The Sanders Classification and Obesity: Do Obese Kids With AIS Present With More Advanced Skeletal Maturity?

INTRODUCTION: Obese and overweight (OOW) patients with adolescent idiopathic scoliosis (AIS) have been shown to initially present with a more advanced Risser score compared to normal weight (NW) patients. The Sanders Maturity Scale (SMS) is now more commonly used by surgeons to assist with treatment decisions because it more reliably predicts skeletal maturity. However, the relationship between SMS and obesity has not been described. We hypothesize that in patients with AIS, OOW patients will have a higher SMS score on initial presentation when compared to NW patients. METHODS: Billing data from 2 different institutions were used to identify patients with AIS presenting to a pediatric orthopaedic spine surgeon for an initial visit between July 2012 and March 2020. We excluded those without height/weight data, spine radiographs, or left-hand radiographs for measuring SMS stage. Body mass index-for-age percentiles were calculated and used to group patients into NW (<85th percentile) or OOW (85th percentile and above) per Centers for Disease Control guidelines. After collecting preliminary data, a power analysis was performed using average SMS scores between NW and OOW patients with an alpha of 0.5, determining a needed sample size of approximately 300 male and 300 female subjects. RESULTS: Five hundred ninety patients (296 female, 294 male) were identified. The SMS stage at presentation was significantly greater in OOW compared to NW patients for both females (5.9±1.8 vs. 5.2±1.7; P =0.003) and males (4.9±1.9 vs. 4.1±1.8; P =0.002). The major curve magnitude for OOW females was significantly different from NW females (36±16 degrees vs. 30±16 degrees; P =0.004). The major curve magnitude was not different for OOW and NW males ( P =0.3). CONCLUSION: At initial presentation, OOW patients present at a greater skeletal maturity as measured by the SMS compared with NW patients. OOW female patients present with a greater major curve magnitudes than NW female patients. These results highlight negative implications of the pediatric obesity epidemic as it relates to the AIS population. These findings can be used to counsel families and provide anticipatory guidance for the AIS treatment plan. LEVEL OF EVIDENCE: Level III-cross-sectional study.

Effect of pelvic fixation on ambulation in children with neuromuscular scoliosis.

BACKGROUND: The effect of posterior spinal fusion (PSF) incorporating the pelvis on an ambulatory patient's ability to mobilize after the fusion is not well understood. AIM: To see whether a posterior spinal fusion with pelvic fixation using iliac or sacral alar iliac screws in ambulatory neuromuscular scoliosis (NMS) patients influences postoperative ambulatory ability. METHODS: A retrospective review of all patients with NMS that underwent PSF with fixation incorporating the pelvis between January 1, 2012 and February 29, 2019. A total of 118 patients were eligible, including 11 ambulatory patients. The primary outcome was the maintenance of ambulatory status postoperatively. Secondary outcomes included postoperative curve magnitude, pelvic obliquity, and complications, comprising infections, instrumentation failure, and any unplanned returns to the operative room. RESULTS: The ambulatory function was maintained in all 11 ambulatory NMS patients. One patient had an improvement in functional status with equipment-free ambulation postoperatively. An average postoperative follow-up was 19 mo. The overall complication rate was 19.4% (n = 23) with no significant differences between the groups in infection (P = 0.365), hardware failure (P = 0.505), and reoperation rate (P = 1.0). Ambulatory status did not affect complication rate (P = 0.967). CONCLUSION: Spinal fusion to the pelvis in ambulatory patients with NMS provides effective deformity correction without the reduction in ambulatory capabilities.

Does Obesity Affect Preoperative Shoulder Balance in Adolescent Idiopathic Scoliosis?

BACKGROUND: Obese patients with adolescent idiopathic scoliosis (AIS) have been shown to present with larger curve magnitudes preoperatively. However, the effect of obesity on shoulder balance in AIS remains unknown. The purpose of our study was to determine if overweight and obese patients with AIS have worse radiographic shoulder balance on initial presentation when compared with normal weight patients. METHODS: AIS patients <18 years old, with Lenke 1 or 2 curves, who underwent a posterior spinal fusion between March 2013 and December 2018 were retrospectively evaluated. BMI-for-age percentiles as defined by the Center for Disease Control and Prevention were used: obese (≥95th percentile), overweight (85th to <95th percentile), and normal weight (5th to <85th percentile). Shoulder height was measured via the radiographic shoulder height (RSH) method, with an RSH ≤ 1 cm considered balanced. The primary outcome was preoperative shoulder balance. Secondary outcomes included postoperative shoulder balance, major curve correction, and UIV selection. RESULTS: One hundred eighty-four patients (116 [63%] normal weight and 68 [37%] overweight/obese) were included. The mean age at surgery was 13.1 ± 2 years, and mean follow-up was 17.4 ± 13 months. Preoperative shoulder imbalance was significantly greater in the overweight/obese group compared to the normal weight group (1.9 ± 1 cm vs. 1.5 ± 1 cm, p = 0.04). The odds ratio of presenting with unbalanced shoulders was 2.0 (95% CI: 1.02-3.83, p = 0.04) for the overweight/obese group. No significant differences were found for postoperative shoulder balance, UIV selection, or major curve correction. CONCLUSIONS: Overweight and obese patients with AIS are twice as likely to present with unbalanced shoulders preoperatively; however, this difference is not clinically relevant with a mean difference of 0.4 cm between cohorts. Finally, the preoperative BMI percentile did not show a significant effect on the chosen UIV or curve magnitude correction. LEVEL OF EVIDENCE: Level III: this is a retrospective case-control study.

