS: Twenty-six patients received methadone (average 15.1 ± 1.9 years) and were matched with 52 control patients without methadone (average 14.7 ± 2.2 years). There were no significant differences in total opioid usage at any time-interval prior to hospital discharge or in cumulative opioid usage. Additionally, patients had a similar VAS pain level at discharge (methadone: 4.0 ± 2.3 vs control: 3.8 ± 1.9; P = 0.572). Total opioid usage was correlated with LOS. There were no opioid-related medication complications in either cohort. CONCLUSION: There was no decrease of in-hospital opioid usage when methadone was used with an ERAS protocol. Total opioid usage is correlated with hospital LOS following PSF.

Short term outcomes of an enhanced recovery after surgery (ERAS) pathway versus a traditional discharge pathway after posterior spinal fusion for adolescent idiopathic scoliosis.

PURPOSE: Enhanced Recovery after Surgery (ERAS) pathways have been shown to decrease length of stay (LOS) after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). The aim of this study was to compare immediate post-operative outcomes following an ERAS pathway with a traditional pathway for AIS. METHODS: A prospective dual-center study of patients treated using an ERAS pathway (203 patients) or a traditional discharge (TD) pathway (73 patients) was performed with focus on pain at discharge, quality of life at one month, and return to school/work. RESULTS: LOS was 55% less in the ERAS group (4.8 days TD vs. 2.2 days ERAS, p < 0.001). Length of surgery (4.8 h TD vs. 2.8 h, p < 0.001) and EBL (500 cc vs. 240 cc, p < 0.001) were greater in the TD group, likely related to larger curve magnitudes ((62.0° TD vs. 54.0° ERAS, p < 0.001), a higher percentage of patients undergoing osteotomies (94% vs. 46%, p < 0.001) and more levels fused (11.4 ± 1.6 vs. 10.1 ± 2.6, p < 0.001) in the TD group. Regression analysis showed no difference in Visual Analog Score (VAS) score at discharge or quality of recovery using the QOR9 instrument between groups at follow up. There was no difference in return to school (p = 0.43) and parents' return to work (p = 0.61) between the groups. CONCLUSION: Patients managed with an ERAS pathway had similar pain scores at discharge than those managed with a TD pathway. Both groups showed evidence of rapid return to normalcy by the first follow up visit.

Postoperative Dexamethasone Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

BACKGROUND: Surgeons have hesitated to use steroids in patients undergoing posterior spinal fusion because of the risk of wound complications. The literature has supported the use of postoperative steroids in other areas of orthopaedics on the basis of more rapid recovery and improved postoperative pain control. We hypothesized that a short course of postoperative dexamethasone following posterior spinal fusion for the treatment of adolescent idiopathic scoliosis (AIS) would decrease opioid usage without increasing wound-healing problems. METHODS: Consecutive patients undergoing posterior spinal fusion for the treatment of AIS from 2015 to 2018 at a single hospital were included. A review of demographic characteristics, curve characteristics, surgical data, and postoperative clinic notes was performed. Opioid usage was determined by converting all postoperative opioids given into morphine milligram equivalents (MME). RESULTS: Sixty-five patients underwent posterior spinal fusion for the treatment of AIS without postoperative steroids (the NS group), and 48 patients were managed with 3 doses of postoperative steroids (the WS group) (median, 8.0 mg/dose). There was no difference between the groups in terms of curve magnitude, number of vertebrae fused, or estimated blood loss. There was a 39.6% decrease in total MME used and a 29.5% decrease in weight-based MME used in the group receiving postoperative steroids (82.0 mg [1.29 mg/kg] in the NS group versus 49.5 mg [0.91 mg/kg] in the WS group]; p < 0.001). This difference persisted after accounting for gabapentin, ketorolac, and diazepam usage; surgical time; curve size; levels fused; and number of osteotomies (median decrease, 0.756 mg/kg [95% CI, 0.307 to 1.205 mg/kg]; p = 0.001). Three patients in the NS group (4.6%) and 4 patients in the WS group (8.3%) developed wound dehiscence requiring wound care (p = 0.53). One patient in the NS group required surgical debridement for the treatment of an infection. Patients in the WS group were more likely to walk at the time of the initial physical therapy evaluation (60.4% versus 35.4%; p = 0.013). CONCLUSIONS: A short course of postoperative steroids after posterior spinal fusion was associated with a 40% decrease in the use of opioids, with no increase in wound complications. Surgeons may consider the use of perioperative steroids in an effort to decrease the use of postoperative opioids following posterior spinal fusion for the treatment of AIS. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Magnetically controlled growing instrumentation for early onset scoliosis: Caution needed when interpreting the literature.

