The Fate of The Broken Tether: How Do Curves Treated with Vertebral Body Tethering Behave After Tether Breakage?

STUDY DESIGN: Retrospective, Multicenter. OBJECTIVE: Assess curve progression and occurrence of revision surgery following tether breakage after vertebral body tethering (VBT). SUMMARY OF BACKGROUND DATA: Tether breakage after VBT is common with rates up to 50% reported. In these cases, it remains unknown whether the curve will progress or remain stable. METHODS: Adolescent and juvenile idiopathic scoliosis patients in a multicenter registry with ≥2 year-follow-up after VBT were reviewed. Broken tethers were listed as postoperative complications and identified by increased screw divergence of >5° on serial radiographs. Revision procedures and curve magnitude at subsequent visits were recorded. RESULTS: Of 186 patients who qualified for inclusion, 84 (45.2%) patients with tether breakage were identified with a mean age at VBT of 12.4±1.4 years and mean curve magnitude at index procedure of 51.8°±8.1°. Tether breakage occurred at a mean of 30.3±11.8 months and mean curve of 33.9°±13.2°. Twelve patients (12/84, 14.5%) underwent 13 revision procedures after VBT breakage, including 6 tether revisions and 7 conversions to fusion. All tether revisions occurred within 5 months of breakage identification. No patients with curves <35° after breakage underwent revision. Revision rate was greatest in skeletally immature (Risser 0-3) patients with curves ≥35° at time of breakage (Risser 0-3: 9/17, 53% vs. Risser 4-5: 3/23, 13%, P=0.01).Curves increased by 3.1° and 3.7° in the first and second year, respectively. By two years, 15/30 (50%) progressed >5° and 8/30 (26.7%) progressed greater than 10°. Overall, 66.7% (40/60) reached a curve magnitude >35° at their latest follow-up, and 14/60 (23.3%) reached a curve magnitude greater than 45°. Skeletal maturity did not affect curve progression after tether breakage (P>0.26), but time to rupture did (P=0.048). CONCLUSION: While skeletal immaturity and curve magnitude were not independently associated with curve progression, skeletally immature patients with curves ≥35° at time of rupture are most likely to undergo additional surgery. Most patients can expect progression at least 5° in the first two years after tether breakage, though longer-term behavior remains unknown. LEVEL OF EVIDENCE: III.

Development of Consensus-Based Best Practice Guidelines for the Peri- and Post-operative Care of Pediatric Patients with Spinal Deformity and Programmable Implanted Devices.

STUDY DESIGN: Modified Delphi consensus study. OBJECTIVE: To develop consensus-based best practices for the care of pediatric patients who have implanted programmable devices (IPDs) and require spinal deformity surgery. SUMMARY OF BACKGROUND DATA: Implanted programmable devices (IPDs) are often present in patients with neuromuscular or syndromic scoliosis who require spine surgery. Guidelines for monitoring and interrogating these devices during the peri-operative period are not available. METHODS: A panel was assembled consisting of 25 experts (i.e., spinal deformity surgeons, neurosurgeons, neuro-electrophysiologists, cardiologists, and otolaryngologists). Initial postulates were based on literature review and results from a prior survey. Postulates addressed the following IPDs: vagal nerve stimulators (VNS), programmable ventriculo-peritoneal shunts (VPS), intrathecal baclofen pumps (ITBP), cardiac pacemakers and implantable cardioverter-defibrillators (ICD), deep brain stimulators (DBS), and cochlear implants. Cardiologist and otolaryngologists participants responded only to postulates on cardiac pacemakers or cochlear implants, respectively. Consensus was defined as ≥80% agreement, items that did not reach consensus were revised and included in subsequent rounds. A total of three survey rounds and one virtual meeting were conducted. RESULTS: Consensus was reached on 39 total postulates across six IPD types. Postulates addressed general spine surgery considerations, use of intraoperative monitoring and cautery, use of magnetically-controlled growing rods (MCGRs), and use of an external remote controller to lengthen MCGRs. Across IPD types, consensus for the final postulates ranged from 94.4-100%. Overall, experts agreed that MCGRs can be surgically inserted and lengthened in patients with a variety of IPDs and provided guidance for the use of intraoperative monitoring and cautery, which varied between IPD types. CONCLUSION: Spinal deformity correction surgery often benefits from the use of intraoperative monitoring, monopolar and bipolar cautery, and MCGRs. Final postulates from this study can inform the peri- and post-operative practices of spinal deformity surgeons who treat patients with both scoliosis and IPDs. LEVEL OF EVIDENCE: V- Expert opinion.

