Comparison of quality of life outcomes in a de-intensification treatment regimen for p16 + oropharyngeal cancer.

BACKGROUND: Platinum and taxane-based neoadjuvant chemotherapy with surgery (NAC + S) is a novel de-intensified treatment modality that is currently under investigation. METHODS: All patients treated for HPV positive OPSCC with NAC + S at a single institution between 2006 and 2020 were contacted to complete the University of Washington Quality of life questionnaire (UW-QOL) at least 2 years following the completion of treatment. RESULTS: The UW-QOL surveys were received from 25 of 48 eligible patients (52.1%). The mean follow-up time was 4.3 years (range 2.0-7.6 years). The overall mean score for the physical subscale was 92.4 (Standard deviation, SD = 10.9), and the social-emotional subscale was 91.1 (11.8). Compared to the normative cohort, the NAC + S cohort had a worse appearance (Mean scores Normative vs. NAC + S: 93 vs. 84.0, p = 0.009). CONCLUSION: NAC + S offers favorable long-term QOL, as evidenced by near-normal scores in most QOL domains.

Despite limitations in content range, the SCIM-III is reproducible and a valid indicator of physical function in youths with spinal cord injury and dysfunction.

STUDY DESIGN: Multi-center, repeated measures OBJECTIVES: Evaluate psychometric properties of the SCIM-III in children. SETTING: Seven facilities in North America METHODS: One-hundred and twenty-seven youths, mean age of 10.8 years and chronic spinal cord injury/dysfunction completed two administrations of the Spinal Cord Independence Measure-III (SCIM-III). Mean, standard deviation, range values were calculated for SCIM-III total and subscales for the entire sample, four age groups and injury characteristics. Test-retest reliability, concurrent validity, and floor and ceiling effects were examined. RESULTS: Total SCIM-III and self-care (SC) subscale scores for the youngest age group were lower than those for the three older age groups. There were statistically significant differences in SC subscale scores between neurological level (NL) C5-T1 and T2 -T12; C5-T1 and L1-S4/5; and T2-T12 and L1-S4/5 and in in-room, and indoor/outdoor mobility subscale scores between C1-C4 and T2-T12; C1-C4 and L1-S4/5; C5-T1 and T2-T12; C5-T1 and L1-S4/5; and T2-T12 and L1-S4/5. All scores between motor complete and motor incomplete differed. Test-retest reliability was good (ICC values = > 0.84) and there was moderate to strong correlation between SCIM-III and the FIM® Instrument (r = 0.77-0.92). Ceiling effects were present in the SC subscale for the oldest age group (24%) and for NL L1-S4/5 (35.5%) and in in-room mobility subscale for 6-12 (45.7%), 13-15 (30.43%) and 16-17 (60%) ages, paraplegia (42.4%), tetraplegia (37.1%), incomplete injuries (50%), and T2-T12 (38%) and L1-S4/5 (100%) NL. CONCLUSION: Despite limitations in content range, the SCIM-III is reproducible, and a valid indicator of physical functioning in youth with SCI/D 6 years of age and older. SPONSORSHIP: The study was funded by the Craig H. Neilsen Foundation, Spinal Cord Injury Research on the Translation Spectrum, Senior Research Award Grant #282592 (Mulcahey, PI).

Recommendations for mobility in children with spinal cord injury.

BACKGROUND: Mobility is an important aspect of the rehabilitation of children with spinal cord injury (SCI), is a necessary component of life, and is critical in a child's development. Depending upon the individual's age and degree of neurological impairment, the nature of mobility may vary. OBJECTIVES: The objective of this article is to establish recommendations surrounding the selection of mobility for children with SCI. METHODS: Extensive literature review and multidisciplinary peer review. RESULTS: Types of mobility including power, manual, upright, and community are discussed, and recommendations are made based on medical necessity, neurological level, ASIA Impairment Scale score, and developmental considerations and challenges. CONCLUSION: Mobility is critical for proper development to occur in the pediatric population, and it may be challenging to make recommendations for mobility in children with SCI. It is essential for clinicians providing care to children with SCI to address mobility in a comprehensive and longitudinal manner across the children's environments.

Relationship between neurological injury and patterns of upright mobility in children with spinal cord injury.

