Bracing for juvenile idiopathic scoliosis: retrospective review from bracing to skeletal maturity.

BACKGROUND: Juvenile idiopathic scoliosis (JIS) outcomes with brace treatment are limited with poorly described bracing protocols. Between 49 and 100% of children with JIS will progress to surgery, however, young age, long follow-up, and varying treatment methods make studying this population difficult. The purpose of this study is to report the outcomes of bracing in JIS treated with a Boston brace™ and identify risk factors for progression and surgical intervention. METHODS: This is a single-center retrospective review of 175 patients with JIS who initiated brace treatment between the age of 4 and 9 years. A cohort of 140 children reached skeletal maturity; 91 children had surgery or at least 2 year follow-up after brace completion. Standard in-brace protocol for scoliosis 320° was a Boston brace for 18-20 h/day after MRI (n = 82). Family history, MRI abnormalities, comorbidities, curve type, curve magnitude, bracing duration, number of braces, compliance by report, and surgical interventions were recorded. RESULTS: Children were average 7.9 years old (range 4.1-9.8) at the initiation of bracing. The Boston brace™ was prescribed in 82 patients and nine used night bending brace. Mid-thoracic curves (53%) was the most frequent deformity. Maximum curve at presentation was on average 30 ± 9 degrees, in-brace curve angle was 16 ± 8 degrees, and in-brace correction was 58 ± 24 percent. Patients were braced an average of 4.6 ± 1.9 years. 61/91 (67%) went on to posterior spinal fusion at 13.3 ± 2.1 (range 9.3-20.9) years and curve magnitude of 61 ± 12 degrees. Of those that underwent surgery, 49/55 (86%) progressed > 10°, 6/55 (11%) stabilized within 10°, and 0/55 (0%) improved > 10° with brace wear. No children underwent growth-friendly posterior instrumentation. Of the 28 who did not have surgical correction, 3 (11%) progressed > 10°, 13/28 (46%) stabilized within 10°, and 12/28 (43%) improved > 10° with brace wear. CONCLUSIONS: This large series of JIS patients with bracing followed to skeletal maturity with long-term follow-up. Surgery was avoided in 33% of children with minimal to no progression, and no child underwent posterior growth-friendly constructs. Risk factors of needing surgery were noncompliance and larger curves at presentation.

Spinal Fusion in Pediatric Patients With Low Bone Density: Defining the Value of DXA.

BACKGROUND: Children with medical complexity are at increased risk of low bone mineral density (BMD) and complications after spinal fusion compared with idiopathic scoliosis patients. Our aim was to compare treatments and outcomes of children with medical complexity undergoing spinal fusion in those who had dual-energy x-ray absorptiometry (DXA) scans versus those who did not in an effort to standardize the workup of these patients before undergoing spinal surgery. METHODS: We conducted a retrospective review of patients with low BMD who underwent spinal fusion at a tertiary care pediatric hospital between 2004 and 2016. We consulted with a pediatric endocrinologist to create standard definitions for low BMD to classify each subject. Regardless of DXA status, all patients were given a clinical diagnosis of osteoporosis [at least 2 long bone or 1 vertebral pathologic fracture(s)], osteopenia (stated on radiograph or by the physician), or clinically low bone density belonging to neither category. The last classification was used for patients whose clinicians had documented low bone density not meeting the criteria for osteoporosis or osteopenia. Fifty-nine patients met the criteria, and 314 were excluded for insufficient follow-up and/or not meeting a diagnosis definition. BMD Z -scores compare bone density ascertained by DXA to an age-matched and sex-matched average. Patients who had a DXA scan were also given a DXA diagnosis of low bone density (≤-2 SD), slightly low bone density (-1.0 to -1.9 SD), or neither (>-1.0 SD) based on the lowest BMD Z -score recorded. RESULTS: Fifty-nine patients were analyzed. Fifty-four percent had at least 1 DXA scan preoperatively. Eighty-one percent of DXA patients received some form of treatment compared with 52% of non-DXA patients ( P =0.03). CONCLUSIONS: Patients referred for DXA scans were more likely to be treated for low BMD, although there is no standardized system in place to determine which patients should get scans. Our research highlights the need to implement clinical protocols to optimize bone health preoperatively. LEVEL OF EVIDENCE: Level II-retrospective prognostic study.

