Thriving in Residency: a Qualitative Study.

BACKGROUND: While a great deal of research has brought attention to the issue of physician burnout in recent years, and resident physician burnout in particular, the topics of physician well-being, and by extension physician thriving, have been relatively understudied. Consequently, we propose a model of resident physician thriving. Objective To understand what factors contribute to a subjective sense of thriving among resident physicians. DESIGN: In this study, we conducted in-depth interviews from May 2020 through February 2021 with resident physicians to determine what factors have contributed to their sense of thriving in their careers as well as in their lives more generally. We used a snowball sampling technique to recruit participants. Validated instruments were used to quantify the participant's subjective level of job and life satisfaction as well as their level of career burnout. To derive our conclusions, we employed thematic content analysis using a grounded theory-based approach. PARTICIPANTS: Resident physicians in the internal medicine, pediatrics, and combined internal medicine-pediatrics residency programs at a single university-affiliated institution. APPROACH: We interviewed those residents with high life, career, and residency satisfaction who did not meet criteria for burnout to explore those factors that contribute to their sense of thriving. KEY RESULTS: Thirty-seven screening interviews were conducted. Twenty-four participants met criteria for life, career, and residency satisfaction while also not meeting criteria for burnout. The six key themes contributing to resident thriving that we identified during the course of our analysis included program leadership, learning climate, connectedness, joy in medicine, life balance, and intrinsic factors. CONCLUSIONS: This project proposes a model of resident thriving that can potentially inform program structure, culture, and values.

Operative treatment of the young cerebral palsy hip.

Hip dysplasia, subluxation, and eventual hip dislocation are commonly encountered in the cerebral palsy population secondary to spasticity and loss of motor control, especially in those patients with more severe neurologic involvement. The treatment of hip disorders in these patients should take into account the degree of limb and hip involvement, pain severity, and overall functioning. Conservative management focuses on mitigating spasticity and preserving range of motion in order to provide an environment in which the femoral head remains concentrically reduced in the acetabulum. However, operative management, consisting of soft tissue or tendon releases, femoral or pelvic osteotomies, or hip salvage procedures, is sometimes necessary to treat the painful, subluxated, or dislocated hip. Radiographic hip surveillance in the pediatric cerebral palsy population is used to guide operative treatment. Long term hip containment is generally improved when surgical intervention is performed in the earlier stages of dysplasia. Younger patients who demonstrate progressive hip subluxation despite conservative measures may be carefully selected to undergo soft tissue procedures. Bony reconstruction, with adjunctive soft tissue procedures, is often necessary to better contain the proximal femur in patients above the age of four years.

Evaluation of assessment of caregiver experience with neuromuscular disease: reliability and responsiveness of a new caregiver-reported outcome measure in patients with cerebral palsy.

BACKGROUND: Cerebral palsy (CP) is the most common cause of chronic childhood disability. Caregivers often provide prolonged care over patients' life span, thus measuring the impact of the disease and its treatments on caregivers has become a recent focus in research. The current study aims to present an evaluation of the reliability and responsiveness of assessment of caregiver experience with neuromuscular disease (ACEND) following botulinum toxin injection to relieve spasticity in children with CP. METHODS: Patients with baseline ACEND scores and at least one assessment following botulinum toxin injection were enrolled. Data on their gender, age, diagnoses, and functional levels (according to The Gross Motor Function Classification System, GMFCS), and ACEND scores were analyzed. Statistical analyses performed included paired t-test and linear regression. RESULTS: Baseline ACEND scores (117.7±47.7) were strongly correlated with follow-up scores (120.4±49.5) with a coefficient of 0.929 (P<0.001), suggesting the high reliability of the questionnaire. Paired-sample t-test revealed an insignificant average improvement in ACEND of 2.7 (P=0.352). The ICD-10 code and the GMFCS level were found to be significant predictors for baseline (P=0.043, P<0.001) and follow-up ACEND scores (P=0.025, P<0.001). Male gender was a significant predictor for improvement in ACEND scores. CONCLUSIONS: We demonstrated the reliability of ACEND through strong correlations of scores before and after botulinum toxin injection. In terms of responsiveness, while the burden of care is largely determined by ICD-10 diagnosis and the GMFCS level, changes in care burden are only related to the gender of the patient and the follow-up time interval.

Symptomatic cervical spinal stenosis in spastic cerebral palsy.