Incidental dural tears during pediatric posterior spinal fusions.

PURPOSE: To characterize the frequency of incidental dural tears in pediatric spine surgery, their treatment, complications, and results of long-term follow-up. METHODS: A retrospective review of all pediatric patients who underwent a posterior spinal fusion (PSF) between 2004-2019 at a tertiary children's hospital was conducted. Electronic medical records were reviewed for patient demographics, intra-operative data, presence of an incidental dural tear, repair method, and patient outcomes. RESULTS: 3043 PSFs were reviewed, with 99 dural tears identified in 94 patients (3.3% overall incidence). Mean follow-up was 35.7 months (range 0.1-142.5). When the cause of the dural tear was specified, 69% occurred during exposure, 5% during pedicle screw placement, 4% during osteotomy, 2% during removal of implants, and 2% during intra-thecal injection of morphine. The rate of dural tears during primary PSF was significantly lower than during revision PSF procedures (2.6% vs. 6.2%, p < 0.05). 86.9% of dural tears were repaired and/or sealed intraoperatively, while 13.1% had spontaneous resolution. Postoperative headaches developed in 13.1% of patients and resolved at a mean of 7.6 days. There was no difference in the incidence of headaches in patients that were ordered bedrest vs. no bedrest (p > 0.99). Postoperative infections occurred in 9.5% of patients and 24.1% patients were identified to have undergone a revision surgery. CONCLUSIONS: Incidence of intra-operative dural tears in pediatric spine surgery is 3.3%. Although complications associated with the dural tear occur, most resolve over time and there were no long-term sequelae in patients with 2 years of follow up. LEVEL OF EVIDENCE: Level IV.

Lowest instrumented vertebrae in early onset scoliosis: is there a role for a more selective approach?

PURPOSE: This purpose of this study was to assess the impact of patient and implant characteristics on LIV selection in ambulatory children with EOS and to assess the relationship between the touched vertebrae (TV), the last substantially touched vertebrae (LSTV), the stable vertebrae (SV), the sagittal stable vertebrae (SSV), and the LIV. METHODS: A multicenter pediatric spine database was queried for patients ages 2-10 years treated by growth friendly instrumentation with at least 2-year follow up. The relationship between the LIV and preoperative spinal height, curve magnitude, and implant type were assessed. The relationships between the TV, LSTV, SV, SSV, and the LIV were also evaluated. RESULTS: Overall, 281 patients met inclusion criteria. The LIV was at L3 or below in most patients with a lumbar LIV: L1 (9.2%), L2 (20.2%), L3 (40.9%), L4 (29.5%). Smaller T1 - T12 length was associated with more caudal LIV selection (p = 0.001). Larger curve magnitudes were similarly associated with more caudal LIV selection (p = < 0.0001). Implant type was not associated with LIV selection (p = 0.32) including MCGR actuator length (p = 0.829). The LIV was caudal to the TV in 78% of patients with a TV at L2 or above compared to only 17% of patients with a TV at L3 or below (p < 0.0001). CONCLUSIONS: Most EOS patients have an LIV of L3 or below and display TV-LIV and LSTV-LIV incongruence. These findings suggest that at the end of treatment, EOS patients rarely have the potential for selective thoracic fusion. Further work is necessary to assess the potential for a more selective approach to LIV selection in EOS. LEVEL OF EVIDENCE: III.

Spinal Manifestations of Skeletal Dysplasia: A Practical Guide for Clinical Diagnosis.

