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.

Analysis of ANRIL Isoforms and Key Genes in Patients with Severe Coronary Artery Disease.

ANRIL (Antisense Noncoding RNA in the INK4 Locus), also named CDKN2B-AS1, is a long non-coding RNA with outstanding functions that regulates genes involved in atherosclerosis development. ANRIL genotypes and the expression of linear and circular isoforms have been associated with coronary artery disease (CAD). The CDKN2A and the CDKN2B genes at the CDKN2A/B locus encode the Cyclin-Dependent Kinase inhibitor protein (CDKI) p16INK4a and the p53 regulatory protein p14ARF, which are involved in cell cycle regulation, aging, senescence, and apoptosis. Abnormal ANRIL expression regulates vascular endothelial growth factor (VEGF) gene expression, and upregulated Vascular Endothelial Growth Factor (VEGF) promotes angiogenesis by activating the NF-κB signaling pathway. Here, we explored associations between determinations of the linear, circular, and linear-to-circular ANRIL gene expression ratio, CDKN2A, VEGF and its receptor kinase insert domain-containing receptor (KDR) and cardiovascular risk factors and all-cause mortality in high-risk coronary patients before they undergo coronary artery bypass grafting surgery (CABG). We found that the expression of ANRIL isoforms may help in the prediction of CAD outcomes. Linear isoforms were correlated with a worse cardiovascular risk profile while the expression of circular isoforms of ANRIL correlated with a decrease in oxidative stress. However, the determination of the linear versus circular ratio of ANRIL did not report additional information to that determined by the evaluation of individual isoforms. Although the expressions of the VEFG and KDR genes correlated with a decrease in oxidative stress, in binary logistic regression analysis it was observed that only the expression of linear isoforms of ANRIL and VEGF significantly contributed to the prediction of the number of surgical revascularizations.

Percutaneous epiphysiodesis using transphyseal screws (PETS) versus tension-band plating (TBP): comparative study of outcomes for correcting limb length discrepancy.

OBJECTIVES: The best effective treatment strategy for limb length discrepancy (LLD) is still being debated. The goal of this study was to compare the efficacy and results of tension-band plating (TBP) and percutaneous epiphysiodesis using transphyseal screws (PETS) for LLD correction. METHODS: From June 2008 to January 2019, children who had lower extremity epiphysiodesis with either TBP or PETS were reviewed retrospectively. At the conclusion of treatment, LLD, angular deformity, and complications were reviewed. The t-test or Wilcoxon rank sum test was used to compare continuous variables. Categorical variables were evaluated using Fisher's exact test or χ2 test. RESULTS: A total of 32 epiphysiodeses with TBP (14 patients, 24 femur/tibias) or PETS (13 patients, 23 femur/tibias) were compared. TBPs were conducted while the patients were younger (11.0 vs. 13.1 years, p = 0.005). The treatment durations were similar in both groups (TBP: 23.5 months vs. PETS: 24 months, p = 0.132). PETS had significantly shorter operative time (p = 0.047), length of hospital stay (p = 0.014), and time to return to full activity (p = 0.043). LLD in the TBP group reduced from 2.64 to 1.38 cm (p = 0.005), while in the PETS group it decreased from 2.76 to 1.08 cm (p = 0.001). During treatment, the rate of LLD correction was 0.49 ± 0.9 cm/year for limbs treated with TBP and 1.0 ± 1.1 cm/year for limbs treated with PETS (p = 0.185). At the end of treatment, 8 TBP cases (47%) and 9 PETS cases (60%) had achieved LLD ≤ 2 cm (p = 0.502), and at the most recent follow-up, this had grown to 11 (65%) in the TBP group and 12 (80%) in the PETS group. There were no significant differences in the total number of complications between groups (p > 0.05). Revision surgery was required in 11 TBP and 3 PETS limbs due to persistent LLD or angular deformity (AD) (p = 0.016). Logistic regression did not reveal any significant association between TBP and the rate of complication or revision surgery. CONCLUSION: PETS and TBP are both effective methods for limb length equalization. PETS, on the other hand, was linked to a shorter operative time, a shorter hospital stay, a faster recovery to pre-operative function, and a lower complication rate. The rate of revision surgery due to persistent LLD or AD was higher in TBP. We advise surgeons against utilizing TBP to correct LLD. LEVEL OF EVIDENCE: III.

