High Satisfaction in Adolescent Idiopathic Scoliosis Patients on Enhanced Discharge Pathway.

BACKGROUND: Recently, there have been several reports of using an enhanced discharge pathway following posterior spinal fusion (PSF) in patients with adolescent idiopathic scoliosis (AIS). No previous studies have prospectively examined patient satisfaction of patients with AIS using an enhanced discharge pathway. The purpose of this study was to evaluate patient satisfaction with an enhanced discharge pathway for PSF and whether patients felt that their length of stay was appropriate. METHODS: Patients with AIS undergoing PSF were prospectively enrolled. At their first postoperative clinic visit, patients were administered a survey regarding their experience. RESULTS: Of the 46 patients enrolled (mean age, 14 y), 1 was discharged on postoperative day (POD) 2, 33 were discharged on POD 3, 9 were discharged on POD 4, and 3 were discharged on POD 5. Eighty (37/46) of patients felt that they were discharged at an appropriate time, whereas 20% (9/46) felt they were discharged too early. Patients who felt they were discharged at an appropriate time (mean, 3.2 d) had a trend toward shorter stays than those who felt they were discharged too early (mean, 3.7 d). Overall patient satisfaction of hospital stay was high with a mean of 9 on a 10-point scale (range, 1 to 10). There was no correlation between length of stay and patient satisfaction (P=0.723). Patients who felt they were discharged early had a significantly higher mean FACES pain scores than those who felt they were discharged about right both as inpatients (mean, 4.8 vs. 3.4; P=0.0319) and at their first postoperative clinic visit (5.4 vs. 2.9; P=0.004). CONCLUSIONS: Eighty percent of patients with AIS who underwent PSF felt that the time of discharge was appropriate with an enhanced discharge pathway. There was no correlation between patient satisfaction and length of stay. LEVEL OF EVIDENCE: Level II.

Comparison of Ponte Osteotomies and 3-Column Osteotomies in the Treatment of Congenital Spinal Deformity.

BACKGROUND: Congenital spinal deformity (CSD) has traditionally been treated with 3-column osteotomies [hemivertebrectomy (HV) or vertebral column resection (VCR)] to address rigid deformities. Alternatively, multiple Ponte osteotomies (PO) may provide correction while minimizing risk. The purpose of this study was to compare safety and outcomes of patients undergoing surgical treatment for CSD with these 3 procedures. METHODS: Retrospective review of CSD patients treated with posterior spinal fusion between 1996 to 2013. Patients treated with multiple Ponte osteotomies (PO group) were compared with those managed with 3-column osteotomies (HV/VCR group). Patients with previous instrumentation, isolated cervical deformity, growing spine instrumentation, or <2 year follow-up were excluded. Deformity angular ratio (DAR) was calculated as curve magnitude divided by number of levels of the deformity. RESULTS: There were 49 patients [17 PO, 32 HV/VCR (26 HV, 6 VCR)]. For the PO group, mean age was 14 years, and they had an average of 4 ponte osteotomies and 11 levels fused. Mean total DAR was 25 and mean number of congenital anomalies was 1.8 in the PO group. The HV/VCR group had a mean age of 7 years and 5 levels fused. Mean total DAR was 28 and mean number of congenital anomalies was 2.1 in the HV/VCR group. Patients had a mean of 54.1% correction of coronal deformity in the PO group and 54.4% in the HV/VCR group (P=0.78). Signal changes were observed less frequently with PO (1/17) and HV (1/26) than with VCR (4/6), P=0.001. Revision rates were 17.6% (3/17) in the PO group and 37.5% (12/32) in the HV/VCR group (P=0.35). CONCLUSIONS: Patients with CSD and a mean total DAR of 25 treated with multiple PO and long fusions had correction comparable with the HV/VCR group. Patients treated with VCR had the highest incidence of signal changes and postoperative neurologic deficits. LEVEL OF EVIDENCE: Level III.

A Comparison of Maximal Voluntary Ventilation and Forced Vital Capacity in Adolescent Idiopathic Scoliosis Patients.