Skeletal dysplasias are a group of genetic conditions defined by atypical bone or cartilage growth and development. Skeletal abnormalities include short stature, limb deformity, joint contracture, and spinal deformity. Over 90% of disorders have a known genetic mutation that can definitively determine the diagnosis. As patients may present with a primary spinal concern, a careful clinical and radiographic evaluation can allow the physician to develop a working diagnosis to guide additional evaluation. Spinal manifestations include scoliosis and kyphoscoliosis, cervical instability, cervical kyphosis, thoracolumbar kyphosis, spinal stenosis, and atypical vertebral body morphology. An understanding of the affected conditions, prevalence, and natural history of these radiographic findings aids the orthopaedic surgeon in establishing a diagnosis and guides appropriate orthopaedic care.

Coronal decompensation following thoracic vertebral body tethering in idiopathic scoliosis.

PURPOSE: Post-operative coronal decompensation (CD) continues to be a challenge in the treatment of adolescent idiopathic scoliosis (AIS). CD following selective spinal fusion has been studied. However, there is currently little information regarding CD following Vertebral Body Tethering (VBT). Thus, the goal of this study is to better understand the incidence and risk factors for CD after VBT. METHODS: Retrospective review of a prospective multicenter database was used for analysis. Inclusion criteria were patients undergoing thoracic VBT, a minimum 2-year follow-up, LIV was L1 or above, skeletally immature (Risser ≤ 1), and available preoperative and final follow-up AP and lateral upright radiographs. Radiographic parameters including major and minor Cobb angles, curve type, LIV tilt/translation, L4 tilt, and coronal balance were measured. CD was defined as the distance between C7PL and CSVL > 2 cm. Multiple logistic regression model was used to identify significant predictors of CD. RESULTS: Out of 136 patients undergoing VBT, 94 patients (86 female and 6 male) met the inclusion criteria. The mean age at surgery was 12.1 (9-16) and mean follow-up period was 3.4 years (2-5 years). Major and minor curves, AVR, coronal balance, LIV translation, LIV tilt, L4 tilt were significantly improved after surgery. CD occurred in 11% at final follow-up. Lenke 1A-R (24%) and 1C (26%) had greater incidence of CD compared to 1A-L (4%), 2 (0%), and 3 (0%). LIV selection was not associated with CD. Multivariate logistic regression analysis yielded 1A-R and 1C curves as a predictor of CD with the odds ratio being 17.0. CONCLUSION: CD occurred in 11% of our thoracic VBT patients. Lenke 1A-R and 1C curve types were predictors for CD in patients treated with VBT. There were no other preoperative predictors associated with CD.

Increasing Cervical Kyphosis Correlates With Cervical Degenerative Disk Disease in Patients With Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective review. OBJECTIVE: Our goal was to investigate the incidence of cervical degenerative disk disease (DDD) in patients with adolescent idiopathic scoliosis (AIS), before surgical intervention. SUMMARY OF BACKGROUND DATA: AIS is often associated with thoracic hypokyphosis and compensatory cervical kyphosis. In adults, cervical kyphosis is associated with DDD. Although cervical kyphosis has been reported in up to 60% AIS patients, the association with cervical DDD has not been reported. MATERIALS AND METHODS: A retrospective review was conducted from January 2014 to December 2019 of all consecutive AIS patients. Inclusion criteria were AIS patients over 10 years of age with cervical magnetic resonance imaging and anterior-posterior and lateral spine radiographs within 1 year of each other. Magnetic resonance imaging were reviewed for evidence of cervical DDD. Severity of cervical changes were graded using the Pfirrmann classification and by a quantitative measure of disk degeneration, the magnetic resonance signal intensity ratio. RESULTS: Eighty consecutive patients were included (mean age: 14.1 years, SD=2.5 years). Increasing cervical kyphosis was significantly correlated to decreasing thoracic kyphosis ( r =0.49, P <0.01) and increasing major curve magnitude ( r =0.22, P =0.04). Forty-five patients (56%) had the presence of DDD (grades 2-4) with a mean cervical kyphosis of 11.1° (SD=9.5°, P <0.01). More cervical kyphosis was associated with more severe cervical DDD as graded by Pfirrmann classification level ( P <0.01). Increasing cervical kyphosis was also positively associated with increasing magnetic resonance signal intensity ratio ( P <0.01). Nine patients had ventral cord effacement secondary to DDD with a mean cervical kyphosis of 22.8° (SD=8.6°) compared with 2.6° (SD=11.2°) in those who did not ( P <0.01). CONCLUSIONS: Cervical kyphosis was significantly associated with increasing severity of cervical DDD in patients with AIS. Patients with evidence of ventral cord effacement had the largest degree of cervical kyphosis with a mean of 22.8±8.6°. This is the first study to evaluate the association between cervical kyphosis in AIS with cervical DDD.