BACKGROUND: The predictors and patterns of upright mobility in children with a spinal cord injury (SCI) are poorly understood. OBJECTIVE: The objective of this study was to develop a classification system that measures children's ability to integrate ambulation into activities of daily living (ADLs) and to examine upright mobility patterns as a function of their score and classification on the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) exam. METHODS: This is a cross-sectional, multicenter study that used a convenience sample of subjects who were participating in a larger study on the reliability of the ISNCSCI. A total of 183 patients between 5 and 21 years old were included in this study. Patients were asked if they had participated in upright mobility in the last month and, if so, in what environment and with what type of bracing. Patients were then categorized into 4 groups: primary ambulators (PrimA), unplanned ambulators (UnPA), planned ambulators (PlanA), and nonambulators. RESULTS: Multivariate analyses found that only lower extremity strength predicted being a PrimA, whereas being an UnPA was predicted by both lower extremity strength and lack of preservation of S45 pinprick sensation. PlanA was only associated with upper extremity strength. CONCLUSIONS: This study introduced a classification system based on the ability of children with SCI to integrate upright mobility into their ADLs. Similar to adults, lower extremity strength was a strong predictor of independent mobility (PrimA and UnPA). Lack of pinprick predicted unplanned ambulation, but not being a PrimA. Finally, upper extremity strength was a predictor for planned ambulation.

Trends in Swallowing Outcomes Following Deintensified Treatment in Selected p16+ Oropharyngeal Carcinoma.

Objective: Identify trends in swallowing outcomes in p16+ oropharyngeal squamous cell carcinoma following neoadjuvant chemotherapy+surgery (NAC+S) versus neoadjuvant chemotherapy+surgery+radiation (NAC+S+R). Study Design: Cohort study. Setting: Single academic institution. Methods: Swallowing outcome was measured using a validated questionnaire, MD Anderson Dysphagia Inventory (MDADI). MDADI scores were compared between NAC+S and NAC+S+R groups in short-term (<1 year), middle-term (1-3 years), and long-term (>3 years). Clinical factors associated with MDADI scores were explored using a linear mixed model. Statistical significance was established at p < .05. Results: Sixty-seven patients met the inclusion criteria and were divided into 2 groups: NAC+S (57 [85.1%]) and NAC+S+R (10 [14.9%]). All patients had improved MDADI scores in the middle-term compared to short-term (NAC+S: score increase = 3.43, p = .002; NAC+S+R: score increase = 11.18, p = .044), long-term compared to short-term (NAC+S: score increase = 6.97, p < .001; NAC+S+R: score increase = 20.35, p < .001), and long-term compared to middle-term (NAC+S: score increase = 3.54, p = .043; NAC+S+R: score increase = 9.18, p = .026). NAC+S patients had better MDADI scores than NAC+S+R patients at short-term (83.80 vs 71.26, p = .001). There was no significant difference in swallowing function in the middle-term or long-term. Conclusion: Regardless of treatment type, swallowing will likely be improved in the middle-term and long-term compared to the short-term. Patients treated with NAC+S+R will have worse short-term swallowing function. However, in the middle-term and long-term, there is no significant difference in swallowing function between patients treated with NAC+S and NAC+S+R.

Spinal cord injuries in young children: a review of children injured at 5 years of age and younger.

AIM: To determine the epidemiology and complications of spinal cord injuries (SCIs) in children injured at 5 years of age and younger who were seen between 1981 and 2008 at a children's hospital in the USA. METHOD: Complications studied were scoliosis, hip dysplasia, latex allergies, autonomic dysreflexia, pressure ulcers, spasticity, deep venous thrombosis, and kidney stones. Demographic and injury-related factors included age at injury, etiology, level of injury, American Spinal Injury Association Impairment Scale (AIS), and SCIs without radiological abnormalities (SCIWORA). RESULTS: Of the 159 individuals seen (92 males, 67 females) median age at injury was 2 years (range 0 y-5 y 11 mo). Forty-nine percent were injured in vehicular accidents, 60% had complete injuries, 66% had paraplegia, and 72% had SCIWORA. Ninety-six percent developed scoliosis, 57% had hip dysplasia, and 7% had latex allergy. Thirty-four percent with injuries at or above T6 experienced autonomic dysreflexia, 41% developed pressure ulcers, and 61% experienced spasticity. Of those without bowel or bladder control, 82% were on intermittent catheterization and 69% were on a bowel program. Median age of initiating wheelchair use was 3 years 4 months (range 1 y 2 mo-12 y 5 mo). Twenty-four were community ambulators, and they were more likely to have AIS D lesions (half the key muscle functions below the level of injury have a muscle grade 3 or greater) and less likely to have skeletal complications. INTERPRETATION: The epidemiology, complications, and manifestations of SCIs in children injured at a young age are unique and differ distinctively from adolescent and adult-onset SCIs.