STUDY DESIGN: Prospective, single center. OBJECTIVE: To compare maximal voluntary ventilation (MVV) and forced vital capacity (FVC) testing in the outpatient scoliosis clinic to determine their relative feasibility and sensitivity in assessing pulmonary function in the AIS population. SUMMARY OF BACKGROUND DATA: Evidence of compromised pulmonary function in patients with severe AIS is well established. The American Thoracic Society (ATS) has established criteria for the reliability and accuracy of pulmonary function tests (PFTs), including MVV and FVC. METHODS: A total of 91 AIS patients with thoracic curves of 20° or greater were enrolled in the orthopedic clinic. Patients performed PFTs using the CareFusion MicroLoop Spirometer. MVV and FVC values were collected. Results were considered reliable or "passing" when ATS spirometer guidelines were met. RESULTS: Eighty-seven of the 91 patients (96%) met ATS criteria for the MVV test and 43 of the 91 patients (47%) met criteria for the FVC test. Both MVV (r = -0.41, p < .01) and FVC (r = -0.37, p = .01) were significantly correlated with thoracic Cobb angle. The percentile predicted (%predicted) MVV (r = -0.24, p = .03) and %predicted FVC (r = -0.32, p = .04) were also significantly correlated with thoracic Cobb angle. Of those who passed both tests (42/91 patients), 26% had abnormal MVV results with normal FVC results, and 5% had abnormal FVC results with normal MVV results. CONCLUSION: MVV and FVC correlated closely with Cobb angle. Twice as many AIS patients could perform an MVV test compared with an FVC test. MVV seems to be a more practical and sensitive PFT than FVC for assessing the pulmonary function of AIS patients in the orthopedic clinic setting. LEVEL OF EVIDENCE: Level II.

Outcomes of salvage hip surgery in children with cerebral palsy.

This study compared the outcomes of four salvage procedures in treating painful dislocated hips in patients with cerebral palsy: Schanz osteotomy, Girdlestone, Castle, and McHale procedures. A retrospective review of cerebral palsy patients treated between 1990 and 2014 with minimum 6-month follow-up was carried out. Of 69 hips (62 patients), there were 36 McHales, 24 Castles, four Girdlestones, and five Schanz procedures at a mean age of 13.9 years. All four procedures provided pain relief. Proximal femoral migration was similar following the procedures, but heterotopic ossification was more common after the Castle procedure. Bone resorption and revision surgery were more frequent after the McHale procedure.

Gomco Versus Mogen? No Effect on Circumcision Revision Rates.

OBJECTIVES: Elective newborn circumcision, one of the most common surgical procedures in the world, is often performed with either the Gomco clamp or the Mogen clamp. Our aims were to determine differential circumcision revision and complication rates due to surgical technique and differences in outcomes when residents versus attending physicians performed the procedure. METHODS: We conducted a retrospective chart review of newborns who underwent elective circumcision at our children's hospital from January 2013 to June 2017 using Current Procedural Terminology codes for newborn circumcision and repair of an incomplete circumcision. We excluded patients who were initially circumcised by a physician other than a pediatrician and procedures that were performed after 31 days of age. The primary outcome was the rate of circumcision revisions. The secondary outcome was the incidence of minor and major complications. We used independent sample t tests, analysis of variance, Fisher's exact test, and logistic regression models in the analysis. RESULTS: We analyzed 979 Gomco and 718 Mogen procedures. Both groups had similar complication (26 of 1697 or 1.53%) and revision rates (8 of 1697 or 0.47%). Attending physicians and residents had similar revision rates overall, but residents using the Gomco clamp had a higher rate of revision (2 of 249 or 0.80%) than attending physicians (2 of 730 or 0.27%; P = .003). Older age at primary procedure was significantly associated with revision (P = .03). CONCLUSIONS: Elective newborn circumcision is associated with similar complication and revision rates after the use of either Gomco or Mogen clamps. There were no differences in outcomes when the procedure was performed by pediatric residents or attending pediatricians.

Raising Mean Arterial Pressure Alone Restores 20% of Intraoperative Neuromonitoring Losses.

STUDY DESIGN: Multicenter prospective. OBJECTIVE: To assess the effect of intraoperative interventions in restoring intraoperative neuromonitoring (IONM) signals in pediatric spine surgery. SUMMARY OF BACKGROUND DATA: No prior studies have prospectively examined the rate of return of IONM signals by increasing blood pressure (BP) alone. METHODS: Patients undergoing posterior spinal deformity surgery were enrolled at their preoperative appointment. Surgeons completed an intraoperative data form on patients who experienced an IONM change defined as a 50% or greater decrease in either transcranial motor evoked potentials or somatosensory evoked potentials. RESULTS: Four hundred fifty two patients were enrolled with 30 (7%) having IONM change. Thirty patients met inclusion criteria (mean age, 12 yrs, range, 5-19) and had the following diagnoses: idiopathic scoliosis (43%), neuromuscular scoliosis (13%), congenital scoliosis (10%), early onset scoliosis (7%), and other (27%). 20% (6/30) had return of signals due to an increase in BP alone with no other interventions (mean arterial pressure [MAP] increased from mean of 68 [range, 58-76] to 86 mmHg [range, 75-95]). Signals returned to baseline after mean of 16 minutes (range, 2-45). In 60% of patients (18/30), MAP was raised from a mean of 72 mmHg (range, 55-84) to 86 mmHg (range, 75-100) in conjunction with other interventions and had mean return of signals in 37 minutes (range, 8-210). Six (20%) of patients had signals return to baseline after a mean of 6 minutes (range, 3-13) in which MAP did not change appreciably. All patients had return of signals at the conclusion of the procedure with one patient having postoperative neurological sequale. CONCLUSION: In this prospective study of 452 pediatric spinal deformity surgeries, raising MAPs above 85 mmHg should be considered the first step in response to IONM signal changes, as this alone was successful in 20% of patients without sacrificing deformity correction. LEVEL OF EVIDENCE: 2.