Prescription Opioid Use for Adolescents With Neurocognitive Disability Undergoing Surgery: A Pilot Study.

INTRODUCTION: Parents frequently report retaining unused opioid pills following their child's surgery due to fear of untreated postoperative pain. Assessment of pain in adolescents with neurocognitive disability is challenging. We hypothesized that parents of adolescents with neurocognitive disability may report less opioid use and higher opioid pill retention. METHODS: Adolescents (13-20 y) undergoing elective surgery (posterior spinal fusion, hip reconstruction, arthroscopy, tonsillectomy) were prospectively enrolled from a tertiary children's hospital from 2019 to 2020. Only adolescents prescribed opioids at discharge were included. Parents completed a preoperative survey collecting sociodemographic characteristics and two postoperative surveys at 30- and 90-d. Neurocognitive disability was determined at time of enrollment by caregiver report, and included adolescents with cerebral palsy, severe autism spectrum disorder, and discrete syndromes with severe neurocognitive disability. RESULTS: Of 125 parent-adolescent dyads enrolled, 14 had neurocognitive disability. The median number of opioid pills prescribed at discharge did not differ by neurocognitive disability (29, interquartile range {IQR}: 20.0-33.3 versus 30, IQR: 25.0-40.0, P = 0.180). Parents of both groups reported similar cumulative days of opioid use (7.0, IQR: 3.0-21.0 versus 6.0, IQR:3.0-10.0, P = 0.515) and similar number of opioid pills used (4, IQR: 2.0-4.5 versus 12, IQR: 3.5-22.5, P = 0.083). Parents of both groups reported similar numbers of unused opioid pills (17, IQR: 12.5-22.5 versus 19, IQR: 8.0-29.0, P = 0.905) and rates of retention of unused opioids (15.4% versus 23.8%, P = 0.730). CONCLUSIONS: The number of opioid pills prescribed did not differ by neurocognitive disability and parents reported similar opioid use and retention of unused opioid pills. Larger studies are needed to identify opportunities to improve postoperative pain control for children with neurocognitive disability.

Rib-to-spine and rib-to-pelvis magnetically controlled growing rods: does the law of diminishing returns still apply?

PURPOSE: The Law Of Diminishing Returns (LODR) has been demonstrated for traditional growing rods, but there is conflicting data regarding the lengthening behavior of Magnetically Controlled Growing Rods (MCGR). This study examines a cohort of patients with early-onset scoliosis (EOS) with rib-to-spine or rib-to-pelvis-based MCGR implants to determine if they demonstrate the LODR, and if there are differences in lengthening behaviors between the groups. METHODS: A prospectively collected multicenter EOS registry was queried for patients with MCGR with a minimum 2-year follow-up. Patients with rib-based proximal anchors and either spine- or pelvis-based distal anchors were included. Patients with non-MCGR, unilateral constructs, < 3 lengthenings, or missing > 25% datapoints were excluded. Patients were further divided into Primary-MCGR (pMCGR) and Secondary-MCGR (sMCGR). RESULTS: 43 rib-to-spine and 31 rib-to-pelvis MCGR patients were included. There was no difference in pre-implantation, post-implantation and pre-definitive procedure T1-T12 height, T1-S1 height, and major Cobb angles between the groups (p > 0.05). Sub-analysis was performed on 41 pMCGR and 19 sMCGR rib-to-spine patients, and 31 pMCGR and 17 sMCGR rib-to-pelvis patients. There is a decrease in rod lengthenings achieved at subsequent lengthenings for each group: rib-to-spine pMCGR (rho = 0.979, p < 0.001), rib-to-spine sMCGR (rho = 0.855, p = 0.002), rib-to-pelvis pMCGR (rho = 0.568, p = 0.027), and rib-to-pelvis sMCGR (rho = 0.817, p = 0.007). Rib-to-spine pMCGR had diminished lengthening over time for idiopathic, neuromuscular, and syndromic patients (p < 0.05), with no differences between the groups (p > 0.05). Rib-to-pelvis pMCGR neuromuscular patients had decreased lengthening over time (p = 0.01), but syndromic patients had preserved lengthening over time (p = 0.65). CONCLUSION: Rib-to-spine and rib-to-pelvis pMCGR and sMCGR demonstrate diminished ability to lengthen over subsequent lengthenings.