Swallowing Function Following Neoadjuvant Chemotherapy and Transoral Robotic Surgery for Oropharyngeal Carcinoma: A 2-Year Follow-up.

OBJECTIVE: To evaluate 2-year follow-up swallowing function in patients with human papillomavirus-related oropharyngeal squamous cell carcinoma (HPV+ OPSCC) who completed neoadjuvant chemotherapy and transoral robotic surgery (NAC+S). STUDY DESIGN: Retrospective analysis of patients with OPSCC treated with NAC+S between 2010 and 2021. SETTING: A single academic institution. METHODS: This is a cross-sectional study of patient-reported swallowing function, assessed with the MD Anderson Dysphagia Inventory (MDADI) at least 2 years after completion of treatment. The inclusion criteria are patients with HPV+ OPSCC who underwent NAC+S at least 2 years ago. Those requiring adjuvant radiation or chemoradiation or experiencing relapse were excluded from the study. RESULTS: Completed MDADIs were received from 37 patients at a median 3.8 years posttreatment (interquartile range, 2.0-8.6 years). Of those, 94.6% (n = 35) were male and 81.1% (n = 30) were White. The median age at OPSCC diagnosis was 59.0 years (interquartile range, 41-80 years). The most frequent primary subsite of OPSCC was the base of the tongue (n = 20, 54.1%), followed by the tonsils (n = 16, 43.2%). In addition, 75.7% (n = 28) had stage IVa disease (TNM seventh edition), and 29 (78.4%) had scores ≥80, classified as optimal function. When compared with patients who received bilateral neck dissection, patients who received unilateral neck dissection were associated with an age <65 years old (P = .036) and lower clinical TNM stage (P = .04), as well as higher composite, emotional, functional, and physical MDADI scores (P = .017, .046, .013, and .05, respectively). CONCLUSION: Patients with OPSCC who were treated with NAC+S achieved satisfactory long-term swallowing outcomes. Unilateral neck dissection was significantly associated with higher MDADI scores in this patient cohort.

How low can you go? Implant density in posterior spinal fusion converted from growing constructs for early onset scoliosis.

STUDY DESIGN: Retrospective, multicenter comparative. OBJECTIVES: Our purpose was to compare early onset scoliosis (EOS) patients treated with ultra-low, low, and high implant density constructs when undergoing conversion to definitive fusion. Larson et al. demonstrated that implant density (ID) at fusion does not correlate with outcomes in the treatment of adolescent idiopathic scoliosis, but did not address growth-friendly graduates. METHODS: EOS patients treated with growth-friendly constructs converted to fusion between 2000 and 2017 were reviewed from a multicenter database. ID was defined as number of pedicle screws, hooks, and sublaminar/bands per level fused. Patients were divided into ultra-low ID (< 1.3), low (≥ 1.3 and < 1.6), and high ID (≥ 1.6). EXCLUSION CRITERIA: < 2 years follow-up from fusion or inadequate radiographs. RESULTS: A total of 152 patients met inclusion criteria with 39 (26%) patients in the high ID group, 33 (22%) patients in the low ID group, and 80 (52%) in the ultra-low ID group. Groups were similar in operative time (p = 0.61), pre-fusion major curve (p = 0.71), mean number of levels fused (p = 0.58), clinical follow-up (p = 0.30), and radiographic follow-up (p = 0.90). Patients in the low ID group (11.6 ± 1.5 years) were slightly younger at the time of definitive fusion than patients in the ultra-low ID group (12.9 ± 2.2 years) and high ID group (12.5 ± 1.7 years) (p = 0.009). There was significantly more blood loss in the high ID group than the other two groups (high ID: 946.8 ± 606.0 mL vs. low ID: 733.9 ± 434.5 mL and ultra-low ID: 617.4 ± 517.2 mL; p = 0.01), but there was no significant difference with regard to percent of total blood volume lost (high ID: 59.3 ± 48.7% vs. low ID: 54.5 ± 37.5% vs. ultra-low ID: 51.7 ± 54.9%; p = 0.78). There was a difference in initial improvement in major curve between the groups (high ID: 21.6° vs. low ID: 18.0° vs. ultra-low ID: 12.6°; p = 0.01). However, during post-fusion follow-up, correction decreased 7.1° in the high ID group, 2.6 in the low ID group, and 2.8 in the ultra-low ID group (p = 0.19). At final follow-up, major curve correction from pre-fusion was similar between groups (high ID: 14.5° vs. low ID: 15.5° vs. ultra-low ID: 9.7°, p = 0.14). At final follow-up, there was no difference in T1-T12 length gain (p = 0.85), T1-S1 length gain (p = 0.68), coronal balance (p = 0.56), or sagittal balance (p = 0.71). The revision rate was significantly higher in the ultra-low ID group (13.8%; 11/80) versus the high ID group (2/39; 5.1%) and low ID group (0/33; 0%) (p = 0.04). CONCLUSIONS: Although an ID < 1.3 in growth-friendly graduates produces similar outcomes with regard to curve correction and spinal length gain as low and high ID, this study suggests that an ID < 1.3 is associated with an increased revision rate. LEVEL OF EVIDENCE: III.