Biomechanical Effects of Thoracolumbosacral Orthosis Design Features on 3D Correction in Adolescent Idiopathic Scoliosis: A Comprehensive Multicenter Study.

STUDY DESIGN: Multicenter numerical study. OBJECTIVE: To biomechanically analyze and compare various passive correction features of braces, designed by several centers with diverse practices, for three-dimensional (3D) correction of adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: A wide variety of brace designs exist, but their biomechanical effectiveness is not clearly understood. Many studies have reported brace treatment correction potential with various degrees of control, making the objective comparison of correction mechanisms difficult. A Finite Element Model simulating the immediate in-brace corrective effects has been developed and allows to comprehensively assess the biomechanics of different brace designs. METHODS: Expert clinical teams (one orthotist and one orthopedist) from six centers in five countries participated in the study. For six scoliosis cases with different curve types respecting SRS criteria, the teams designed two braces according to their treatment protocol. Finite Element Model simulations were performed to compute immediate in-brace 3D correction and skin-to-brace pressures. All braces were randomized and labeled according to 21 design features derived from Society on Scoliosis Orthopaedic and Rehabilitation Treatment proposed descriptors, including positioning of pressure points, orientation of push vectors, and sagittal design. Simulated in brace 3D corrections were compared for each design feature class using ANOVAs and linear regressions (significance P ≤ 0.05). RESULTS: Seventy-two braces were tested, with significant variety in the design approaches. Pressure points at the apical vertebra level corrected the main thoracic curve better than more caudal locations. Braces with ventral support flattened the lumbar lordosis. Lateral and ventral skin-to-brace pressures were correlated with changes in thoracolumbar/lumbar Cobb and lumbar lordosis (r =- 0.53, r = - 0.54). Upper straps positioned above T10 corrected the main thoracic Cobb better than those placed lower. CONCLUSIONS: The corrective features of various scoliosis braces were objectively compared in a systematic approach with minimal biases and variability in test parameters, providing a better biomechanical understanding of individual passive mechanisms' contribution to 3D correction.

Performing Multiple Posterior Spinal Fusions in 1 Day: A Comparison of Perioperative Outcomes Between Morning and Afternoon Cases.

BACKGROUND: High-volume centers for idiopathic scoliosis (IS) have difficulty in scheduling posterior spinal fusions (PSFs) due to operating room availability, particularly during school vacation. A solution is for 1 surgeon to perform 2 PSF cases back-to-back. This study aims to compare morning and afternoon PSF cases performed by the same surgeon for perioperative outcomes. METHODS: A retrospective review of PSF cases for IS that occurred on the same day as another PSF by the same surgeon between January 2013 and December 2019 was conducted. Perioperative outcomes included surgical time, estimated blood loss, length of stay, and inpatient opioid consumption normalized by the patient's weight. Postoperative outcomes included complications, revision rate, curve correction, and patient-reported outcomes using the Scoliosis Research Society-30. RESULTS: A total of 95 patients (87% female), mean age 15.6 years, were analyzed, with 48 morning cases and 47 afternoon cases. The median follow-up was 1.9 years (range: 0.3 to 6.1 y). Tests for equivalency determined equivalence in median anesthesia and mean surgical duration (P=0.05). The groups had similar initial curve correction (P=0.43) and rate of complications at 90 days postoperative (2 in each group for a total of 4 complications). No significant differences were seen between Scoliosis Research Society-30 scores at 6 months or in those who have reached 2 years postoperative. CONCLUSIONS: Little literature exists on the safety of a surgeon performing 2 PSF cases in 1 day, particularly in regard to pain outcomes, 30- and 90-day complication rates, and quality of life measures. This study indicates that few differences in safety, pain, and quality of life outcomes may appear between morning and afternoon PSF cases. LEVEL OF EVIDENCE: Level II.

Efficacy of bracing in skeletally immature patients with moderate-severe idiopathic scoliosis curves between 40° and 60°.

