Evolving Surgical Management for Early-Onset Scoliosis in Spinal Muscular Atrophy Type 1 Given Improvements in Survival.

CASE: We present a case of an 18-month-old child with early-onset scoliosis in the setting of spinal muscular atrophy (SMA) type 1 whose rapidly progressive scoliosis is successfully managed with magnetic growing rods, the youngest age of implantation in a patient with SMA we are currently aware of. Technical challenges, complications, and outcome are described in this case presentation. CONCLUSION: Patients with SMA type 1 and early-onset scoliosis can be managed with growing-rod constructs given dramatic improvements in medical care that have expanded life expectancy.

Changes in cerebral oxygenation based on intraoperative ventilation strategy.

INTRODUCTION: Cerebral oxygenation can be monitored clinically by cerebral oximetry (regional oxygen saturation, rSO2) using near-infrared spectroscopy (NIRS). Changes in rSO2 have been shown to precede changes in pulse oximetry, providing an early detection of clinical deterioration. Cerebral oximetry values may be affected by various factors, including changes in ventilation. The aim of this study was to evaluate the changes in rSO2 during intraoperative changes in mechanical ventilation. PATIENTS AND METHODS: Following the approval of the institutional review board (IRB), tissue and cerebral oxygenation were monitored intraoperatively using NIRS. Prior to anesthetic induction, the NIRS monitor was placed on the forehead and over the deltoid muscle to obtain baseline values. NIRS measurements were recorded each minute over a 5-min period during general anesthesia at four phases of ventilation: 1) normocarbia (35-40 mmHg) with a low fraction of inspired oxygen (FiO2) of 0.3; 2) hypocarbia (25-30 mmHg) and low FiO2 of 0.3; 3) hypocarbia and a high FiO2 of 0.6; and 4) normocarbia and a high FiO2. NIRS measurements during each phase were compared with sequential phases using paired t-tests. RESULTS: The study cohort included 30 adolescents. Baseline cerebral and tissue oxygenation were 81% ± 9% and 87% ± 5%, respectively. During phase 1, cerebral rSO2 was 83% ± 8%, which decreased to 79% ± 8% in phase 2 (hypocarbia and low FiO2). Cerebral oxygenation partially recovered during phase 3 (81% ± 9%) with the increase in FiO2 and then returned to baseline during phase 4 (83% ± 8%). Each sequential change (e.g., phase 1 to phase 2) in cerebral oxygenation was statistically significant (p < 0.01). Tissue oxygenation remained at 87%-88% throughout the study. CONCLUSION: Cerebral oxygenation declined slightly during general anesthesia with the transition from normocarbia to hypocarbic conditions. The rSO2 decrease related to hypocarbia was easily reversed with a return to baseline values by the administration of supplemental oxygen (60% vs. 30%).

Changes in Cerebral Oxygenation during Transfusion Therapy.

This study assesses the effects of transfusion of autologous or allogeneic blood on cerebral and tissue oxygenation during spinal surgery. Packed red blood cell transfusions are indicated to improve oxygen delivery to tissues. There are limited data demonstrating changes in tissue oxygenation with blood administration. Tissue (deltoid) and cerebral oxygenation were monitored using near-infrared spectroscopy during spinal surgery in patients. As indicated, cell saver or allogeneic blood was administered. Tissue and cerebral oxygenation were recorded before and after transfusion. The study enrolled 50 patients, 33 of whom (17 males and 16 females) received allogeneic blood (n = 8) or autologous blood (n = 25). Patients ranged in age from 9 to 19 years (14.0 ± 2.3 years) and in weight from 16.8 to 122.7 kg (54.6 ± 25.7 kg). Tissue oxygenation increased from 83 ± 9 (pretransfusion) to 86 ± 7 at the end of transfusion (p = .002) and remained at the same level (86 ± 7) in the post-transfusion period. Cerebral oxygenation increased from 76 ± 8 (pretransfusion) to 84 ± 8 at the end of transfusion (p < .001) and remained at 84 ± 8 in the post-transfusion period. Changes in tissue and cerebral oxygenation were similar between cell saver and allogeneic blood and between starting hemoglobin value <8 gm/dL and starting hemoglobin ≥8 gm/dL. In conclusion, although both cerebral and tissue oxygenation increased during the administration of either allogeneic or autologous blood, the clinical impact was likely limited given the high initial tissue and cerebral oxygenation values. No differences were noted between autologous (cell saver) and allogeneic blood or based on the starting hemoglobin value.

Utilization of Orthopaedic Trauma Surgical Time: An Evaluation of Three Different Models at a Level I Pediatric Trauma Center.

OBJECTIVE: Over the past decade, our institution has instituted three different scheduling models in an attempt to care for pediatric trauma at our Level I Trauma Center. This has been in response to a number of factors, including a limited number of physicians covering the call schedule, increasing competition for operating room (OR) time after hours (pediatric surgery, urology, neurosurgery), an attempt to fully utilize OR time during the daytime, fully staffed hours, and optimizing patients' timeliness to surgery. We examined the three on-call systems in place at our institution to determine whether a more flexible approach to pediatric trauma call resulted in delays in treatment. METHODS: We retrospectively reviewed patient records for three distinct 1-year periods with three different surgical call schedules: (i) a traditional call schedule in which the call physician was responsible for patients who presented to our emergency room; (ii) a half-day trauma block OR reserved the morning following call; and (iii) a full-day trauma block. Variables included date of injury, time of admission, admission diagnosis, cause of injury, and OR procedure and start time. RESULTS: We reviewed 951 cases over the entire study, 268 during the traditional call schedule, 282 during the half-call block and 401 over the time period of the full-day block. Mechanisms of injury were similar among the three groups, with falls and motor vehicle accidents being the leading causes. The average delay time was 17:40 for the traditional call group, 15:10 for the half-block call group, and 15:09 for the full-day block group. Our findings suggest that there was a high incidence of cases performed on weekdays after peak staffing hours with a traditional call model (59%). In contrast, half-day and full-day block models saw only 4% and 1% of the cases performed after peak staffing hours, respectively. There was a statistically significant difference in the number of patients admitted to the OR among the three groups (χ(2) = 488.8449, P < 0.0001). The number of patients seen during Monday through Friday was also statistically significant among the three groups (χ(2) = 382.0576, P < 0.0001). CONCLUSIONS: The institution of more flexible and physician-directed half-call and full-day blocks did result in delays in treatment. However, it also has demonstrated benefits to patients in reducing the number of operative cases performed after weekday peak staffing hours; helped our institution better manage its staffing and financial resources; and provided the treating surgeon flexibility in determining the timing of operative care.

A retrospective quality improvement study of ketorolac use following spinal fusion in pediatric patients.

BACKGROUND: There are studies and literature that support the claim that ketorolac use after spinal fusion in the adult population can increase the risk of pseudarthrosis, instrumentation failure, and/or nonunion. There is limited research when using ketorolac in the pediatric population, especially short-term use. METHODS: Chart review of 46 pediatric patients who had prior spinal fusions for scoliosis between July 2003 and August 2005. Twenty-five of the patients received ketorolac and 21 did not. The lengths of stay, incidence of curve progression, and/or incidence of nonunion or instrumentation failure were compared in the 2 groups. RESULTS: At the 1-year follow-up, 95% of the patients returned and at the 3-year follow-up, 52% of the patients returned and there was no clinical or radiographic evidence of curve progression, nonunion, or instrumentation failure. LEVEL OF EVIDENCE: This is a retrospective study looking at results of 2 patient groups. This is a level III study.