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.

Concave and convex growth do not differ over tethered vertebral segments, even with open tri-radiate cartilage.

PURPOSE: To assess the following hypotheses related to vertebral body tethering (VBT): 1. VBT is associated with asymmetric (concave > convex) increases in height over the instrumented vertebra. 2. The instrumented Cobb angle improves following VBT surgery with growth. METHODS: This is a retrospective case series of pediatric patients from a multicenter scoliosis registry treated with VBT between 2013 to 2021. INCLUSION CRITERIA: patients with standing radiographs at < 4 months and ≥ 2 years after surgery. Distances between the superior endplate of the UIV and the inferior endplate of the LIV were measured at the concave corner, mid-point, and convex corner of the endplates. The UIV-LIV angle was recorded. Subgroup analyses included comparing different Risser scores and tri-radiate cartilage (TRC) closed versus open using student t-tests. RESULTS: 83 patients met inclusion criteria (92% female; age at time of surgery 12.5 ± 1.4 years) with mean follow-up time of 3.8 ± 1.4 years. Risser scores at surgery were: 0 (n = 33), 1 (n = 12), 2 (n = 10), 3 (n = 11), 4 (n = 12), and 5 (n = 5). Of the 33 Risser 0 patients, 17 had an open TRC, 16 had a closed TRC. The UIV-LIV distance at concave, middle, and convex points significantly increased from immediate post-op to final-follow-up for Risser 0 patients, but not for Risser 1-5 patients. Increases in UIV-LIV distance were not significantly different between concave, middle, and convex points for all groups. There was no significant improvement or worsening in UIV-LIV angle for any group. CONCLUSION: At a mean of 3.8 years following VBT, 33 Risser 0 patients demonstrated significant growth in the instrumented segment, though there was no difference between concave or convex growth, even for patients with open TRC.

Deformity angular ratio is associated with neuromonitoring changes without a vertebral column resection: spinal deformity is more influential than type of surgery.

PURPOSE: The purpose of this study is to investigate the effect of the deformity angular ratio (DAR) on intra-operative neuromonitoring (IONM) signal changes during posterior spinal fusion (PSF) without vertebral column resection (VCR). METHODS: Retrospective review of severe pediatric spinal deformity patients treated with PSF without VCR or three-column osteotomy from 2008 to 2018. Exclusion criteria were prior instrumentation, lack of IONM, and incomplete radiographic data. Coronal DAR (C-DAR), sagittal DAR (S-DAR), and total DAR (T-DAR) were calculated and compared between patients with IONM signal loss and those without. RESULTS: Two hundred and fifty-three patients met inclusion criteria. Forty-seven of two hundred and fifty-three (19%) patients had IONM signal loss. Intra-operative wake-up test was performed in seven cases; three of seven (43%) had a neurological deficit on wake-up test. All neurological deficits resolved at a mean of 41 days postop. IONM loss was associated with increased kyphosis (p = 0.003) and was not associated with Cobb angle (p = 0.16). S-DAR (p = 0.03) and T-DAR (p = 0.005) were associated with IONM signal loss but C-DAR was not (p = 0.06). Increased incidence of IONM signal loss was seen with S-DAR > 7 (p = 0.02) or T-DAR > 27 (p = 0.02). Twenty-four of ninety-two (26%) patients with S-DAR > 7 had IONM signal loss compared to twenty-three of one hundred and sixty-one (14%) with S-DAR ≤ 7 (OR, 2.1; 95% CI, 1.1-4.0). Seven of sixteen (44%) patients with T-DAR > 27 had signal loss compared to forty of two hundred and thirty-seven (17%) patients with T-DAR ≤ 27 (OR, 3.8; 95% CI, 1.3-10.9). CONCLUSION: Patients with S-DAR > 7 or T-DAR > 27 have a higher risk of IONM loss during pediatric PSF even in the absence of a VCR or three-column osteotomies.