AIM: To describe the prevalence of symptomatic cervical spinal stenosis (CSS) in spastic cerebral palsy (CP) and associated characteristics. METHOD: This cross-sectional study of adults (>18y) with CP (2006-2016) at a single institution compared the patient characteristics (demographics, comorbidities, surgical history, medications, Gross Motor Function Classification System [GMFCS] level, and CP type) of patients with and without CSS. RESULTS: Of 424 patients (mean age 33y 4mo, SD 13y 6mo, range 18-78y; 225 females, 199 males), 32 patients (7.5%) had symptomatic CSS. GMFCS levels in the study cohort were distributed as follows: level I, 25%; level II, 25%; level III, 22%; level IV, 19%; level V, 9%. Twenty-five out of 32 (78.1%) patients had spastic CP, two (6.3%) had dystonic CP, and one (3.1%) had mixed characteristics. Individuals with CSS were older (mean age 54y 6mo, SD 10y 5mo vs mean age 31y 7mo, SD 12y 1mo, p<0.05) and had a higher body mass index (26.1, SD 4.8 vs 23.4, SD 6.2, p<0.05) than those without CSS. Presentations included upper-extremity symptoms (73%), ambulation decline (70%), neck pain (53%), and incontinence (30%). Common stenosis levels were C5-C6 (59%), C4-C5 (56%), and C6-C7 (53%). INTERPRETATION: Symptomatic CSS was identified in 7.5% of this adult cohort during the 2006 to 2016 period. Diagnosis in CP is difficult due to impaired communication and pre-existing gait abnormalities and spasticity. Given the high prevalence of symptomatic CSS in adults, we propose developing screening guidelines. Physicians must maintain a high level of suspicion for CSS if patients present with changes in gait or spasticity.

Validation of Pediatric Self-Report Patient-Reported Outcomes Measurement Information System (PROMIS) Measures in Different Stages of Legg-Calvé-Perthes Disease.

OBJECTIVES: Patient-reported outcomes (PRO) assessing health-related quality of life (HRQoL) are important outcome measures, especially in Legg-Calvé-Perthes disease (LCPD) where symptoms (pain and limping), activity restrictions, and treatments vary depending on the stage of the disease. The purpose of this study was to investigate the validity of the Patient-reported Outcomes Measurement Information System (PROMIS) for measuring HRQoL of patients with LCPD in various stages of the disease. METHODS: This is a multicenter validity study. Patients with LCPD between 4 and 18 years old were included and classified into modified Waldenström stages of disease: Early (1 or 2A), Late (2B or 3), or Healed (4). Seven PROMIS domains were collected, including Pain Interference, Fatigue, Mobility, Depression, Anger, Anxiety, and Peer Relationships. Convergent, discriminant, and known group validity was determined. RESULTS: A total of 190 patients were included (mean age: 10.4±3.1 y). All 7 domains showed the worst scores in patients in the Early stage (known group validity). Within each domain, all domains positively correlated to each other (convergent validity). Patients who reported more anxiety, depression, and anger were associated with decreased mobility and increased fatigue and pain. Peer relationships had no to weak associations with other domains (discriminant validity). CONCLUSIONS: PROMIS has construct validity in measuring the HRQoL of patients in different stages of LCPD, suggesting that PROMIS has potential to serve as a patient-reported outcome tool for this population. LEVEL OF EVIDENCE: Diagnostic level III study.

Variation Among Pediatric Orthopaedic Surgeons When Treating Medial Epicondyle Fractures.

BACKGROUND: Medial epicondyle fractures are a common pediatric and adolescent injury accounting for 11% to 20% of elbow fractures in this population. This purpose of this study was to determine the variability among pediatric orthopaedic surgeons when treating pediatric medial epicondyle fractures. METHODS: A discrete choice experiment was conducted to determine which patient and injury attributes influence the management of medial epicondyle fractures by pediatric orthopaedic surgeons. A convenience sample of 13 pediatric orthopaedic surgeons reviewed 60 case vignettes of medial epicondyle fractures that included elbow radiographs and patient/injury characteristics. Displacement was incorporated into the study model as a fixed effect. Surgeons were queried if they would treat the injury with immobilization alone or open reduction and internal fixation (ORIF). Statistical analysis was performed using a mixed effect regression model. In addition, surgeons filled out a demographic questionnaire and a risk assessment to determine if these factors affected clinical decision-making. RESULTS: Elbow dislocation and fracture displacement were the only attributes that significantly influenced surgeons to perform surgery (P<0.05). The presence of an elbow dislocation had the largest impact on surgeons when choosing operative care (ß=-0.14; P=0.02). In addition, for every 1 mm increase in displacement, surgeons tended to favor ORIF by a factor of 0.09 (P<0.01). Sex, mechanism of injury, and sport participation did not influence decision-making. In total, 54% of the surgeons demonstrated a preference for ORIF for the included scenarios. On the basis of the personality Likert scale, participants were neither high-risk takers nor extremely risk adverse with an average-risk score of 2.24. Participant demographics did not influence decision-making. CONCLUSIONS: There is substantial variation among pediatric orthopaedic surgeons when treating medial epicondyle fractures. The decision to operate is significantly based on the degree of fracture displacement and if there is a concomitant elbow dislocation. There is no standardization regarding how to treat medial epicondyle fractures and better treatment algorithms are needed to provide better patient outcomes. LEVEL OF EVIDENCE: Level V.

