Prevalence of junctional kyphosis in early-onset scoliosis: can it be corrected at final fusion?

PURPOSE: To investigate the risk and predictive factors of junctional issues after conversion from Traditional growing rod (TGR) to definitive spinal fusion in Early-onset scoliosis (EOS). METHODS: Retrospective review of a multicenter EOS database. TGR patients who received final fusion with at least two-year follow-up were included. Proximal (PJA) and Distal junctional angles (DJA) on pre-final fusion, post-final fusion (within one year of surgery), and at latest follow-up were measured on lateral upright spinal radiographs. Differences in values among designated time points and predictive factors of junctional issues were evaluated statistically. RESULTS: Forty-six of 251 patients (28 females, 18 males and mean age at final fusion: 12 ± 2 [9-17] years) met the inclusion criteria. Mean follow-up between first postoperative measurement and latest follow-up was 49 ± 22 (24-112) months. No statistical differences in PJA and DJA values were available at pre-fusion, first post-fusion, or latest follow-up (p = 0.827, p = 0.076). Fifty percent of patients had extension of TGR instrumentation at fusion, either proximal or distal. No factor including sex and etiology, lumbar lordosis, thoracic kyphosis, major curve magnitude, PJA, and DJA at pre-fusion was found to be a predictive issue for extension of index TGR instrumentation, except the history of at least one implant-related complication during the period from index surgery to the definitive fusion. CONCLUSION: PJA and DJA remained stable when transitioning from TGR to final posterior spinal fusion. But 50% of patients had extension of construction at fusion, either proximal or distal.

Comparison of Intended Lengthening of Magnetically Controlled Growing Rods: Ultrasound Versus X-Ray.

BACKGROUND: In the treatment of early onset scoliosis (EOS), there has been a trend to use magnetically controlled growing rods (MCGR) in order to reduce the number of surgeries. To confirm the amount of lengthening, spine radiographs were required. Recently, ultrasound (US) has been added to monitor lengthening of MCGR to avoid radiation exposure. Our aim was to determine whether US is as accurate as plain radiography (x-ray) in determining the amount of length achieved at individual MCGR lengthening episodes. METHODS: Retrospective study; inclusion criteria: EOS cases with dual MCGR with minimum 12 months follow-up. Intended lengthening IL (mm), lengthening on US (mm) and x-ray (mm) were documented from medical records for both right and left rods. Primary (no surgery before MCGR) and conversion (other types of instrumentation were replaced with MCGR) cases were reviewed separately. P-values determined with analysis of variance. RESULTS: Sixteen cases with 100 lengthening episodes met the inclusion criteria. Eleven were primary MCGR cases with 67 episodes. Mean follow-up was 19±5 months. Significant differences were found between IL (3.4±1 mm), US (2.7±1.9 mm), and x-ray (4.1±2.2 mm) (P<0.001). The difference between IL and x-ray was minimal, but statistically significant (P=0.046). US showed statistically lower values than both IL (P=0.001) and x-ray (P<0.001). The mean ratio of x-ray/IL, US/IL, and US/x-ray were 1.1, 0.75, and 0.84, respectively. Five conversion cases had 33 episodes. Mean follow-up was 21±2 months. Significant differences were found between IL (3.4±0.8 mm), US (1.3±0.8 mm), and x-ray (1.7±0.9 mm) (P<0.001) but there was no significant difference between US and x-ray (P=0.283). IL was significantly higher than both US (P< 0.001) and x-ray (P<0.001). The mean ratio of x-ray/IL, US/IL, and US/x-ray were 0.64, 0.41, and 1.1, respectively. CONCLUSIONS: US can provide confirmatory information of noninvasive lengthening of MCGR. However, US tended to underestimate the achieved length as measured by x-ray in primary cases. Conversion cases demonstrate better concordance between US and x-ray but in these cases less overall length was achieved at each lengthening episode. LEVEL OF EVIDENCE: Level III.

Early Onset Scoliosis: Is there an Improvement in Quality of Life With Conversion From Traditional Growing Rods to Magnetically Controlled Growing Rods?