BACKGROUND: Magnetically controlled growing rods (MCGR) are a novel treatment option for early onset scoliosis (EOS). Although the complication profile with MCGR use has been reviewed, these reviews do not take into account important implants modifications, termed iterations, that were made due to early on postoperative complications is not well reported or understood. AIM: To assess the effect of MCGR implant iterations on post-operative complications in EOS. METHODS: A systematic review was performed to identify studies investigating MCGR specifically for the treatment of EOS, refined to those reporting the implant iteration, specifically the incorporation of the keeper plate to the implant design. Articles with mixed implant iteration usage were excluded. Complications following surgery were recorded as well as potential risk factors and compared between implant cohorts. RESULTS: Although 20 articles were identified for inclusion, 5 included mixed implant iteration leaving a total of 271 patients identified through 15 clinical studies that met inclusion criteria. The average follow-up was 25.4-mo. Pre-keeper plate implants were utilized in 3 studies with a total of 49 patients. Overall, 115 (42.4%) post-operative complications were identified, with 87% defined as major. The addition of the keeper plate significantly decreased the rate of post-operative complications per study (35.7% vs 80.6%, P = 0.036), and the rate of distraction failure (8.1% vs 40.8%, P = 0.02). Unplanned reoperation occurred in 69 (26.7%) patients but was not different between implant iteration cohorts (25.5% without keeper plate vs 27.1% with keeper plate, P = 0.92). CONCLUSION: MCGR for EOS has a cumulative complication rate of 42.4% but this is significantly reduced to 35.7% when reviewing only keeper-plate enabled implants. However, 25% of published articles included mixed implant iterations. Future studies should discern between implants iterations when reporting on the usage of MCGR for EOS.

Nighttime bracing with the Providence thoracolumbosacral orthosis for treatment of adolescent idiopathic scoliosis: A retrospective consecutive clinical series.

BACKGROUND:: Orthotic treatment for adolescent idiopathic scoliosis is a mainstay in nonoperative treatment to prevent progressive spinal deformity. OBJECTIVE:: To determine the effectiveness of the Providence orthosis in the treatment of adolescent idiopathic scoliosis. STUDY DESIGN:: Retrospective review. METHODS:: Patients treated with a Providence orthosis for adolescent idiopathic scoliosis were reviewed. Inclusion criteria included the following: age of 10-18 years; curve magnitude of 25°-40°; Risser stage of 0-2; and, if female, <1 year post menarche at the time of brace initiation. Failure was defined as curve magnitudes progressing >5° or to >45° or surgery. Radiographs and clinical information were recorded and compared between treatment success and failure cohorts. RESULTS:: 56 patients (51 female and 5 male; average of 12.26 years) were identified with average of 2.21-year follow-up and a 57.1% success rate for preventing curve progression. Factors associated with successful treatment included curve apex T10 and caudal and Risser sign ⩾ 1. Multivariate analysis identified Risser ⩾ 1 and curve apex T10 and caudal as independent predictors of successful treatment. CONCLUSION:: The Providence nighttime orthosis can be an effective treatment for adolescent idiopathic scoliosis. Curve Apex at T10 or caudal was an independent predictors of treatment success. CLINICAL RELEVANCE: This study identifies variables associated with treatment success using the Providence nighttime orthosis in a consecutive series of adolescent idiopathic scoliosis patients. This information provides the foundation for identifying ideal patients for nighttime bracing to guide clinical treatment.

Septic Arthritis of the Hip-Risk Factors Associated With Secondary Surgery.

INTRODUCTION: Septic arthritis of the hip (SAH) is a common condition encountered by pediatric orthopaedic surgeons and is treated with arthrotomy and irrigation. Depending on the response to initial treatment, some patients require surgical treatment beyond the index procedure. The purpose of this study was to investigate risk factors for repeat surgical intervention after initial arthrotomy for presumed SAH. METHODS: A multicenter retrospective review of all children who underwent surgical arthrotomy for presumed SAH over a ten-year period was conducted. Variables queried included demographics, clinical presentation, laboratory parameters, imaging, infecting organism, presence of osteomyelitis, and surgical interventions performed. Logistic regression was used to predict the risk of a second procedure. Chi-square was used to compare patients who required further surgery and those who did not. RESULTS: One hundred and thirty-eight patients (139 hips) qualified for inclusion. The average age at initial surgery was 6.1 years (range, zero to 17 years), and 57% of the patients were male. Concomitant osteomyelitis was diagnosed in 55 cases (40%). An infecting organism was identified from 70 (50%) index intraoperative cultures, with Staphylococcus aureus infections (methicillin-resistant Staphylococcus aureus [MRSA], 27; methicillin-sensitive Staphylococcus aureus, 25) being the most frequent. Fifty-six patients (41%) underwent subsequent surgical intervention, at an average of 5.5 days (range, 2 to 95) from the index procedure. Independent risk factors for repeat surgical procedures included presenting C-reactive protein >10 mg/dL (P = 0.002) and presenting erythrocyte sedimentation rate >40 (P = 0.011). The odds of repeat surgical intervention were significantly increased by the presence of concomitant osteomyelitis (odds ratio, 3.4; P = 0.001) and positive index intraoperative cultures for MRSA (odds ratio, 1.19; P = 0.001). Preoperative MRI before the index procedure was not universal (73/138; 53%), and acquisition of preoperative MRI was not associated with secondary surgical intervention (P = 0.389). DISCUSSION: Forty-one percent of children in this multicenter cohort underwent at least one repeat surgical procedure after the index arthrotomy for management of presumed SAH. Risk factors for return to the operating room include elevated initial erythrocyte sedimentation rate and C-reactive protein, infection with MRSA, and presence of osteomyelitis. LEVEL OF EVIDENCE: Level 3, case-cohort series. Type of evidence, therapeutic.