Gross Motor Function Classification System Specific Growth Charts-Utility as a Risk Stratification Tool for Surgical Site Infection Following Spine Surgery.

BACKGROUND: There is currently minimal evidence that preoperative malnutrition increases surgical site infection (SSI) risk in children with cerebral palsy (CP) undergoing spinal deformity surgery. Growth charts specifically for patients with CP have been created to aid in the clinical interpretation of body mass index (BMI) as a marker of nutritional status, but to our knowledge these charts have never been used to risk stratify patients before orthopaedic surgery. We hypothesize that patients with CP who have BMI-for-age below the 10th percentile (BMI≤10) on CP-specific growth charts are at increased risk of surgical site infection following spinal deformity surgery compared with patients with BMI-for-age above the 10th percentile (BMI>10). METHODS: Single-center, retrospective review comparing the rate of SSI in patients with CP stratified by BMI-for-age percentiles on CP-specific growth charts who underwent spinal deformity surgery. Odds ratios with 95% confidence intervals and Pearson χ tests were used to analyze the association of the measured nutritional indicators with SSI. RESULTS: In total, 65 patients, who underwent 74 procedures, had complete follow-up data and were included in this analysis. Ten patients (15.4%) were GMFCS I-III and 55 (84.6%) were GMFCS IV-V; 39 (60%) were orally fed and 26 (40%) were tube-fed. The rate of SSI in this patient population was 13.5% with 10 SSIs reported within 90 days of surgery. There was a significant association between patients with a BMI below the 10th percentile on GMFCS-stratified growth charts and the development of SSI (OR, 13.6; 95% CI, 2.4-75.4; P=0.005). All SSIs occurred in patients that were GMFCS IV-V. There was no association between height, weight, feeding method, or pelvic instrumentation and development of SSI. CONCLUSIONS: CP-specific growth charts are useful tools for identifying patients at increased risk for SSI following spinal instrumentation procedures, whereas standard CDC growth charts are much less sensitive. There is a strong association between preoperative BMI percentile on GMFCS-stratified growth charts and SSI following spinal deformity surgery. LEVEL OF EVIDENCE: Level III-Retrospective Study.

Post-Operative Pain Assessment and Management in Cerebral Palsy (CP): A Two-Pronged Comparative Study on the Experience of Surgical Patients.

INTRODUCTION: This study compares the current practice patterns of pain assessment and management between children with and without CP following either posterior spinal instrumentation and fusion (PSIF) or hip osteotomy (HO). METHODS: Two cohorts of CP patients were retrospectively identified and matched with non-CP patients based on age, surgical procedure, and approach to post-operative pain management. Sixteen CP patients undergoing PSIF and twenty-two undergoing HO were respectively matched with the same numbers of non-CP patients receiving the same procedures. The frequency of assessments conducted, highest pain scores recorded on each post-operative day (POD), and the amount of adjuvant analgesics administered were collected for POD 0-4. RESULTS: Patients with CP were significantly more frequently evaluated for pain post-operatively, tended to have lower pain scores as measured by current scales, and received slightly fewer analgesics. Patients with CP differed from their non-CP counterparts in both frequency and method of post-operative pain assessment. CONCLUSIONS: The purpose of this study is to elucidate the current state of post-operative pain assessment and management in children with CP undergoing major orthopaedic surgeries, to improve CP patient/caregiver understanding and expectation of the post-operative experience regarding pain, and to provide recommendations for improving the post-operative care for these patients.