Training Youth With SCI to Improve Efficiency and Biomechanics of Wheelchair Propulsion: A Pilot Study.

Background: Long-term manual wheelchair users are at an increased risk of developing upper extremity (UE) joint pain and injuries due to the repetitive nature of wheelchair propulsion. Youth who sustain spinal cord injuries (SCIs) may be at even greater risk due to the many years they may be wheelchair dependent. There has been a decreasing trend in duration of initial rehabilitation, therefore little time is spent on training of proper wheelchair propulsion. An objective evaluation along with proper training may help prevent the risk of UE pain and injuries over time. Objective: To develop a training program to improve the efficiency and biomechanics of wheelchair propulsion in youth with SCI and evaluate changes made following propulsive training. Methods: Manual wheelchair users between 4 and 21 years old with SCI were recruited from one hospital. Demographic and clinical measures were collected and the subjects completed the Wheelchair User's Shoulder Pain Index. SmartWheel metrics were collected at baseline and following propulsive training on a roller system. Analyses assessed differences in SmartWheel metrics pre and post training. Results: The 23 participants were between 7 and 19 years of age; 57% were male and 69% with paraplegia. Significant improvements were found for SmartWheel metrics of peak backwards force that improved from -3.08 Newtons (N) ± 2.1 pre training to -2.37 N ± 1.9 (p = .041) post training and for push mechanical effectiveness that improved from .575 ± .14 at baseline to .631 ± .17 post training (p = .033). Conclusion: Our results suggest that an objective wheelchair assessment and propulsive training may be a valuable tool for youth with SCI.

Ambulation in children and youth with spinal cord injuries.

OBJECTIVE: To delineate the natural history of ambulation of children and youth with spinal cord injuries (SCls). DESIGN: Retrospective single-center. PARTICIPANTS/METHODS: One hundred sixty-nine subjects who sustained SCI at 18 years of age or younger and who were followed up for at least 4 years. RESULTS: Ambulation was significantly associated with age at injury and neurological impairment but not gender. Younger age at injury was associated with greater likelihood of ambulation, higher level of ambulation, and greater duration of ambulation. Lesser severity of neurological impairment was associated with greater likelihood of ambulation. Excluding ASIA D lesions, household ambulation was noted in 5% of subjects with tetraplegic, 26% with high thoracic, 30% with low thoracic, 44% with upper lumbar, and 33% with lower lumbar lesions. Of the 7 community-level ambulators with non-ASIA D lesions, none had cervical or high thoracic injuries, 3 had low thoracic, 1 had upper lumbar, and 3 had lower lumbar lesions. Using multiple regression analysis, predictive factors for ambulation were younger age at injury, total ASIA motor score, and ASIA impairment scale score. Less cumbersome orthotics were associated with higher levels of ambulation. CONCLUSION: Ambulation status is a function of neurological impairment, age at injury, and type of orthotic.

Paper #13: Early Onset Scoliosis: Results of Cotrel Mehta Casting from a Single Institution.

Early onset scoliosis can lead to significant chest wall deformity resulting in severe restrictive pulmonary disease and premature demise. Treatment of the spinal deformity should control the curvature but allow for continued growth of the spine and thorax. Serial derotational casting can potentially preserve and redirect spinal growth to achieve curve correction.