STUDY DESIGN: Retrospective case-series. OBJECTIVES: To evaluate the outcomes of bracing in skeletally immature patients with moderate-severe idiopathic scoliosis (IS) curves ≥ 40°. BACKGROUND: In contrast to prior beliefs, the recent studies have reported successful outcomes with brace treatment may occur in some patients with moderate-severe scoliosis ≥ 40°. Despite other encouraging case-series, non-operative treatment is rarely attempted and the efficacy of bracing large curves remains uncertain. METHODS: 100 skeletally immature children (mean 11.8 ± 2.36 years; range 6.1-16.5) with IS ≥ 40° were identified. 80 were adolescent IS (80%) and 20 juvenile IS (20%). The Risser plus score was used to evaluate skeletal maturity. 66 children were Risser 0 (66%). SRS-SOSORT outcome guidelines were used: > 5° progression, stabilization between - 5° and 5° and, > 5° improvement. RESULTS: Mean initial Cobb was 45° ± 3.9° (range 40°-59°), with in-brace and  % correction of 30° ± 8.7° (range 7°-48°) and 34 ± 17.5% (range 2-84%), respectively. 57 progressed (57%), 32 stabilized (32%), and 11 improved (11%) after a median of 1.8 years (IQR 1.2-2.9). Open triradiate cartilage at presentation (p = 0.005) and less in-brace correction (p = 0.009) were associated with progression. 58 children (58%) underwent surgery after a mean of 3.0 years (range 0.7-7.3). Surgical patients were younger (11.2 vs. 12.7 years; p = 0.003), more often Risser 0 (79% vs. 48%; p < 0.001); however, presented with similar curves (45° vs. 44°; p = 0.31). Open triradiate cartilage at presentation (OR 15.3; 95% CI 4.3-54.6; p < 0.001) and less in-brace correction (p = 0.03) increased the likelihood of surgery. All 20 JIS patients avoided temporary growth rods, with 18 (90%) eventually requiring surgery. CONCLUSION: Non-operative treatment was successful in 42% of children. Risk factors for surgery were younger age, open triradiates, and less in-brace correction. Bracing can be effective in delaying surgery until skeletal maturity in patients with curves ≥ 40°. Patients should be counseled on the risks and benefits of bracing and surgery. LEVEL OF EVIDENCE: Level IV.

Retraction Note: Brace classification study group (BCSG): part one - definitions and atlas.

[This retracts the article DOI: 10.1186/s13013-016-0102-y.].

Efficacy of Intraoperative Neurophysiologic Monitoring for Pediatric Cervical Spine Surgery.

STUDY DESIGN: Clinical case series. OBJECTIVE: To investigate the efficacy of intraoperative neuromonitoring in pediatric cervical spine surgery. SUMMARY OF BACKGROUND DATA: Intraoperative neuromonitoring (IONM) consisting of somatosensory-evoked potentials (SSEP) and transcranial motor-evoked potentials (tcMEP) has been shown to effectively prevent permaneny neurologic injury in deformity surgery. The role of IONM during pediatric cervical spine surgery is not well documented. Advances in cervical spine instrumentation have expanded the surgical options in pediatric populations. The goal of this study is to report the ability of IONM to detect neurologic injury during pediatric cervical spine instrumentation. METHODS: A single institution database was queried for pediatric-aged patients who underwent cervical spine instrumentation and fusion between 2011 and 2014. Age, diagnosis, surgical indication, number of instrumented levels, and a complete IONM were extracted. Sensitivity and specificity for the detection of neurologic deficits were calculated with exact 95% confidence intervals. Positive and negative predictive values were calculated with estimated 95% confidence intervals. RESULTS: Sixty-seven patients who underwent cervical spine instrumentation were identified with a mean age of 11.6 years (range 1-18). Diagnoses included instability (27), congenital (11), kyphosis (8), fracture (7), tumor (7), arthritis (4), and basilar invagination (3). Mean number of vertebral levels fused was 4 (range 2-7). All patients underwent cervical instrumentation with SSEP and tcMEP monitoring. A significant change in tcMEP monitoring was observed in 7 subjects (10%). There were no corresponding SSEP changes in these patients. The sensitivity of combined IONM was 75% [95% CI = 24.9, 98.7] and the specificity was 98.5% [92.7, 99.9]. CONCLUSION: tcMEP is a more sensitive indicator to spinal cord injury than SSEP, which is consistent with previous studies. IONM changes in 10% of a patient population are significant enough to warrant intraoperative determination if true SCI has occurred or is underway and intervene accordingly. LEVEL OF EVIDENCE: 4.