Perioperative Complications After Spinal Fusion in Pediatric Patients With Congenital Heart Disease.

BACKGROUND: Children with congenital heart disease (CHD) have been reported to be at increased risk of developing scoliosis following cardiac surgery. Previous sample studies have reported that these patients may safely undergo posterior spinal fusion (PSF) with low complication rates. The goal of this study is to provide an updated analysis of the perioperative complication profile for posterior spinal fusion in a large cohort of pediatric patients with CHD, using a nationwide database. METHODS: A retrospective cohort study was conducted using 30-day perioperative outcomes data from the NSQIP-P database. Our inclusion criteria were all pediatric patients who underwent posterior spinal fusion by CPT code. Patients were subdivided into two groups: those with a history of cardiac surgery for CHD and those without. Postoperative complications were classified according to the Clavien-Dindo system. Risk factors were assessed in univariate and multivariate logistic regression analyses, with significance set at p < .05. RESULTS: Our results included 3,426 pediatric patients (68.2% female, 31.8% male) with a median age at spinal fusion of 13.7 ± 2.87 years. A CHD diagnosis was present in 312 patients, with 128 having had prior cardiac surgery. The overall complication rate was 6.68%, with a 10.9% rate in the prior cardiac surgery cohort (p = .068). The most common overall perioperative complications were unplanned readmission (3.5%), reoperation (2.6%), and superficial wound dehiscence (2.5%). Patients with a history of cardiac surgery were not at increased risk for postoperative complications; however, blood transfusion (p < .001), bronchopulmonary dysplasia (p < .001), combined bronchopulmonary dysplasia and previous cardiac surgery (p = .004), and a neuromuscular diagnosis (p < .001) were all risk factors for major postoperative complications in this cohort. CONCLUSIONS: Children with scoliosis who have undergone cardiac surgery to address CHD are not at an increased risk of perioperative complications within 30 days of undergoing a posterior spinal fusion. However, patients who underwent cardiac surgery for CHD who also had bronchopulmonary dysplasia or an associated neuromuscular diagnosis are at increased risk for perioperative complications. It is important for pediatric orthopedic spine surgeons to be familiar with an updated profile of potential perioperative obstacles they may face when treating these patients, as seen in a large and representative cohort. LEVEL OF EVIDENCE: Level III.

Accuracy of robot-assisted pedicle screw insertion in adolescent idiopathic scoliosis: is triggered electromyographic pedicle screw stimulation necessary?

BACKGROUND: Screw malpositioning is an identifiable cause of intraoperative neurophysiologic changes. Although triggered screw electromyography (t-EMG) has been found to exhibit high sensitivity for identifying malpositioned screws, no previous study has assessed the utility of combining t-EMG with robotic-assisted pedicle screw placement for identifying malpositioned screws. We sought to evaluate the utility of t-EMG used in combination with robotic-assisted pedicle screw placement for identifying malpositioned screws in patients with adolescent idiopathic scoliosis (AIS). METHODS: Patients undergoing robotic-assisted posterior spinal fusion with pedicle screw fixation for AIS underwent retrospective review from a single surgeons prospectively collected database. Preoperative demographic data and curve characteristics were recorded. Computed tomography (CT) scans were reviewed, measuring pedicle width and classifying pedicle morphology using the channel classification system. Pedicle data was compared against intra-operative t-EMG data, with a minimal threshold of 8 mA used for screw removal and screw path examination and the rate of screw re-direction recorded. All pedicle screws were verified using image intensification. RESULTS: Forty-nine patients (11 males, 38 females, average age 14.49 years) with an average curve magnitude of 51 degrees and placement of 844 pedicle screws to attain an average curve correction of 67.7%. The incidence of an absent pedicle (type C or D morphology) was 2%. Overall, 24 screws (2.8%) were identified with an abnormal t-EMG threshold. All screws were found to have an intact medial wall upon probing and were reinserted without re-direction. No patient or curve characteristic was predictive of abnormal t-EMG amplitude but smaller pedicles correlated with smaller amplitudes. CONCLUSIONS: With precise pre-operative planning, robotic-assisted pedicle screw placement has shown to be a safe and effective method in treating AIS patients as shown by the lack of medial pedicle breach and malpositioned screws. We found no evidence to support combined use of t-EMG for identifying medially malpositioned screws.