Physician collections are 71% less for early onset scoliosis casting than for growing rod instrumentation: A retrospective cohort study.

Growing rod (GR) instrumentation and the elongation, derotation, and flexion (EDF) casting technique are 2 alternatives for the treatment of early-onset scoliosis. Our purpose was to investigate the cost of these treatment options. This was a retrospective cohort study of patients with early-onset scoliosis treated at 2 institutions from 2007 to 2014 with either GR instrumentation or EDF casting. Patients with <2 years of follow-up were excluded. Physician and hospital charges and collections, total procedures, and procedure times until final follow-up or time of fusion were compared. Nineteen patients met the inclusion criteria; 8 in the GR group and 11 in the EDF casting group. There were no significant differences between the groups in age (P = .23), public versus private insurance (P = 1.0), or major curve (P = .21) at the initiation of treatment. Excluding final fusion, the EDF casting patients had an average of 2.1 (range: 0.7-6.6) procedures/year while the GR patients had an average of 1.5 (range: 0.8-2.7) procedures/year. The average procedure time for the EDF group was 104.2 minutes; the average procedure time for the GR group, excluding the index procedure, was 62.40 minutes (P = .001). Physician charges were 85% less for the EDF group (EDF= $1892.75, GR= $12,354.53, P < .001). Physician collections were 71% less for the EDF group (EDF= $731.10, GR= $2554.88, P = .001). Hospital charges and collections were similar between the groups (P = .82, P = .42). Physician charges for casting were approximately 18% of that of GRs. Compared to GRs, physician collections were 71% less for EDF casting patients per year.

Rate and risk factors for pediatric cervical spine fusion pseudarthrosis: opportunity for improvement.

PURPOSE: Although the pediatric population typically has a high union rate, the cervical spine has a reputation for frequent pseduarthrosis, as high as 38% in some prior series. Our purpose was to examine the rate and risk factors for pseudarthrosis in pediatric cervical spine fusions. METHODS: Retrospective review of all patients with ≥ 2 years follow-up undergoing cervical spinal fusion between January 2004 and December 2019 at a tertiary pediatric hospital. Pseudarthrosis was defined as an absence of radiographic union as assessed by the attending surgeon for which revision surgery was performed. RESULTS: 64 patients (mean age: 8.4 ± 4.7 years) met inclusion criteria. Mean follow-up was 63.3 ± 41.4 months (range: 24-187 months). 28 fusions (44%) included the occiput. 41 patients (64%) had instrumentation, while 23 patients (36%) had uninstrumented fusions. 48 (75%) patients had a halo for a mean of 97.6 ± 49.5 days. The incidence of pseudarthrosis was as follows: overall = 8/64 (12.5%); posterior fusion = 14.8% (8/54); anterior fusions = 0% (0/4); and anteroposterior fusions = 0% (0/6). The rate of pseudarthrosis was over 8 times higher in fusions involving the occiput (occipitocervical fusion: 25.0%; 7/28 vs. cervical alone: 2.8%; 1/36; p = 0.02). Although not statistically significant, the rate of pseudarthrosis was 3 times higher in uninstrumented fusions (21.7%; 5/23) than instrumented fusions (7.3%; 3/41) (p = 0.12). In patients with uninstrumented fusion to the occiput, pseudarthrosis rate was 35.7% (5/14), which was higher compared to those who did not (6.0%; 3/50) (p = 0.01). Incidence of pseudarthrosis was similar in patients who received autograft (13.0%; 7/54) compared to allograft alone (10.0%; 1/10) (p > 0.999). CONCLUSIONS: The pseudarthrosis rate in pediatric cervical spine fusions remained high despite frequent use of halo immobilization and autograft. Patients with uninstrumented occipitocervical fusions are at particularly high risk with more than 1 in 3 developing a pseudarthrosis. STUDY DESIGN: Retrospective, Comparative. LEVEL OF EVIDENCE: III.