Clinical relevance of circulating angiogenic cells in patients with ischemic stroke.

BACKGROUND: Endothelial progenitor cells (EPCs) are circulating angiogenic cells with endothelial features associated with risk for stroke. We aimed to delve into their functional characteristics. EPCs were isolated and cultured from Ischemic Stroke (IS) patients and predictors of their variance evaluated. METHODS: This is a single-center observational study evaluating 187 consecutively hospitalized patients with IS. EPCs were isolated from blood samples. The number of circulating angiogenic cells (CACs), colony-forming units (CFU-ECs) and the emergence of late outgrowths endothelial cells (LOECs) were counted. We collected clinical variables and measured the stromal cell-derived factor 1 alpha (SDF1α) serum levels. We also examined the relative telomere length and the expression of osteogenic gene markers in CACs. RESULTS: CACs counts and CFU-ECs colony numbers were positively correlated (rho = 0.41, p < 0.001, n = 187). We found significant differences according to whether thrombolytic treatment was performed in the distribution of CFU-ECs (odds ratio (OR) = 2.5; 95% confidence interval (CI) 1.01-6.35; p = 0.042) and CACs (OR = 4.45; 95% IC 1.2-15.5; p = 0.012). The main determinants of CACs variation were the number of risks factors, thrombolysis treatment, arterial hypertension, LOECs occurrence, and the vascular endothelial growth factor expression, whereas CFU-ECs variations depended on hemoglobin content and the relative reduction in the National Institutes of Health Stroke Scale (NIHSS) criteria. The main predictors of LOECs appearance were thrombolysis and length of hospital stay. CONCLUSIONS: Our study supports the relevance of patient risk factors and treatments in the analysis of the functional properties of EPCs.

Posterior-only Resection of Single Hemivertebrae With 2-Level Versus >2-Level Fusion: Can We Improve Outcomes?

BACKGROUND: The outcomes of congenital scoliosis (CS) patients undergoing hemivertebra (HV) resection surgery with a 2-level fusion versus a >2-level fusion are unclear. We hypothesized that CS patients undergoing HV resection and a >2-level fusion have decreased curve progression and reoperation rates compared with 2-level fusions. METHODS: Retrospective review of prospectively collected data from a multicenter scoliosis database. Fifty-three CS patients (average age 4.5, range 1.2 to 10.9 y) at index surgery were included. Radiographic and surgical parameters, complications, as well as revision surgery rates were tracked at a minimum of 2-year follow-up. RESULTS: Twenty-six patients had a 2-level fusion while 27 patients had a >2-level fusion with similar age and body mass index between groups. The HV was located in the lumbar spine for 69% (18/26) 2-level fusions and 30% (8/27) >2-level fusions ( P =0.006). Segmental HV scoliosis curve was smaller in 2-level fusions compared to >2-level fusions preoperatively (38 vs. 50 degrees, P =0.016) and at follow-up (25 vs. 34 degrees, P =0.038). Preoperative T2-T12 (28 vs. 41 degrees, P =0.013) and segmental kyphosis (11 vs. 23 degrees, P =0.046) were smaller in 2-level fusions, but did not differ significantly at postoperative follow-up (32 vs. 39 degrees, P =0.22; 13 vs. 11 degrees, P =0.64, respectively). Furthermore, the 2 groups did not significantly differ in terms of surgical complications (27% vs. 22%, P =0.69; 2-level fusion vs. >2-level fusion, respectively), unplanned revision surgery rate (23% vs. 22%, 0.94), growing rod placement or extension of spinal fusion (15% vs. 15%, P =0.95), or health-related quality of life per the EOS-Questionnaire 24 (EOSQ-24). Comparison of patients with or without the need for growing rod placement or posterior spinal fusion revealed no significant differences in all parameters analyzed. CONCLUSIONS: Two-level and >2-level fusions can control congenital curves successfully. No differences existed in curve correction, proximal junctional kyphosis or complications between short and long-level fusion after HV resection. Both short and long level fusions are viable options and generate similar risk of revision. The decision should be individualized by patient and surgeon.