Anesthesia Exposure in Children: Practitioners Respond to the 2016 FDA Drug Safety Communication.

In December 2016, the US Food and Drug Administration (FDA) issued a drug safety warning stating that 11 commonly used anesthetic and sedative medications had potential neurotoxic effects when used in children under the age of 3 years and in pregnant women during the third trimester. A panel presentation at the sixth biennial Pediatric Anesthesia Neurodevelopmental Assessment (PANDA) symposium addressed the FDA announcement in a session entitled "Anesthesia Exposure in Children During Surgical and Non-Surgical Procedures: How Do We Respond to the 2016 FDA Drug Safety Communication?" Panelists included representatives from pediatric anesthesiology, obstetrics, pediatric surgery, and several pediatric surgical subspecialties. Each panelist was asked to address the following questions: How has the FDA labelling change affected your clinical practice including patient discussions, timing, and frequency of procedures? Has your professional society provided any guidelines for this discussion? Has there been any discussion of this topic at your national meetings? The panelists provided important perspectives specific to each specialty, which generated a lively discussion and a detailed response from the Deputy Director of the Division of Anesthesia and Addiction of the FDA describing the FDA procedures that led to this drug safety warning.

Housing Voucher Take-Up and Labor Market Impacts.

Low participation rates in government assistance programs are a major policy concern in the United States. This paper studies take-up of Section 8 housing vouchers, a program in which take-up rates are quite low among interested and eligible households. We link 18,109 households in Chicago that were offered vouchers through a lottery to administrative data and study how baseline employment, earnings, public assistance, arrests, residential location, and children's academic performance predict take-up. Our analysis finds mixed evidence of whether the most disadvantaged or distressed households face the largest barriers to program participation. We also study the causal impact of peer behavior on take-up by exploiting idiosyncratic variation in the timing of voucher offers. We find that the probability of lease-up increases with the number of neighbors who recently received voucher offers. Finally, we explore the policy implications of increasing housing voucher take-up by applying reweighting methods to existing causal impact estimates of voucher receipt. This analysis suggests that greater utilization of vouchers may lead to larger reductions in labor market activity. Differences in take-up rates across settings may be important to consider when assessing the external validity of studies identifying the effects of public assistance programs.

The Integrative Conjugative Element clc (ICEclc) of Pseudomonas aeruginosa JB2.

Integrative conjugative elements (ICE) are a diverse group of chromosomally integrated, self-transmissible mobile genetic elements (MGE) that are active in shaping the functions of bacteria and bacterial communities. Each type of ICE carries a characteristic set of core genes encoding functions essential for maintenance and self-transmission, and cargo genes that endow on hosts phenotypes beneficial for niche adaptation. An important area to which ICE can contribute beneficial functions is the biodegradation of xenobiotic compounds. In the biodegradation realm, the best-characterized ICE is ICEclc, which carries cargo genes encoding for ortho-cleavage of chlorocatechols (clc genes) and aminophenol metabolism (amn genes). The element was originally identified in the 3-chlorobenzoate-degrader Pseudomonas knackmussii B13, and the closest relative is a nearly identical element in Burkholderia xenovorans LB400 (designated ICEclc-B13 and ICEclc-LB400, respectively). In the present report, genome sequencing of the o-chlorobenzoate degrader Pseudomonas aeruginosa JB2 was used to identify a new member of the ICEclc family, ICEclc-JB2. The cargo of ICEclc-JB2 differs from that of ICEclc-B13 and ICEclc-LB400 in consisting of a unique combination of genes that encode for the utilization of o-halobenzoates and o-hydroxybenzoate as growth substrates (ohb genes and hyb genes, respectively) and which are duplicated in a tandem repeat. Also, ICEclc-JB2 lacks an operon of regulatory genes (tciR-marR-mfsR) that is present in the other two ICEclc, and which controls excision from the host. Thus, the mechanisms regulating intracellular behavior of ICEclc-JB2 may differ from that of its close relatives. The entire tandem repeat in ICEclc-JB2 can excise independently from the element in a process apparently involving transposases/insertion sequence associated with the repeats. Excision of the repeats removes important niche adaptation genes from ICEclc-JB2, rendering it less beneficial to the host. However, the reduced version of ICEclc-JB2 could now acquire new genes that might be beneficial to a future host and, consequently, to the survival of ICEclc-JB2. Collectively, the present identification and characterization of ICEclc-JB2 provides insights into roles of MGE in bacterial niche adaptation and the evolution of catabolic pathways for biodegradation of xenobiotic compounds.