Brace Classification Study Group (BCSG): part one - definitions and atlas.

BACKGROUND: The current increase in types of scoliosis braces defined by a surname or a town makes scientific classification essential. Currently, it is a challenge to compare braces and specify the indications of each brace. A precise definition of the characteristics of current braces is needed. As such, the International Society for Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT) mandated the Brace Classification Study Group (BCSG) to address the pertinent terminology and brace classification. As such, the following study represents the first part of the SOSORT consensus in addressing the definitions and providing a visual atlas of bracing. METHODS: After a short introduction on the braces, the aim of the BCSG is described and its policies/general consideration are outlined. The BSCG endeavor embraces the very important SOSORT - Scoliosis Research Society cooperation, the history of which is also briefly narrated. This report contains contributions from a multidisciplinary panel of 17 professionals who are part of the BCSG. The BCSG introduced several pertinent domains to characterize bracing systems. The domains are defined to allow for analysis of each brace system. RESULTS: A first approach to brace classification based on some of these proposed domains is presented. The BCSG has reached a consensus on 139 terms related to bracing and has provided over 120 figures to serve as an atlas for educational purposes. CONCLUSIONS: This is the first clinical terminology tool for bracing related to scoliosis based on the current scientific evidence and formal multidisciplinary consensus. A visual atlas of various brace types is also provided.

Displaced intra-articular fractures of the great toe in children: intervene with caution!

BACKGROUND: Intra-articular fractures of the proximal phalanx of the great toe in children are extremely rare and sparsely reported in the literature. We have noted a series of these fractures at our institution. The purpose of this report is to present a retrospective case series of children with intra-articular fractures managed operatively in order to highlight the inherent difficulties in managing these fractures. METHODS: Operative notes and billing records were searched from 2001 to 2011 to identify all children aged 18 years or younger who underwent surgical intervention for an intra-articular fracture of the proximal phalanx of the great toe. Charts and imaging studies were retrospectively reviewed to identify the mechanism of injury, fracture classification, operative details, clinical results, and complications. RESULTS: Seven boys and 3 girls with a mean age of 12.6 years (range, 8.7 to 15.7 y) were identified. The mechanism of injury was a direct blow from a stubbed toe (8 cases) or a dropped object onto the foot (2 cases). There were 7 intra-articular fractures of the proximal phalanx base, 4 of which occurred in the setting of an open physis. Mean fracture displacement was 4.4 mm. Open reduction was necessary in 9 cases, with K-wire fixation used in 9 cases. Median follow-up was 50.5 months (range, 11 to 123 mo). Seven fractures healed at a mean of 7.9 weeks. Nine patients returned to full activity without limitation at latest follow-up. Six patients had significant complications: 2 underwent revision open reduction internal fixation (one for postoperative redisplacement and the other for painful nonunion), 1 suffered a refracture, 1 developed posttraumatic arthritis requiring interphalangeal joint fusion, 1 developed an asymptomatic fibrous nonunion with avascular necrosis of the fragment, and 1 had K-wire migration necessitating early surgical removal. CONCLUSIONS: Intra-articular fractures of the great toe primarily occur in adolescents after direct impact injuries. The most common location was the proximal phalangeal base. There is a high complication rate after surgical intervention, although most patients were asymptomatic at latest follow-up. LEVEL OF EVIDENCE: IV (retrospective case series).

The pendulum swings back to scoliosis screening: screening policies for early detection and treatment of idiopathic scoliosis - current concepts and recommendations.

This editorial article initiates the school scoliosis screening thematic series of the Scoliosis journal. The various issues on screening policies are discussed; clinical and practical recommendations of setting up school screening programs are also described.