BACKGROUND: Modern treatment of early onset scoliosis (EOS) includes implantation of traditional growing rods (TGR) or magnetically controlled growing rods (MCGR) for posterior-based distraction if nonoperative treatment plans failed. The recent MCGR innovation has largely been expected to improve patient and family burden by avoiding frequent return to the operating room. At least one study has shown no HRQoL difference between TGR and MCGR, but none have specifically investigated a cohort of conversion patients whose families have experienced both. METHODS: An EOS database was queried for all patients treated with TGR, MCGR, and those converted from TGR to MCGR who had at least 1 pretreatment and 1 posttreatment HRQoL assessment (EOSQ-24). Data on demographics, diagnoses, and major curve size, as well as EOSQ-24 domain scores were studied. RESULTS: There were 156 TGR, 114 MCGR, and 32 conversion patients, with an average of 2.0 years between first and final EOSQ-24 surveys. There was no significant difference in outcome in any EOSQ-24 domain between the converts and the other 2 treatment groups. There was a significant post-op improvement in MCGR versus TGR in transfers and energy level (P=0.01; P=0.01). CONCLUSIONS: Although patient families and their surgeons may subjectively report improved HRQoL after conversion from TGR lengthenings to in-office MCGR lengthenings, these improvements were seen in transfer and fatigue domains, not burden or satisfaction. Although the EOSQ-24 is a well-validated EOS metric, it may not be sensitive enough to overcome the QoL floor-effect associated with the diagnosis itself, or perhaps the improvement in QoL must be assessed over a longer interval to assess meaningful change. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

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

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

Raising Mean Arterial Pressure Alone Restores 20% of Intraoperative Neuromonitoring Losses.

STUDY DESIGN: Multicenter prospective. OBJECTIVE: To assess the effect of intraoperative interventions in restoring intraoperative neuromonitoring (IONM) signals in pediatric spine surgery. SUMMARY OF BACKGROUND DATA: No prior studies have prospectively examined the rate of return of IONM signals by increasing blood pressure (BP) alone. METHODS: Patients undergoing posterior spinal deformity surgery were enrolled at their preoperative appointment. Surgeons completed an intraoperative data form on patients who experienced an IONM change defined as a 50% or greater decrease in either transcranial motor evoked potentials or somatosensory evoked potentials. RESULTS: Four hundred fifty two patients were enrolled with 30 (7%) having IONM change. Thirty patients met inclusion criteria (mean age, 12 yrs, range, 5-19) and had the following diagnoses: idiopathic scoliosis (43%), neuromuscular scoliosis (13%), congenital scoliosis (10%), early onset scoliosis (7%), and other (27%). 20% (6/30) had return of signals due to an increase in BP alone with no other interventions (mean arterial pressure [MAP] increased from mean of 68 [range, 58-76] to 86 mmHg [range, 75-95]). Signals returned to baseline after mean of 16 minutes (range, 2-45). In 60% of patients (18/30), MAP was raised from a mean of 72 mmHg (range, 55-84) to 86 mmHg (range, 75-100) in conjunction with other interventions and had mean return of signals in 37 minutes (range, 8-210). Six (20%) of patients had signals return to baseline after a mean of 6 minutes (range, 3-13) in which MAP did not change appreciably. All patients had return of signals at the conclusion of the procedure with one patient having postoperative neurological sequale. CONCLUSION: In this prospective study of 452 pediatric spinal deformity surgeries, raising MAPs above 85 mmHg should be considered the first step in response to IONM signal changes, as this alone was successful in 20% of patients without sacrificing deformity correction. LEVEL OF EVIDENCE: 2.

Paper #40: Is There an Improvement in Quality of Life with Early Onset Scoliosis Managed with Traditional Growing Rods Converted to Magnetically Controlled Growing Rods?

Introduction of magnetically controlled growing rods (MCGR) for early onset scoliosis treatment was anticipated to improve quality of life for patients and their families. A cohort of patients converted from traditional growing rods to MCGR may be best suited to detect this improvement and have not previously been examined. Using the validated EOSQ-24, no HRQoL differences were detected between TGR, MCGR, or converted patient cohorts.

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

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

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

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

Electronic monitoring of orthopedic brace compliance.

PURPOSE: Brace compliance measurement in adolescent idiopathic scoliosis (AIS) has been the subject of a few recent studies. Various sensors have been developed to measure compliance. We have developed a temperature-based data logger-the Cricket-specifically for scoliosis braces, with associated custom software, that is embedded directly in the brace. The purpose of this study was to analyze patterns of brace wear and patient compliance among children with AIS using the Cricket. METHODS: Fifty-five AIS patients prescribed various brace-time regimens were monitored using the Cricket. All subjects were treated with the Wilmington brace. The compliance rate for each group was determined. RESULTS: Overall compliance among subjects was 69.9 ± 31.5 %. Only 14.5 % met or exceeded prescribed brace time. This is consistent with previous compliance monitoring results. CONCLUSION: The results of this study objectively show the difference between prescribed and actual brace wear time and reaffirm the Cricket sensor as an accurate and comfortable brace-monitoring device.