Genomic Methods and Microbiological Technologies for Profiling Novel and Extreme Environments for the Extreme Microbiome Project (XMP).

The Extreme Microbiome Project (XMP) is a project launched by the Association of Biomolecular Resource Facilities Metagenomics Research Group (ABRF MGRG) that focuses on whole genome shotgun sequencing of extreme and unique environments using a wide variety of biomolecular techniques. The goals are multifaceted, including development and refinement of new techniques for the following: 1) the detection and characterization of novel microbes, 2) the evaluation of nucleic acid techniques for extremophilic samples, and 3) the identification and implementation of the appropriate bioinformatics pipelines. Here, we highlight the different ongoing projects that we have been working on, as well as details on the various methods we use to characterize the microbiome and metagenome of these complex samples. In particular, we present data of a novel multienzyme extraction protocol that we developed, called Polyzyme or MetaPolyZyme. Presently, the XMP is characterizing sample sites around the world with the intent of discovering new species, genes, and gene clusters. Once a project site is complete, the resulting data will be publically available. Sites include Lake Hillier in Western Australia, the "Door to Hell" crater in Turkmenistan, deep ocean brine lakes of the Gulf of Mexico, deep ocean sediments from Greenland, permafrost tunnels in Alaska, ancient microbial biofilms from Antarctica, Blue Lagoon Iceland, Ethiopian toxic hot springs, and the acidic hypersaline ponds in Western Australia.

Effect of Preoperative Indications Conference on Procedural Planning for Treatment of Scoliosis.

STUDY DESIGN: This study determines the rate of change in the scoliosis surgery plan in cases presented in preoperative indications conference. OBJECTIVES: To determine the effect of preoperative indications conference on the plan of surgery and to identify characteristics that increased the likelihood of change. SUMMARY OF BACKGROUND DATA: Preoperative indications conferences are used as a teaching and planning tool. Levels of fusion, construct options, and necessity for osteotomies are often debated in the planning of scoliosis surgery. METHODS: Scoliosis surgeries were presented at preoperative indications conference with four attending pediatric orthopedic surgeons present. The operative surgeon committed to a surgical plan before conference. A consensus-based plan was made without knowledge of the operative surgeon's preconference plan. Changes of plan were classified as major, minor, or no change. RESULTS: Of the 107 surgical plans, 50 were index surgeries, 13 were revisions, and 44 were scheduled growing rod lengthenings. There were two major changes, including a change to a growing construct from planned fusion, and a change in fusion levels in an adolescent idiopathic scoliosis (AIS) patient. There were 13 minor changes, which included changes in fusion levels (1 to 3; mean = 1.23) and the addition of an osteotomy. The rate of change was 28% for index surgeries and 7.69% for revisions. Of the 14 changes in the 50 index surgeries, there were 8 AIS, 3 cerebral palsy, 1 congenital scoliosis, 1 Ehlers-Danlos, and 1 patient with an undetermined neuromuscular condition. There was 1 change in 13 revision surgeries. There were no changes for growing rod lengthenings and no cancellations as a result of indications conference. CONCLUSIONS: Although revision scoliosis surgery is complex, index AIS/JIS surgery was most subject to the influence of indications conference. This likely reflects controversy around choosing levels of fusion. LEVEL OF EVIDENCE: IV.

An Independent Evaluation of the Validity of a DNA-Based Prognostic Test for Adolescent Idiopathic Scoliosis.

BACKGROUND: ScoliScore is a DNA-based prognostic test, designed and used to help to predict the risk of curve progression in patients with adolescent idiopathic scoliosis. The role of this test in clinical practice remains unclear as the published results of the ScoliScore have not been validated independently. The purpose of this study was to determine if the ScoliScore effectively predicted the risk of curve progression in patients with mild and moderate adolescent idiopathic scoliosis in two urban academic medical centers. METHODS: One hundred and twenty-six patients with adolescent idiopathic scoliosis who met inclusion criteria at two centers were administered the ScoliScore test. Two groups were created: a progression group (those who had a Cobb angle of >40° or those who had undergone surgical fusion) and a non-progression group (those who had skeletal maturity without curve progression to 40°). ScoliScore values and risk levels were compared between the two groups. The negative predictive value was calculated for low-risk scores and the positive predictive value was calculated for high-risk scores. RESULTS: There was no significant difference (p = 0.706) in the mean ScoliScore (and standard deviation) between patients with curve progression (107 ± 55 points) and those without curve progression (102 ± 62 points). There was also no significant difference (p = 0.399) in curve progression between patients with high-risk scores (26.7%) and those with low-risk scores (12.9%). The positive predictive value of the test was 0.27 (95% confidence interval, 0.09 to 0.55), and the negative predictive value was 0.87 (95% confidence interval, 0.69 to 0.96). ScoliScores and rates of progression were not affected by brace-wear. CONCLUSIONS: ScoliScores did not differ between patients with and without curve progression, and the negative and positive predictive values were lower in our study than in the previously published validation study by the developers of the test. This may be due to differences in our test population, genetic variability, or failure of patients in the non-progression group to follow up.