The Effect of Spinopelvic Parameters on the Development of Proximal Junctional Kyphosis in Early Onset: Mean 4.5-Year Follow-up.

BACKGROUND: Proximal junctional kyphosis (PJK) is a major complication after posterior spinal surgery. It is diagnosed radiographically based on a proximal junctional angle (PJA) and clinically when proximal extension is required. We hypothesized that abnormal spinopelvic alignment will increase the risk of PJK in children with early-onset scoliosis (EOS). METHODS: A retrospective study of 135 children with EOS from 2 registries, who were treated with distraction-based implants. Etiologies included 54 congenital, 10 neuromuscular, 37 syndromic, 32 idiopathic, and 2 unknown. A total of 89 rib-based and 46 spine-based surgeries were performed at a mean age of 5.3±2.83 years. On sagittal radiographs, spinopelvic parameters were measured preoperatively and at last follow-up: scoliosis angle (Cobb method, CA), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope and PJA. Radiographic PJK was defined as PJA≥10 degrees and PJA≥10 degrees greater than preoperative measurement. The requirement for the proximal extension of the upper instrumented vertebrae was considered a proximal junctional failure (PJF). Analysis of risk factors for the development of PJK and PJF was performed. RESULTS: At final follow-up (mean: 4.5±2.6 y), CA decreased (P<0.005), LL (P=0.029), and PI (P<0.005) increased, whereas PI-LL (pelvic incidence minus lumbar lordosis) did not change (P=0.706). Overall, 38% of children developed radiographic PJK and 18% developed PJF. Preoperative TK>50 degrees was a risk factor for the development of radiographic PJK (relative risk: 1.67, P=0.04). Children with high postoperative CA [hazard ratio (HR): 1.03, P=0.015], postoperative PT≥30 degrees (HR: 2.77, P=0.043), PI-LL>20 degrees (HR: 2.92, P=0.034), as well as greater preoperative to postoperative changes in PT (HR: 1.05, P=0.004), PI (HR: 1.06, P=0.0004) and PI-LL (HR: 1.03, P=0.013) were more likely to develop PJF. Children with rib-based constructs were less likely to develop radiographic PJK compared with children with spine-based distraction constructs (31% vs. 54%, respectively, P=0.038). CONCLUSIONS: In EOS patients undergoing growth-friendly surgery for EOS, preoperative TK>50 degrees was associated with increased risk for radiographic PJK. Postoperative PI-LL>20 degrees, PT≥30 degrees, and overcorrection of PT and PI-LL increased risk for PJF. Rib-based distraction construct decreased the risk for radiographic PJK in contrast with the spine-based constructs. LEVEL OF EVIDENCE: Level III.

Establishing Consensus on the Best Practice Guidelines for Use of Halo Gravity Traction for Pediatric Spinal Deformity.

BACKGROUND: Although halo gravity traction (HGT) has been used to treat children with severe spinal deformity for decades, there is a distinct lack of high-quality evidence to speak to its merits or to dictate ideal manner of implementation. In addition, no guidelines exist to drive research or assist surgeons in their practice. The aim of this study was to establish best practice guidelines (BPG) using formal techniques of consensus building among a group of experienced pediatric spinal deformity surgeons to determine ideal indications and implementation of HGT for pediatric spinal deformity. METHODS: The Delphi process and nominal group technique were used to formally derive consensus among leaders in pediatric spine surgery. Initial work identified significant areas of variability in practice for which we sought to garner consensus. After review of the literature, 3 iterative surveys were administered from February through April 2018 to nationwide experts in pediatric spinal deformity. Surveys assessed anonymous opinions on ideal practices for indications, preoperative evaluation, protocols, and complications, with agreement of 80% or higher considered consensus. Final determination of consensus items and equipoise were established using the Nominal group technique in a facilitated meeting. RESULTS: Of the 42 surgeons invited, responses were received from 32, 40, and 31 surgeons for each survey, respectively. The final meeting included 14 experts with an average 10.5 years in practice and average 88 annual spinal deformity cases. Experts reached consensus on 67 items [indications (17), goals (1), preoperative evaluations (5), protocols (36), complications (8)]; these were consolidated to create final BPG in all categories, including statements to help dictate practice such as using at least 6 to 8 pins under 4 to 8 lbs of torque, with a small, tolerable starting weight and reaching goal weight of 50% TBW in ∼2 weeks. Nine items remained items of equipoise for the purposes of guiding future research. CONCLUSIONS: We developed consensus-based BPG for the use and implementation of HGT for pediatric spinal deformity. This can serve as a measure to help drive future research as well as give new surgeons a place to begin their practice of HGT. LEVEL OF EVIDENCE: Level V-expert opinion.