The effect of serial growing rod lengthening on the sagittal profile and pelvic parameters in early-onset scoliosis.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To report the effect of repeated growing rod (GR) lengthenings on the sagittal and pelvic profile in patients with early-onset scoliosis. SUMMARY OF BACKGROUND DATA: Posterior distraction-based GRs have gained popularity as a technique for the surgical management of early-onset scoliosis. However, there are no published studies on the effect of serial GR lengthenings on sagittal balance, thoracic kyphosis (TK), lumbar lordosis (LL), and pelvic parameters. METHODS: We retrospectively reviewed data from a multicenter early-onset scoliosis database. Forty-three patients who were able to walk with minimum 2-year follow-up who underwent single- or dual-GR surgery were included for review. Mean number of lengthenings was 6.4 (range, 3-16). Mean preoperative age was 5.6 years (standard deviation, 2.4 yr), and mean follow-up was 3.5 years. Maximum TK, LL, and sagittal balance were assessed preoperatively, after index surgery, and at the latest follow-up. RESULTS: There was a significant decrease both in TK and LL after index surgery, which then increased during the lengthening period. There was a significant increase in both proximal junctional kyphosis and distal junctional angle. Pelvic parameters (pelvic tilt, pelvic incidence, sacral slope) were unchanged during the treatment period. Significant improvement was observed in sagittal balance. There was a correlation between the change in TK and change in LL. CONCLUSION: TK decreased after index surgery and increased between the index surgery and the latest follow-up, which was accompanied by an increase in LL. All-screw proximal constructs had mean 9° more proximal junctional kyphosis than all-hook proximal constructs. An increase in proximal junctional kyphosis and distal junctional angle was found during the treatment period. Although there was an independent effect of number of lengthenings on TK, there was no significant detrimental effect on other sagittal spinopelvic parameters. GRs had a positive effect on sagittal vertical axis, which returned patients to a more neutral alignment through the course of treatment. LEVEL OF EVIDENCE: 4.

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

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

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

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

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

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

Difficult thoracic pedicle screw placement in adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective radiographic and clinical consecutive case series. OBJECTIVE: The objective of this study was to identify patients treated with posterior spinal fusion and pedicle screw instrumentation for adolescent idiopathic scoliosis (AIS) in whom it was not possible to place a planned pedicle screw, and describe the possible difficulties in screw placement. SUMMARY OF BACKGROUND DATA: Despite the knowledge of anatomic characteristics of upper thoracic spine pedicles and considerable experience in thoracic pedicle screw placement, inserting pedicle screws in some patients with AIS may be difficult. METHODS: We reviewed 96 patients with AIS in whom the intent was to use an all-screw construct in 2004. Placement of the pedicle screws was usually by the freehand method, with intraoperative fluoroscopy used as needed. If a screw could not be safely placed after multiple attempts, a down-going supralaminar or transverse process hook was placed. Medical records were reviewed and radiographs were measured by one of the authors. RESULTS: We identified 17 cases (18%) in which a hook had been placed. All cases had a major thoracic curve (Lenke 1, 2, and 3) and the single hook had always been placed at the most cephalad level of the construct on the patient's right side. The most common levels for hook placement were T3 and T4; these pedicles were noted to be sclerotic, narrow, and have a moderate amount of rotation on the preoperative posterior-anterior and side bending radiographs. CONCLUSIONS: Care should be exercised during pedicle screw instrumentation in the apical region of the proximal thoracic curve, whether structural or nonstructural, especially in the concavity. The preoperative radiographs may give helpful clues to intraoperative challenges of pedicle screw insertion at the uppermost level of instrumentation. Hook fixation was satisfactory in this scenario.

The association of backpack use and back pain in adolescents.

STUDY DESIGN: A cross-sectional study comprising the first phase of an ongoing, longitudinal prospective study was conducted. OBJECTIVE: To investigate the relation between backpack use and back pain in adolescents. SUMMARY OF BACKGROUND DATA: The prevalence of nonspecific back pain increases dramatically during adolescence from less than 10% in the pre-teen-age years up to 50% in 15- to 16-year-olds. There is widespread concern that heavy backpacks carried by adolescents contribute to the development of back pain. METHODS: A total of 1126 children, ages 12 to 18 years, participated by completing a questionnaire about their health, activities, and backpack use. Each child's body weight, height, and backpack weight were measured. A child was classified as having back pain if one or more of the following were reported during the preceding month: neck or back pain that had interfered with school or leisure, neck or back pain with a severity rating of 2 or more on a scale 0 to 10, a visit to a physician or therapist for neck or back pain, or exemption from physical education or sports because of neck or back pain. RESULTS: Of 1122 backpack users, 74.4% were classified as having back pain, validated by significantly poorer general health, more limited physical functioning, and more bodily pain. As compared with no or low use of backpacks at school, heavy use (odds ratio, 1.98; P < 0.0001) was independently associated with back pain. Female gender and larger body mass index also were significantly associated with back pain. As compared with adolescents who had no back pain, adolescents with back pain carried significantly heavier backpacks that represented a significantly greater percentage of their body weights. CONCLUSION: The use of backpacks during the school day and backpack weights are independently associated with back pain.