Adolescent idiopathic scoliosis patients treated with bracing, surgery, or observation showed no difference in behavioral and emotional function over a 2-year period.

The purpose of this study was to assess if behavior and emotional function, as measured by the Pearson Behavioral Assessment Survey for Children, Second Edition (BASC-2) in patients and parents, changes with differing treatment protocols in patients with adolescent idiopathic scoliosis (AIS). One previous study showed abnormal BASC-2 scores in a substantial number of patients diagnosed with AIS; however, no study has assessed how these scores change over the course of treatment. AIS patients aged 12 to 21 years completed the BASC-2. The 176-item questionnaire was administered to subjects at enrollment, assessing behavioral and emotional problems across 16 subscales of 5 domains: school problems, internalizing problems, inattention/hyperactivity, emotional symptoms index, and personal adjustment. Parents were given an equivalent assessment survey. Surveys were administered again after 2 years. Subject treatment groups (bracing, surgery, and observation) were established at enrollment. Patients were excluded if they did not complete the BASC-2 at both time points. Forty-six patients met the inclusion criteria, with 13 patients in the surgical, 20 in the bracing, and 13 in the observation treatment groups. At enrollment, 26% (12/46) of subjects with AIS had a clinically significant score in 1 or more subscales, and after 2 years 24% (11/46) of subjects reported a clinically significant score in at least 1 subscale (P = .8). There were no significant differences in scores between enrollment and follow-up in any treatment group. Similar to what was reported in a previous study, only 36% (4/11) of patients had clinically significant scores reported by both patient and parent, conversely 64% (7/11) of parents were unaware of their child's clinically significant behavioral and emotional problems. Common patient-reported subscales for clinically significant and at-risk scores at enrollment included anxiety (24%; 11/46), hyperactivity (24%; 11/46), attention problems (17%; 8/46), and self-esteem (17%; 8/46). At 2-year follow-up, the most commonly reported subscales were anxiety (28%; 13/46), somatization (20%; 9/46), and self-esteem (30%; 14/46). Patients with AIS, whether observed, braced or treated surgically, showed no significant change in behavior and emotional distress over the course of their treatment, or compared with each other at 2-year follow-up.

Treatments and Sequelae of Pediatric Pathologic Proximal Femur Fractures Due to Benign Bone Cyst.

BACKGROUND: The proximal femur is a common location for pathologic fractures in children, yet there is little published information regarding this injury. The purpose of this study was to investigate the outcomes of pediatric pathologic proximal femur fractures due to benign bone tumors. METHODS: A retrospective review of patients treated for pathologic proximal femur fractures from 2004 to 2018 was conducted. Inclusion criteria were age below 18 years and pathologic proximal femur fracture secondary to a benign bone tumor. Patients were excluded if they had <1 year of follow-up. Medical charts and serial radiographs were reviewed for fracture classification, underlying pathology, treatment, complications, and time to fracture healing. RESULTS: A total of 14 patients were included. Mean age was 6±3 (3 to 11) years, and mean follow-up was 44±21 (22 to 86) months. Index treatment was spica casting in 9/14 (68%) patients, while 5/14 (32%) were treated with internal fixation. Of the 9 patients initially treated with casting, 22% (2/9) required repeat spica casting at a mean of 0.6 months after index treatment, 67% (6/9) required internal fixation at a mean of 20.3 months after index treatment, and 11% (1/9) did not require revision treatment. Eighty-eight percent (8/9) of patients treated with casting required revision treatment compared with 40% (2/5) of those treated with internal fixation (P=0.05). Nonunion occurred after 1 refracture, malunion with coxa vara occurred in 2 fractures, and the remaining 11/14 (84%) fractures had a union at a mean of 4.9±3.0 months All cases of malunion occurred in patients initially treated nonoperatively. There were 19 distinct complications in 10/14 (71%) patients. The incidence of any revision surgery was 64% (9/14). CONCLUSIONS: In this series, pediatric pathologic proximal femur fractures demonstrated prolonged time to union, high incidence of revision surgery (64%), and substantial complication rate (71%). In children with pathologic proximal femur fractures, treatment with internal fixation is recommended as this series showed a 78% failure rate of initial conservative management. LEVEL OF EVIDENCE: Level IV.