[Sociodemographic Patterning of Cardiorespiratory Fitness Derived by Equation in the Chilean Population: Findings from the Chilean Health Survey 2016-2017]. / Fitness cardiorrespiratorio estimado mediante ecuación y su caracterización sociodemográfica en población chilena: Resultados de la Encuesta Nacional de Salud 2016-2017.

BACKGROUND: Cardiorespiratory fitness is a strong predictor of mortality and chronic diseases. However, its estimation is costly and time consuming which may limit it broad use in population-based studies. AIM: To estimate the cardiorespiratory fitness of the Chilean population by using equations and to characterize fitness levels of the Chilean population by sociodemographic factors. MATERIAL AND METHODS: This cross-sectional study included 5,958 adults from the Chilean Health Survey conducted between 2016 and 2017. Cardiorespiratory fitness was estimated from sex-specific equations for men and women and expressed as METs (Energy Metabolic Equivalent). Fitness levels were characterized by sociodemographics factors (age, sex, education, income and area of residency). RESULTS: Fitness levels were higher in men (9.01 METs) than in women (6.76 METs) and in average decrease by 0.59 and 0.34 METs per each year increment in age for men and women, respectively. Fitness levels were 12.7 METs and 7.8 METs for 20-year-old men and women, respectively. However, fitness levels decreased to 7.8 METs and 4.3 METs in 90-year-old men and women, respectively. Fitness levels were also higher in individuals living in urban setting, those with higher education or income levels and lean individuals. CONCLUSIONS: This study reports fitness levels in a nationally representative sample of Chile. Fitness levels were higher in men than women however, its decline with age was more pronounce in men than women.

Association of leisure time and occupational physical activity with obesity and cardiovascular risk factors in Chile.

The aim of this study was to investigate the association between physical activity (PA), both occupational (OPA) and during leisure time (LTPA), with obesity and cardiovascular risk factors in Chilean adults. 5,157 participants from the Chilean National Health Survey 2009-2010 were included in this study. OPA and LTPA levels were assessed using the Global Physical Activity Questionnaire. The association between both PA with obesity and cardiovascular risk factors was determined using logistic regression. Our findings showed a significant trend between higher LTPA and lower odds for obesity (OR 0.64 [95% CI: 0.53; 0.76], central obesity 0.52 [0.44; 0.61]) and other cardiovascular risk factors including diabetes (OR: 0.72 [0.55; 0.94]), hypertension (OR: 0.59 [0.50; 0.71]) and metabolic syndrome (OR: 0.62 [0.50; 0.78]). In contrast, OPA was only associated with lower odds of diabetes (OR: 0.79 [0.65; 0.98]) and hypertension (0.85 [0.74; 0.98]). In conclusion, LTPA was associated with a lower risk of all major cardiovascular risk factors, whereas OPA was only associated with a lower risk of diabetes and hypertension.

[Lifestyles of Chilean housewives. Analysis of the 2009-2010 Chilean Health Survey]. / Caracterización de los estilos de vida en dueñas de casa chilenas. Análisis de la Encuesta Nacional de Salud 2009-2010.