Surgical Outcomes of Obese Patients With Adolescent Idiopathic Scoliosis From Endemic Areas of Obesity in the United States.

BACKGROUND: Obesity rates continue to rise among children and adolescents across the globe. A multicenter research consortium composed of institutions in the Southern US, located in states endemic for childhood obesity, was formed to evaluate the effect of obesity on pediatric musculoskeletal disorders. This study evaluates the effect of body mass index (BMI) percentile and socioeconomic status (SES) on surgical site infections (SSIs) and perioperative complications in patients with adolescent idiopathic scoliosis (AIS) treated with posterior spinal fusion (PSF). METHODS: Eleven centers in the Southern US retrospectively reviewed postoperative AIS patients after PSF between 2011 and 2017. Each center contributed data to a centralized database from patients in the following BMI-for-age groups: normal weight (NW, 5th to <85th percentile), overweight (OW, 85th to <95th percentile), and obese (OB, ≥95th percentile). The primary outcome variable was the occurrence of an SSI. SES was measured by the Area Deprivation Index (ADI), with higher scores indicating a lower SES. RESULTS: Seven hundred fifty-one patients were included in this study (256 NW, 235 OW, and 260 OB). OB and OW patients presented with significantly higher ADIs indicating a lower SES (P<0.001). In addition, SSI rates were significantly different between BMI groups (0.8% NW, 4.3% OW, and 5.4% OB, P=0.012). Further analysis showed that superficial and not deep SSIs were significantly different between BMI groups. These differences in SSI rates persisted even while controlling for ADI. Wound dehiscence and readmission rates were significantly different between groups (P=0.004 and 0.03, respectively), with OB patients demonstrating the highest rates. EBL and cell saver return were significantly higher in overweight patients (P=0.007 and 0.002, respectively). CONCLUSION: OB and OW AIS patients have significantly greater superficial SSI rates than NW patients, even after controlling for SES. LEVEL OF EVIDENCE: Level III.

Outcomes of Vertical Expandable Prosthetic Titanium Ribs in Children With Early-Onset Scoliosis Secondary to Cerebral Palsy.

Purpose Patients who have neuromuscular scoliosis, such as cerebral palsy (CP), often develop spinal deformities that negatively impact quality of life. The vertical expandable prosthetic titanium rib (VEPTR) was designed for thoracic insufficiency syndrome (TIS), but it has also been utilized in patients with CP with restrictive lung disease and spine deformity. Few studies report on VEPTRs in neuromuscular scoliosis; however, none reports on their utilization specifically in patients with CP. Our purpose was to assess if VEPTRs can improve spinal deformity and TIS in these patients. Methods A retrospective chart review was performed of all patients with CP and scoliosis treated with a VEPTR between 2008 and 2017. Eight patients were eligible for this study. The mean follow-up was four years. Outcomes evaluated were Cobb angle, pelvic obliquity, space available for lung ratio (SAL), T1-S1 height, and complication rates. A p-value of less than 0.05 was used for statistical significance. Results There were significant postoperative improvements in Cobb angle, pelvic obliquity, and T1-S1 height, but no statistical difference in SAL. Prior to final fusion, the mean number of VEPTR lengthening procedures was 3. The mean time from index surgery to final fusion was 3.7 years. The most common complications were infection (62.5%) and wound dehiscence (25%). Only 25% of patients did not have a complication. Conclusion VEPTRs demonstrated significant improvement in almost all parameters and may be valuable in improving TIS in patients with CP. The complication and reoperation rates were similar to those of VEPTRs used for other pathological conditions.

The value-added benefit of utilizing two attending surgeons for patients with scoliosis secondary to cerebral palsy.

PURPOSE: The use of two attending surgeons during posterior spinal fusion (PSF) for cerebral palsy (CP) patients has been shown to improve perioperative outcomes. This study aims to determine if the use of two surgeons is associated with an increase in the number of subsequent surgeries that can be performed in the same operating room (OR) during business hours. METHODS: Patients with scoliosis and CP treated with PSF with minimum 90-day follow-up were included. Patients were grouped based on whether one or two attending surgeons performed the case. The primary outcome was the number of surgeries that followed in the same OR before 5 PM. Secondary outcomes included operative time, estimated blood loss (EBL), length of stay, rate of surgical site infection, and rate of unplanned return to the operating room. RESULTS: Thirty-six patients were included (10 with 1 surgeon and 26 with 2 surgeons). The two surgeon group had a significant increase in the average number of surgeries subsequently performed in the same OR during business hours (1.1 vs. 0.3, p = 0.01), as well as shorter mean operative time (159 vs. 307 min, p = 0.007) and EBL (554 vs. 840 cc, p = 0.01; 26 vs. 39%EBV, p = 0.03). CONCLUSION: The use of two attending surgeons was associated with a significant increase in the number of cases subsequently performed in the same OR during business hours, and significant decreases in operative time and EBL. Hospitals should consider the patient care and potential system-level improvements when considering implementation of two surgeon teams for PSF in CP patients. LEVEL OF EVIDENCE: Therapeutic Level III.