Interobserver and intraobserver reliability of the modified Waldenström classification system for staging of Legg-Calvé-Perthes disease.

BACKGROUND: The absence of a reliable classification system for Legg-Calvé-Perthes disease has contributed to difficulty in establishing consistent management strategies and in interpreting outcome studies. The purpose of this study was to assess interobserver and intraobserver reliability of the modified Waldenström classification system among a large and diverse group of pediatric orthopaedic surgeons. METHODS: Twenty surgeons independently completed the first two rounds of staging: two assessments of forty deidentified radiographs of patients with Legg-Calvé-Perthes disease in various stages. Ten of the twenty surgeons completed another two rounds of staging after the addition of a second pair of radiographs in sequence. Kappa values were calculated within and between each of the rounds. RESULTS: Interobserver kappa values for the classification for surveys 1, 2, 3, and 4 were 0.81, 0.82, 0.76, and 0.80, respectively (with 0.61 to 0.80 considered substantial agreement and 0.81 to 1.0, nearly perfect agreement). Intraobserver agreement for the classification was an average of 0.88 (range, 0.77 to 0.96) between surveys 1 and 2 and an average of 0.87 (range, 0.81 to 0.94) between surveys 3 and 4. CONCLUSIONS: The modified Waldenström classification system for staging of Legg-Calvé-Perthes disease demonstrated substantial to almost perfect agreement between and within observers across multiple rounds of study. In doing so, the results of this study provide a foundation for future validation studies, in which the classification stage will be associated with clinical outcomes.

Pediatric surgeons and anesthesiologists expand the dialogue on the neurotoxicity question, rationale for early and delayed surgeries, and practice changes while awaiting definitive evidence.

The Pediatric Anesthesia NeuroDevelopment Assessment team at Columbia University Medical Center Department of Anesthesiology convened its fourth biennial Symposium to address unresolved issues concerning potential neurotoxic effects of anesthetic agents and sedatives on young children and to assess study findings to date. Dialogue initiated at the third Symposium was continued between anesthesiologists, researchers, and a panel of expert pediatric surgeons representing general surgery and dermatology, orthopedic, and urology specialties. The panel explored the need to balance benefits of early surgery using improved technologies against potential anesthetic risks, practice changes while awaiting definitive answers, and importance of continued interprofessional dialogue.

The effect of rod diameter on correction of adolescent idiopathic scoliosis at two years follow-up.

STUDY DESIGN: The review of multicenter national pediatric scoliosis database. OBJECTIVE: The purpose of this study was to compare the radiographic outcomes of patients who underwent scoliosis surgery utilizing different rod diameter constructs by the posterior approach. BACKGROUND: Little attention has specifically been focused on the effect of rod diameter on correction of spinal deformity after posterior spinal instrumentation and fusion in children with adolescent idiopathic scoliosis (AIS). METHODS: The review of national database comprised of 1125 patients, of which 352 patients had a minimum follow-up of 2 years. Of these, 163 patients received 5.5 mm and 189 patients received 6.35 mm diameter rods for posterior spinal instrumentation. RESULTS: The 6.35 mm rods were used more often for patients who were male, taller, heavier, with larger coronal curves, and more flexible curves. Larger diameter rods were also more likely to be stainless steel, implanted with an increased number of implants per level, and an increased number of pedicle screws used on the concavity of the curve. Univariate analysis of coronal curve showed a significant difference between 5.5 and 6.35 mm rods in correction (67.0% vs. 57.3%) at 2 years. Multivariate analysis revealed that the most significant factors affecting coronal curve correction at 2 years were rod diameter, the patient's preoperative coronal major curve and flexibility, and the implant density. In the sagittal plane, preoperative sagittal curve and rod diameter are the predictors of sagittal correction at 2 years. CONCLUSIONS: The study did not support our hypothesis that larger rods would be associated with a greater correction of frontal and sagittal plane in patients with AIS. In addition to rod diameter, implant density and the inherent flexibility and deformity of the patient were found to be influential factors contributing for the correction and maintenance of coronal and sagittal curves in AIS.