BACKGROUND: Housewives represent a important proportion of the Chilean population. However, there is limited evidence about their lifestyles. AIM: To characterize lifestyles and determine the level of compliance with healthy lifestyles guidelines of housewives in Chile. MATERIAL AND METHODS: Housewives from the 2009-2010 National Health Survey were included. The variables studied included levels of physical activity (PA), sedentary behavior, diet, hours of sleep and smoking. Compliance with healthy lifestyle behaviors was evaluated through logistic regression, granting a value of 1 for compliance and 0 for non-compliance. A healthy lifestyle was defined as meeting at least four healthy behaviors. RESULTS: Housewives aged > 55 years had a higher BMI and waist circumference compared to those aged < 40 years. Housewives were also more likely to report moderate alcohol consumption and were more likely to meet a healthier lifestyle score (Odds ratio = 1.52 [95% confidence intervals: 1.09 to 2.11], p = 0.013). No significant age trends were observed for other lifestyle behaviors. CONCLUSIONS: Housewives had high levels of central obesity, excess body weight and high levels of salt intake but low alcohol intake. Their healthy lifestyles behaviors increased along with increasing age.

Staged Growing Rods With Preimplantation of Spinal Anchors for Complex Early Onset Scoliosis.

BACKGROUND: Treatment of early onset scoliosis (EOS) with growing rods (GR) can be challenging in patients with significant deformity, hyperkyphosis, or poor bone quality, due to risks of neurological deficit and hardware pull-out. The objective of this study is to report a series of EOS patients managed with a 2-stage GR technique used to minimize these complications. METHODS: Two-stage GR technique was performed in 8 patients at mean age of 5.4 (range, 3.4 to 7.9) years. At stage 1, proximal and distal anchors were implanted with local fusion. At stage 2, the distraction rods were inserted. There were at least 3 months between stages 1 and 2, and halo-gravity traction was used before stage 2 unless contraindicated. Demographic, clinical, and surgical data were retrospectively reviewed with mean 4.9 (range, 2.0 to 9.4) years of follow-up. Radiographic measurements including Cobb and kyphosis angles were evaluated before stage 1, after halo-gravity traction, after stage 2, and at last follow-up. Indications for staging, anchor healing time, and complications were collected and analyzed. RESULTS: Indications for 2-stage surgery were poor bone quality in 5 patients and neurological changes during initial attempt at GR placement in 3 patients. The mean time between stage 1 and 2 was 23 (15 to 45) weeks. Patients have undergone mean 7 (3 to 16) lengthenings. Three patients have been converted to magnetically controlled GR. The major coronal Cobb angle improved from mean 81 degrees (range, 61 to 97) preoperatively to 40 degrees (24 to 50) after stage 2 and remained at 40 degrees (27 to 53) at last follow-up. Kyphosis remained controlled from 45 degrees (10 to 76) preoperatively to 38 degrees (9 to 61) after stage 2 to 41 degrees (17 to 65) at last follow-up. Complications included superficial wound problems (4 patients), broken rods (2 patients), proximal migration (2 patients), and implant prominence (1 patient). At minimum 2-year follow-up, no patients had lingering neurological complications or instrumentation-bone failure of the GR construct. CONCLUSIONS: Two-stage GR technique can effectively be utilized in EOS patients with poor bone quality or in the event of intraoperative neurological changes. Satisfactory deformity correction can be obtained and routine serial lengthenings can take place with minimal complications. LEVEL OF EVIDENCE: Level IV- case series.

Initial Cast Correction as a Predictor of Treatment Outcome Success for Infantile Idiopathic Scoliosis.