Transforming Your Operating Room into a High Functioning Team: A Survival Guide for Junior Attendings in the OR.

In this article, we outline several key concepts to help develop your operating room team. This is an evolutionary process with numerous benefits to the team members, surgeon, and most importantly the patients. We outline strategies for engaging and preparing your team members so that the operating room runs more efficiently. We also outline the do's and don'ts of building trust amongst team members which is critical to transforming into a high functioning team.

Outcomes of Operatively Managed Lumbar and Sacral Facet Fractures in Pediatric Athletes: A Case Series.

BACKGROUND: Facet fractures have been reported in a total of 6 young athletes in 4 previous publications. These injuries were not diagnosed on magnetic resonance imaging (MRI) or radiographs, and were identified on computed tomography (CT). Our purpose was to report a series of athletes with operatively managed facet fractures. This may be an under-recognized diagnosis. METHODS: Retrospective review of pediatric patients with operatively managed isolated lumbar or sacral facet fractures from 3 tertiary pediatric hospitals from 2014 to 2019. Clinical records and imaging studies were reviewed. RESULTS: Ten patients with symptomatic lumbar or sacral facet fractures met inclusion criteria (mean age at presentation; 13.3±2.1 years, 70% Female). All patients reported competitive participation in sports. On physical examination, 10/10 (100%) of patients had lower back pain that was exacerbated with lumbar spine extension. Limited CT scans demonstrated facet fractures in 10/10 (100%) patients not detected on plain film or MRI. All patients experienced significant relief of pain following excision of the facet fracture fragment. At time of first postoperative visit, 9/10 (90%) patients were pain free while one had generalized back pain thought to be related to fibromyalgia and not facet pathology. At time of last follow-up, 2/10 (20%) of patients reported nonspecific back pain that was not localized in the area of the facet fracture, while 80% (8/10) remained pain free. All patients 100% (10/10) returned to full participation to sports. There were no complications noted in this series. Average follow-up was 27 months (range: 1 to 68 mo). CONCLUSIONS: Athletes with localized back pain exacerbated by spine extension may have a facet fracture. As facet fractures are usually not identified with radiographs or MRI, a limited CT scan should be considered in the evaluation of pediatric athletes with localized back pain exacerbated by extension. In this series, surgical excision of facet fracture fragments was safe and provided predictable pain relief.

Matched Comparison of Magnetically Controlled Growing Rods with Traditional Growing Rods in Severe Early-Onset Scoliosis of ≥90°: An Interim Report on Outcomes 2 Years After Treatment.

BACKGROUND: Severe early-onset scoliosis (EOS) is managed surgically but represents a challenge due to limited implant fixation points, large curve size, and fragile patients with comorbidities. Magnetically controlled growing rods (MCGRs) have the advantage of avoiding surgical intervention for routine lengthening, but their ability to address severe EOS has not been studied, to our knowledge. METHODS: A retrospective review of a prospectively collected international database identified 44 children with severe (≥90°) EOS treated with MCGRs who met our study criteria. Etiology, age, and sex-matched patients treated with traditional growing rods (TGRs) were identified from the same database. Patients were evaluated at a 2-year follow-up. No patients with vertically expandable prosthetic titanium ribs (VEPTRs) were included. The health-related quality of life was evaluated with the 24-Item Early Onset Scoliosis Questionnaire (EOSQ-24). RESULTS: The mean preoperative major coronal curve was 104° in the MCGR group and 104° in the TGR group. At the 2-year follow-up, the mean major coronal curves were 52° and 66° (p = 0.001), respectively. The mean T1-T12 heights were 155 mm and 152 mm preoperatively and 202 mm and 192 mm at the 2-year follow-up (p = 0.088). According to Kaplan-Meier analysis, the 2-year unplanned-revision-free survival was 91% in the MCGR group and 71% in the TGR group (p < 0.005). The 2-year score in the EOSQ-24 pulmonary function domain was better in the MCGR group. There were no other significant differences in the EOSQ-24 scores between the groups. CONCLUSIONS: MCGRs for severe EOS provided significantly better major curve correction with significantly fewer unplanned revisions than TGRs at a 2-year follow-up. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.