Reduction in upper-extremity tone after lumbar selective dorsal rhizotomy in children with spastic cerebral palsy.

OBJECT: Randomized clinical trials have established that lumbar selective dorsal rhizotomy (SDR) reduces lower-extremity tone and improves functional outcome in children with spastic cerebral palsy. Significant data exist to support a secondary effect on upper-extremity function in patients with upper-extremity spasticity. The effects of SDR on upper-extremity tone, however, are not well characterized. In this report, the authors sought to assess changes in upper-extremity tone in individual muscle groups after SDR and tried to determine if these changes could be predicted preoperatively. METHODS: The authors retrospectively reviewed 42 children who underwent SDR at Columbia University Medical Center/Morgan Stanley Children's Hospital of NewYork-Presbyterian between 2005 and 2011. Twenty-five had upper-extremity spasticity. All underwent pre- and postoperative examination for measuring tone (Modified Ashworth Scale) and assessing functional outcome. Follow-up examinations with therapists were performed at least once at a minimum of 2 months postoperatively (mean 15 months). RESULTS: In the upper extremities, 23 (92%) of 25 patients had improvements of at least 1 Ashworth point in 2 or more independent motor groups on the Modified Ashworth Scale, and 12 (71%) of 17 families surveyed reported increases in motor control or spontaneous movement. The mean Modified Ashworth Scale scores for all upper-extremity muscle groups demonstrated an improvement from 1.34 to 1.22 (p < 0.001). Patients with a mean preoperative upper-extremity tone of 1.25-1.75 were most likely to benefit from reduction in tone (p = 0.0019). Proximal and pronator muscle groups were most likely to demonstrate reduced tone. CONCLUSIONS: In addition to improvements in lower-extremity tone and function, SDR has demonstrable effects on upper extremities. Greater than 90% of our patients with elevated upper-extremity tone demonstrated reduction in tone in at least 2 muscle groups postoperatively. Patients with a mean Modified Ashworth Scale upper-extremity score of 1.25-1.75 may encounter the greatest reduction in upper-extremity tone.

Are Breech Rates for Pedicle Screws Higher in the Upper Thoracic Spine?

STUDY DESIGN: A case-control study. OBJECTIVES: To evaluate pedicle screw placement in pediatric patients with various etiologies of scoliosis, and to identify predictors of misplacement. SUMMARY OF BACKGROUND DATA: Accuracy of placement of pedicle screws has not been well documented for posterior spinal instrumentation and fusion performed in the non-idiopathic population. METHODS: A total of 54 patients (29 idiopathic, 16 neuromuscular, and 9 congenital/syndromic scoliosis), ages 5-19 years, were included. Computed tomography scans were obtained on patients postoperatively to assess screw position. Three pediatric orthopedic surgeons evaluated screw placement, and risk factors for misplacement were examined. RESULTS: Of 1,042 pedicle screws, 8.3% were misplaced. Among all etiologies, screws placed at T1 (28.6%) and T2 (18.2%) had higher misplacement rates. T2 screws and curve correction greater than 75% had higher misplacement rates in congenital/syndromic patients; screws at T3, screws at upper end of construct, and proximal screws had significantly higher misplacement rates in neuromuscular patients; and no variables predicted misplacement in idiopathics. Screws placed at the most proximal end of the screw/rod construct also had a higher misplacement rate (14.1%) compared with all remaining levels (7.8%). Nonidiopathic patients had higher anterior misplacement compared with idiopathic. No screws were removed or revised, and no screw-related complications were observed. CONCLUSIONS: Pedicle screw instrumentation in the thoracolumbar spine was safe for pediatric patients. We found that pedicle screws placed at top levels are at higher risk for misplacement among all pediatric scoliosis patients. Nonidiopathic patients are at higher risk for anterior screw misplacement, and the predictive effect of vertebral level is more profound in nonidiopathic patients. Because of these findings, we routinely use fluoroscopic guidance for the placement of T1 and T2 screws, and screws at the proximal end of construct.