BACKGROUND: Cast treatment for infantile idiopathic scoliosis patients ultimately corrects deformity in varying amounts. As the reasons for these differential outcomes are not fully elucidated, the aim of this study was to identify clinical and radiographic variables correlated with better cast correction. METHODS: Patients in the Children's Spine Study Group and Growing Spine Study Group registries who underwent cast treatment for idiopathic scoliosis between 2005 and 2013 with 1-year minimum follow-up were included. Data including major curve and rib-vertebra angle difference before cast, initial in-cast application, after cast treatment, and at most recent follow-up were collected. Univariable and multivariable regression analyses were used to identify factors associated with lower major curves at most recent follow-up. RESULTS: A total of 68 patients were identified and followed for a mean of 2.5 (range, 1.1 to 5.4) years after cast treatment. Cast treatment lasted an average of 16.7 months, with a median of 6 cast applications (range, 2 to 19). Twenty-five subjects (37%) had a most recent major curve <15 degrees (success), whereas 43 had a curve that was >15 degrees (unresolved). Multivariable linear regression determined that younger age (P=0.02), smaller precast major curve (P<0.001), and greater percent major curve correction in initial cast (P=0.006) were associated with smaller major curve at most recent follow-up. Multivariable logistic regression determined that success patients were younger than unresolved patients (average age, 1.4 vs. 2.1 y; P=0.003), and had smaller in-cast major curves after initial cast application (average, 18 vs. 27 degrees; P=0.002). CONCLUSIONS: Infantile idiopathic scoliosis patients casted at an earlier age, with smaller major curves, and greater percent major curve correction in initial cast have the best prognosis. Patients' percent major curve correction, which may represent curve flexibility and/or cast quality, is a predictor of treatment success when age and precast major curve are also taken into account. LEVEL OF EVIDENCE: Level III-retrospective study.

Recurrent spinal deformity after scoliosis surgery in children.

The management of complex spinal deformities in the growing child continues to evolve. The implementation of new techniques and biomaterial constructs has improved outcomes of deformity correction procedures but has also led to unforeseen complications. After spinal alignment through posterior instrumentation and fusion, progressive global decompensation in the coronal and sagittal planes or local decompensation in the vertebral segments adjacent to the fusion have developed in some children. These complications can lead to poor cosmesis, function, and quality of life, and a higher risk for revision surgery. Although postoperative spinal imbalance develops in few children, diligent monitoring of patients with predisposing risk factors for decompensation will allow surgeons to better predict, manage, and potentially prevent these complications.

The effect of rod diameter on correction of adolescent idiopathic scoliosis at two years follow-up.

STUDY DESIGN: The review of multicenter national pediatric scoliosis database. OBJECTIVE: The purpose of this study was to compare the radiographic outcomes of patients who underwent scoliosis surgery utilizing different rod diameter constructs by the posterior approach. BACKGROUND: Little attention has specifically been focused on the effect of rod diameter on correction of spinal deformity after posterior spinal instrumentation and fusion in children with adolescent idiopathic scoliosis (AIS). METHODS: The review of national database comprised of 1125 patients, of which 352 patients had a minimum follow-up of 2 years. Of these, 163 patients received 5.5 mm and 189 patients received 6.35 mm diameter rods for posterior spinal instrumentation. RESULTS: The 6.35 mm rods were used more often for patients who were male, taller, heavier, with larger coronal curves, and more flexible curves. Larger diameter rods were also more likely to be stainless steel, implanted with an increased number of implants per level, and an increased number of pedicle screws used on the concavity of the curve. Univariate analysis of coronal curve showed a significant difference between 5.5 and 6.35 mm rods in correction (67.0% vs. 57.3%) at 2 years. Multivariate analysis revealed that the most significant factors affecting coronal curve correction at 2 years were rod diameter, the patient's preoperative coronal major curve and flexibility, and the implant density. In the sagittal plane, preoperative sagittal curve and rod diameter are the predictors of sagittal correction at 2 years. CONCLUSIONS: The study did not support our hypothesis that larger rods would be associated with a greater correction of frontal and sagittal plane in patients with AIS. In addition to rod diameter, implant density and the inherent flexibility and deformity of the patient were found to be influential factors contributing for the correction and maintenance of coronal and sagittal curves in AIS.

The complex treatment paradigms for concomitant tethered cord and scoliosis: illustrative case.