Reliability of the Spinal Deformity Study Group classification of lumbosacral spondylolisthesis.

STUDY DESIGN: Reliability study of the computer-assisted SDSG (Spinal Deformity Study Group) classification of lumbosacral spondylolisthesis. OBJECTIVE: To assess the intra- and interobserver reliability of the computer-assisted SDSG classification of lumbosacral spondylolisthesis. SUMMARY OF BACKGROUND DATA: The SDSG has proposed a new classification of lumbosacral spondylolisthesis based on slip grade, pelvic incidence (PI), and sacro-pelvic and spinal balance. Three types of low-grade spondylolisthesis are described: low PI (type 1), normal PI (type 2), and high PI (type 3). High-grade spondylolisthesis are defined as type 4 (balanced sacro-pelvis), type 5 (retroverted sacro-pelvis with balanced spine), and type 6 (retroverted sacro-pelvis with unbalanced spine). METHODS: Full-length standing lateral radiographs of the spine of 40 subjects with lumbosacral spondylolisthesis were reviewed twice by 7 observers. Custom software was used by the observers to identify 7 anatomical landmarks on each radiograph to determine the SDSG type for all subjects. Percentage of agreement and κ coefficients were used to determine the intra- and interobserver reliability. RESULTS: All 6 types of spondylolisthesis described in the computer-assisted SDSG classification were identified. Overall intra- and interobserver agreements were 80% (κ: 0.74) and 71% (κ: 0.65), respectively. The intra- and interobserver agreements associated with computerized determination of slip grade were 92% (κ: 0.83) and 88% (κ: 0.78), respectively. As for computerized determination of sacro-pelvic and spinal balance, intra- and interobserver agreements were 86% (κ: 0.76) and 75% (κ: 0.63) for low-grade slips, whereas they were 88% (κ: 0.80) and 83% (κ: 0.75) for high-grade slips. CONCLUSION: Substantial intra- and interobserver reliability was found for the computer-assisted SDSG classification, and all 6 types of lumbosacral spondylolisthesis were identified. Refinement of the computer-assisted classification technique is, however, needed to further increase the reliability of the SDSG classification and facilitate its clinical use.

Incidence of skin complications and associated charges in children treated with hip spica casts for femur fractures.

BACKGROUND: Spica cast immobilization remains the treatment of choice for femur fractures in children aged 6 months to 6 years. The incidence of skin complications and their associated charges have not been well described. This study's purposes were to: (1) determine the rate of skin complications in children treated with spica casts for femur fractures, (2) identify predictors, and (3) calculate the charges associated with skin complications. METHODS: Health records for all patients treated with immediate spica casting for a femur fracture at a major tertiary-care children's hospital from 2003 to 2009 were reviewed and relevant data were abstracted. Descriptive statistics and univariate and multiple logistic regression analyses were used to compare children with and without skin complications and to identify predictors of skin complications. The total charges for skin complications leading to a cast change and early bivalving and lining were calculated. RESULTS: Of the 300 spica cast applications in 297 patients, 77 subjects (28%) had skin complications. Twenty-four (31%) of these 77 patients underwent a cast change in the operating room, 34 (44%) required early bivalving and lining and 19 (25%) required cast trimming and/or skin care. Predictors of skin complications included: child abuse as mechanism of injury, younger age, and cast time more than 40 days. Sex, weight, fracture location, and total number of clinic visits were not statistically significant predictors of skin complications. The median charge for patients who required cast changes for skin complications was $12,719 ($8632 to $53,768), whereas the median charge for bivalving and lining was $416.51 ($403.32 to $449.00). CONCLUSIONS: Spica cast treatment is associated with numerous skin complications and additional charges. Victims of child abuse may benefit from additional clinical oversight. Future research needs to investigate patient education and casting interventions that reduce skin complications. LEVEL OF EVIDENCE: Prognostic Level III-case-control study with patient identified based on outcome-skin complications versus no skin complications.

The effect of reduction and instrumentation of spondylolisthesis on spinopelvic sagittal alignment.