Benign Natural History of Spondylolysis in Adolescence With Midterm Follow-Up.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: To use the Micheli Functional Scale to assess adolescent patients with spondylolysis treated conservatively at midterm follow-up. SUMMARY OF BACKGROUND: Spondylolysis is a common source of back pain for adolescents and is generally managed with bracing and physical therapy. There is little data regarding the results of conservative management of spondylolysis over time. METHODS: Four major academic pediatric institutions performed a retrospective chart review of patients from 5 to 21 years of age with the initial diagnosis of spondylolysis. Inclusion criteria were patients who initially underwent conservative management and had a minimum of 2 years' follow-up. The patients were contacted and asked to complete the Micheli Functional Scale Survey. RESULTS: A total of 295 patients with the diagnosis of spondylolysis were identified and contacted. Sixty-one subjects with spondylolysis completed the follow-up survey. Sixty of 61 respondents (98%) answered questions regarding their current pain level. Thirty-five of 60 (58.3%) reported no pain (0/10) and 47/60 (78%) rated their pain at 3 or less, whereas 22% (13/60) rated their pain as 4 or higher. There was no correlation with pain ratings on the follow-up survey and radiographic healing at initial management. Of the 61 patients, 50 returned to sports (82%), 8 did not return (13%), and 5 returned to most but not all of their sports (8%). No correlation was observed between radiographic healing and return to sports (p = .4885). CONCLUSION: Using a validated functional scale, this study demonstrated that with conservative management of spondylolysis a majority of patients at an average of 8 years out self-report a return to sports (90%), though many reported continued pain (42%) and interference with activities (67%). There was no correlation observed between radiographic evidence of healing and pain or return to sports with a mean follow-up of 8 years. LEVEL OF EVIDENCE: Multicenter retrospective case series.

Pain is the Greatest Preoperative Concern for Patients and Parents Before Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Prospective cross-sectional study. OBJECTIVE: To evaluate patients' and parents' concerns so they can be addressed with appropriate preoperative counseling. SUMMARY OF BACKGROUND DATA: Despite much research on outcomes for posterior spinal fusion (PSF) in adolescent idiopathic scoliosis (AIS), little is available about preoperative fears or concerns. METHODS: Patients with AIS undergoing PSF, their parents, and surgeons were prospectively enrolled and asked to complete a survey on their fears and concerns about surgery at their preoperative appointment. RESULTS: Forty-eight patients and parents completed surveys. Four attending pediatric spine surgeons participated and submitted 48 responses. Mean age of patients was 14.2 years. On a scale of 0 to 10, mean level of concern reported by parents (6.9) was higher than that reported by patients (4.6). Surgeons rated the procedure's complexity on a scale of 0 to 10 and reported a mean of 5.2. Neither patients' nor parents' level of concern correlated with the surgeons' assessment of the procedure's complexity level (R = 0.19 and 0.12, P = 0.20 and P = 0.42, respectively). Top three concerns for patients were pain (25%), ability to return to activities (21%), and neurologic injury (17%). Top three concerns for parents were pain (35%), neurologic injury (21%), and amount of correction (17%). Top three concerns for surgeons were postoperative shoulder balance (44%), neurologic injury (27%), and lowest instrumented vertebrae selection (27%). Patients reported the same concerns 23% of the time as parents, and 17% of the time as surgeons. Parents and surgeons reported the same concerns 21% of the time. CONCLUSION: Pain was the greatest concern for both patients and parents but was rarely listed as a concern by surgeons. Parent and patient level of concern did not correlate to the surgeon's assessment of the procedure's complexity. Neurologic injury was a top concern for all groups, but otherwise there was little overlap between physician, patient, and parent concerns. LEVEL OF EVIDENCE: 3.