BACKGROUND: Scoliosis associated with tethered cord syndrome is one of the most challenging spinal deformities to manage. Multiple surgical approaches have been developed, including traditional staged and concomitant procedures, spine-shortening osteotomies, and individual vertebral column resections. OBSERVATIONS: A 10-year-old female presented with congenital kyphoscoliosis with worsening curve progression, tethered spinal cord, and a history of enuresis. The scoliosis had progressed to a 26° coronal curve and 55° thoracolumbar kyphosis. Preoperative magnetic resonance imaging of the spine revealed a tethered cord between the levels of L3-4 and a large kyphotic deformity at L1. The patient underwent laminectomy, during which intraoperative motor signals were lost. A planned hemivertebrectomy at L1 was performed prior to an L4 laminectomy, untethering of the filum terminale, and posterior spinal fusion from T11 to L2. After surgery, the patient experienced transient lower-extremity weakness, with her neurological function improving from baseline over the next 2 months. Ultimately, the goal of this surgery was to halt the progressive decline in motor function, which was successfully achieved. LESSONS: Much remains to be learned about the treatment of this complicated disease, especially in the setting of concomitant scoliosis. This case serves to exemplify the complex treatment paradigms that exist when attempting to manage this clinical syndrome and that more remains to be learned.

Does Combining Drilling and Curettage to Percutaneous Trans-epiphyseal Screws Improve Correction of Limb Length Discrepancy? A Comparative Study.

Objectives: Physeal drilling and curettage (PDC) and percutaneous epiphysiodesis using transphyseal screws (PETS) are among the most widely used techniques to treat leg-length discrepancy (LLD). This study compared the efficacy and outcomes between PETS alone and PETS combined with PDC (PETS + PDC). Methods: Retrospective study of children who underwent epiphysiodesis of the proximal tibia or distal femur with either PETS or PETS + PDC between 2008 and 2018 at a single institution. Radiographic parameters and complications were reviewed at completion of treatment and most recent follow-up. Results: A total of 23 epiphysiodeses in 15 patients, average age 13.1 years, with either PETS (13 femur/tibias) or PETS + PDC (10 femur/tibias) were included. PETS patients were treated for a longer time (median: 24 months vs 11 months, p = 0.004), however, follow-up time was similar between groups (p = 0.577), on average 2.7 years. In the PETS group, LLD decreased from 2.55 to 0.84 cm at most recent follow-up (p = 0.010), and in the PETS + PDC group from 3.01 to 1.2 cm (p = 0.005), achieving a correction of 1.71 cm for PETS and 1.83 cm for PETS + PDC (p = 0.871). A correction of LLD to ≤ 2 cm was achieved in 8 PETS (89%) and 4 PETS + PDC cases (67%) (p = 0.525). Two PETS patients (22%) and 1 PETS + PDC (17%) patient returned to the OR for further correction due to persistent LLD (p = 1.000). No differences existed in total number of complications, angular deformity or return to physical activity between groups (p ≥ 0.05 for each comparison). Conclusions: This study showed equal efficiency in resolving LLD between the PETS and PETS + PDC procedures with minimal operative complications.Level of Evidence III.

The Impact of Standardized Recovery Pathways on Language Barriers and Inpatient Pain Management.

BACKGROUND AND OBJECTIVES: Inpatient postoperative care is reliant upon clear, open communication between providers and patient-families, and thus is particularly vulnerable to disparities when discordant languages exist. It is not yet understood how standardized postoperative protocols may mitigate disparities related to language discordance. METHODS: This is a retrospective cohort study among adolescent idiopathic scoliosis patients who underwent posterior spinal fusion at a tertiary care children's hospital in Bronx, New York after implementation of a postoperative pathway in 2017. Outcomes reliant upon communication between patient-families and providers were measured, including measures of pain management (number and type of pain medications requested, daily pain assessments, total opioids consumed), as well as outpatient pain scores. RESULTS: A total of 160 patients were included (39 language other than English [LOE]). Between patient cohorts, there were no significant differences in demographic or operative characteristics. On univariate analyses, LOE patients were more likely to be given a basal dosing of patient-controlled analgesia or additional boluses (26% vs 12%, P = .03), consumed 0.53 fewer benzodiazepine medications per day (P = .01), and were more likely to have pain at outpatient follow-up (67% vs 43%, P = .03). On multivariate analyses, LOE patients were more likely to be placed on basally dosed or receive additional boluses of patient-controlled analgesia (odds ratio 3.19, 95% confidence interval 1.15-8.85). CONCLUSIONS: As standardized pathways become more common in health care, it is critical to monitor for components of these protocols that may be vulnerable to language-related disparities, such as therapies reliant on symptom description and outpatient follow-up.