Effect of Gender on Postoperative Morbidity and Mortality Outcomes: A Retrospective Cohort Study.

Full extent of gender differences on postoperative outcomes has never been studied on large scale, specifically postoperative complications. This study aims to assess the effect of gender on 30-day morbidity and mortality after major surgery. A retrospective cohort study was carried out using data of patients undergoing major surgeries from the American College of Surgeons' National Surgical Quality Improvement Program database between 2008 and 2011. Demographics, pre- and perioperative risk factors, as well as 30-day morbidities, both overall and specific, were reviewed. The 30-day mortality data were also assessed. Multivariate logistic regression analyses, basic (Adj1) and extended (Adj2), were used to assess the association between gender and outcomes. Out of 1,409,131 patients, 57.2 per cent were females. Females had lower prevalence of most system-specific risk variables. Overall morbidities were also lower in females versus males, even after adjustment for variables [total overall morbidity: ORadj2 = 0.9 (0.89-0.92), P < 0.0001] except in some cases such as after cardiac surgeries [ORadj2 = 1.29 (1.14-1.44), P < 0.0001] and vascular surgeries [ORadj2 = 1.14 (1.10-1.18), P < 0.0001], where overall morbidities of females were higher. Specific morbidities were also lower in females than in males in all types of complications except central nervous system-related postoperative complications [ORadj2 = 1.15 (1.08-1.22), P < 0.0001] and return to the operating room [ORadj2 = 1.06 (1.04-1.08), P < 0.0001]. The 30-day mortality rate for females was lower than males [ORadj2 = 0.99 (0.96-1.03), P = 0.94]. Female gender was associated with less perioperative morbidity and mortality versus males, but they did worse after cardiovascular procedures and had more central nervous system-related complications. These outcomes should be taken into consideration by surgeons and should be evaluated further in future studies.

Minimally invasive resection of lumbar intraspinal synovial cysts via a contralateral approach: review of 13 cases.

OBJECT: The authors sought to determine patient-related outcomes after minimally invasive surgical (MIS) lumbar intraspinal synovial cyst excision via a tubular working channel and a contralateral facet-sparing approach. METHODS: All the patients with a symptomatic lumbar intraspinal synovial cyst who underwent surgery at the University of Iowa Hospitals and Clinics with an MIS excision via a contralateral approach were treated between July 2010 and August 2014. There was a total of 13 cases. Each patient was evaluated with preoperative neurological examinations, lumbar spine radiography, MRI, and visual analog scale (VAS) scores. The patients were evaluated postoperatively with neurological examinations and VAS and Macnab scores. The primary outcomes were improvement in VAS and Macnab scores. Secondary outcomes were average blood loss, hospital stay duration, and operative times. RESULTS: There were 5 males and 8 females. The mean age was 66 years, and the mean body mass index was 28.5 kg/m(2). Sixty-nine percent (9 of 13) of the cysts were at L4-5. Most patients had low-back pain and radicular pain, and one-third of them had Grade 1 spondylolisthesis. The mean (± SD) follow-up duration was 20.8 ± 16.9 months. The mean Macnab score was 3.4 ± 1.0, and the VAS score decreased from 7.8 preoperatively to 2.9 postoperatively. The mean operative time was 123 ± 30 minutes, with a mean estimated blood loss of 44 ± 29 ml. Hospital stay averaged 1.5 ± 0.7 days. There were no complications noted in this series. CONCLUSIONS: The MIS excision of lumbar intraspinal synovial cysts via a contralateral approach offers excellent exposure to the cyst and spares the facet joint at the involved level, thus minimizing risk of instability, blood loss, operative time, and hospital stay. Prospective randomized trials with longer follow-up times and larger cohorts are needed to conclusively determine the superiority of the contralateral MIS approach over others, including open or ipsilateral minimally invasive surgery.

Minimally invasive pars approach for foraminal disc herniation.

We present a retrospective cohort study on the outcome of patients with foraminal disc herniations (FDH) treated with partial pars resections using minimally invasive surgery (MIS) through a tube. FDH present a challenge due to the more lateral trajectory needed for their excision and thereby more muscle dissection and possibly facet resection. Forty patients, 19 women and 21 men with a mean age ± standard deviation of 58 ± 12 years, underwent MIS for FDH. Data on length of hospital stay, body mass index and outcomes were collected prospectively and reviewed retrospectively. Average length of stay following surgery was 1 ± 1 days. There was one wound infection and four unsatisfactory results. Using the Macnab score, good to excellent results were achieved in 89% of the patients. Based on these results, MIS surgery with partial pars resection is an attractive option in the treatment of FDH with low morbidity and short hospital stays.