BACKGROUND: Reduction of severe spondylolisthesis is controversial. Publications have emphasized the techniques of reduction and associated complications, but there is little knowledge about the effect of reduction on the sagittal balance of the spine and pelvis in the postoperative patient. This study evaluated the effect of surgical reduction and instrumented fusion of spondylolisthesis on the pelvic anatomy and spinopelvic sagittal balance. METHODS: This is a retrospective study of 26 adolescents (mean age, 13.1+/-3.3 years) who had partial surgical reduction and posterior instrumented fusion L4 to sacrum to treat high-grade spondylolisthesis. All patients had radiographs that allowed measurement of sagittal spinopelvic parameters at preoperative, postoperative, and at a minimum of 2 years' follow-up (mean, 7.5+/-5.4 years). A 10-degree reduction in lumbosacral angle and/or 10% reduction of anterior listhesis confirmed the reduction. Radiographic measurements were statistically compared to determine correlations between reduction and sagittal balance. RESULTS: Pelvic incidence increased in 5 (24%) of 21 patients who had posterior instrumented fusion. Pelvic version improved in patients with unbalanced spondylolisthesis as evidenced by reduction of pelvic tilt or/and increased sacral slope. Mean pelvic tilt improved by 5.7 degrees (95% confidence interval, 1.5-9.8 degrees), and mean sacral slope improved by 11.4 degrees (95% confidence interval, 5.9-17.0 degrees). Two of 6 patients with a balanced spondylolisthesis developed a retroverted sacrum at follow-up.There was poor correlation between the amount of surgical reduction (improvement in L5 slip and lumbosacral angle) and the changes in pelvic version. CLINICAL RELEVANCE: Partial reduction and instrumented fusion of spondylolisthesis may lead to increased pelvic incidence due to sacroiliac joint motion or sacral remodeling. In unbalanced spondylolisthesis, pelvic sagittal balanced improved in 75% of patients but did not correlate to the amount of reduction of spondylolisthesis. Other factors, such as achievement of solid arthrodesis, may be more important than reduction of spondylolisthesis in determining spinopelvic sagittal balance. LEVEL OF EVIDENCE: IV-case series.

Reliability and development of a new classification of lumbosacral spondylolisthesis.

BACKGROUND: A classification of lumbosacral spondylolisthesis has been proposed recently. This classification describes eight distinct types of spondylolisthesis based on the slip grade, the degree of dysplasia, and the sagittal sacro-pelvic balance. The objectives of this study are to assess the reliability of this classification and to propose a new and refined classification. METHODS: Standing posteroanterior and lateral radiographs of the spine and pelvis of 40 subjects (22 low-grade, 18 high-grade) with lumbosacral spondylolisthesis were reviewed twice by six spine surgeons. Each radiograph was classified based on the slip grade, the degree of dysplasia, and the sagittal sacro-pelvic balance. No measurements from the radiographs were allowed. Intra- and inter-observer reliability was assessed using kappa coefficients. A refined classification is proposed based on the reliability study. RESULTS: All eight types of spondylolisthesis described in the original classification were identified. Overall intra- and inter-observer agreement was respectively 76.7% (kappa: 0.72) and 57.0% (kappa: 0.49). The specific intra-observer agreement was 97.1% (kappa: 0.94), 85.0% (kappa: 0.69) and 88.8% (kappa: 0.85) with respect to the slip grade, the degree of dysplasia, and the sacro-pelvic balance, respectively. The specific inter-observer agreement was 95.2% (kappa: 0.90), 72.2% (kappa: 0.43) and 77.2% (kappa: 0.69) with respect to the slip grade, the degree of dysplasia, and the sacro-pelvic balance, respectively. CONCLUSION: This study confirmed that surgeons can classify radiographic findings into all eight types of spondylolisthesis. The intra-observer reliability was substantial, while the inter-observer reliability was moderate mainly due to the difficulty in distinguishing between low- and high-dysplasia. A refined classification excluding the assessment of dysplasia, while incorporating the assessment of the slip grade, sacro-pelvic balance and global spino-pelvic balance is proposed, and now includes five types of lumbosacral spondylolisthesis.