Backpacks in children.

Back pain and deformity are common in adolescents. There has been extensive discussion in the lay literature as to the potential for back pain and spinal deformity with backpack use. The scientific literature on this subject is sparse but is increasing. Epidemiologic studies have identified risk factors associated with back pain in adolescents and daily use of a heavy backpack may be important. A book bag weighing more than 15% to 20% of a child's weight is associated with back pain, and improper use of the backpack can result in changes of posture and gait. There is no evidence that structural spinal deformity can result from backpack use. Children who experience back pain are at increased risk of having back pain as adults. The economic impact may be significant, because back pain is a major cause of disability in adults. The current authors review the available scientific literature and comments on this public health issue.

HRQL and severity of brain ultrasound findings in a cohort of adolescents who were born preterm.

PURPOSE: To determine whether health-related quality of life (HRQL) in a cohort of adolescents who were born prematurely is related to the severity of brain ultrasound examination findings during the newborn period. METHODS: This study uses a historical, prospective methodology to investigate the 84 members of a cohort of infants born prematurely (<33 weeks gestation) at Thomas Jefferson University Hospital during a 25-month period, from 1979 to 1981. We extracted the following information from their neonatal intensive care unit (NICU) records: ultrasound examination findings (graded for intraventricular hemorrhage (IVH) and periventricular leukomalacia (PVL); and records of medical illness (respiratory, gastrointestinal, and other) during the NICU stay. We followed-up the members of this cohort 18-19 years later, obtaining data on 53 (63%). We correlated the NICU data with the following self-report outcome measures: HRQL, Disabilities Questionnaire [parental report indicating the severity of complications of prematurity (DISAB)] and psychological assessment tests [Beck Depression Inventory (BDI), Coopersmith Self-Esteem Inventory (CSEI), and Body Shape Questionnaire (BSQ)]. We used the method of multiple discriminant function analysis to determine statistical significance of differences between the two ultrasound groups, grades 0-2 IVH, no PVL vs. grades 3-4 IVH and/or PVL. RESULTS: A statistically significant difference was obtained between the two ultrasound groups (grades 0-2 IVH, no PVL vs. grades 3-4 IVH and/or PVL) among the HRQL variables (Wilks' lambda =.764, df = 5, p <.470). The relative contribution of dependent variables (HRQL1, HRQL2, HRQL3, HRQL4, DISAB) to the group separation was assessed through the interpretation of discriminant function-variable correlation. HRQL1 and DISAB made the largest discriminant between groups, which is supported by results from univariate Student's t-tests. Study subjects with grades 3-4 IVH and/or PVL ultrasound findings obtained much lower HRQL1 scores (better overall estimation of HRQL) and much higher DISAB scores than subjects with grades 0-2 IVH, no PVL ultrasound findings. CONCLUSIONS: It appears that the lower an adolescent's score on overall HRQL (HRQL1), (i.e., the better the self-perceived overall quality of life), the more likely he or she displayed the higher severity of brain ultrasound examination findings during the NICU hospitalization. A larger study of premature infants who are followed into adolescence is required to better understand the factors that determine the association of IVH and PVL with HRQL.

Eating disorder symptomatology is not associated with pregnancy and perinatal complications in a cohort of adolescents who were born preterm.

OBJECTIVES: We attempt to resolve the question of whether pregnancy complications and perinatal trauma, including brain insults, in premature infants increase the susceptibility to eating disorder symptomatology during the adolescent years. METHOD: This study uses a historical, prospective methodology to investigate the 84 members of a cohort of infants born prematurely (<33 weeks gestation) at Thomas Jefferson University Hospital during a 25-month period, from 1979 to 1981. We extracted the following information from their neonatal intensive care unit (NICU) records: ultrasound examination findings (graded on intraventricular hemorrhage [IVH] and periventricular leukomalacia [PVL]), records of pregnancy complications and perinatal trauma, and medical problems during the NICU stay. This method eliminated recall bias, a problem with previous studies. We followed up the members of this cohort, obtaining data on 53 (63%). We correlated the NICU data with the following outcome measures: physical measurements and psychosocial, psychological, and eating disorder symptomatology data obtained by self-report questionnaires. Pregnancy and perinatal complications were combined into one composite variable. We used the method of multiple discriminant function analysis to determine statistical significance between groups. RESULTS: There were no statistically significant differences between the low (0-2) and high (3-7) composite variable of pregnancy/perinatal complications and outcome variables. CONCLUSIONS: These results indicate that traumatic episodes early in life, including brain insults, do not appear to increase the susceptibility of developing eating disorder symptomatology, depression, deficiency of self-esteem, or distortion of body shape during late adolescence.