Evidence-based treatment of Achilles tendon rupture.

The treatment of Achilles tendon rupture has recently seen a shift toward non-operative management, as supported by the literature, yet many surgeons continue to treat these injuries operatively. The evidence clearly supports non-operative management of these injuries except for Achilles insertional tears and for certain patient groups, such as athletic patients, for whom further research is warranted. This nonadherence to evidence-based treatment may be explained by patient preference, surgeon subspecialty, surgeon era of practice or other variables. Further research to understand the reasons behind this nonadherence would help to promote conformity in the surgical community across all specialties and adherence to evidence-based approaches.

Validation of the Critical-Care Pain Observation Tool (CPOT) in pediatric patients undergoing orthopedic surgery.

Background: Postoperative pain cannot be measured accurately among many children with intellectual and developmental disabilities, resulting in underrecognition or delay in recognition of pain. The Critical-Care Pain Observation Tool (CPOT) is a pain assessment tool that has been widely validated in critically ill and postoperative adults. Aims: The objective of this study was to validate the CPOT for use with pediatric patients able to self-report and undergoing posterior spinal fusion surgery. Methods: Twenty-four patients (10-18 years old) scheduled to undergo surgery were consented to this repeated-measure, within-subject study. To examine discriminative and criterion validation, CPOT scores and patients' self-reports of pain intensity were collected prospectively by a bedside rater before, during, and after a nonnociceptive and nociceptive procedure on the day following surgery. Patients' behavioral reactions were video recorded at the bedside and retrospectively viewed by two independent video raters to examine interrater and intrarater reliability of CPOT scores. Results: Discriminative validation was supported with higher CPOT scores during the nociceptive procedure than during the nonnociceptive procedure. Criterion validation was supported with a moderate positive correlation between the CPOT scores and the patients' self-reported pain intensity during the nociceptive procedure. A CPOT cutoff score of ≥2 was associated with the maximum sensitivity (61.3%) and specificity (94.1%). Reliability analyses revealed poor to moderate agreement between bedside and video raters and moderate to excellent consistency within video raters. Conclusions: These findings suggest that the CPOT may be a valid tool to detect pain in pediatric patients in the acute postoperative inpatient care unit after posterior spinal fusion.

Contexte: La douleur postopératoire ne peut pas être mesurée avec précision chez de nombreux enfants atteints de déficience intellectuelle et développementale, entraînant ainsi une méconnaissance ou un retard dans la reconnaissance de la douleur. Le Critical-Care Pain Observation Tool (CPOT) est un outil d'évaluation de la douleur qui a été largement validé chez les adultes gravement malades et postopératoires.Objectifs: L'objectif de cette étude était de valider le CPOT pour une utilisation auprès de patients pédiatriques capables d'autoévaluation et subissant une chirurgie de fusion vertébrale postérieure.Méthodes: Dans le cadre d'une étude intra-sujet, un consentement à cette mesure répétée a été obtenu pour vingt-quatre patients (10­18 ans) devant subir une intervention chirurgicale. Pour examiner la validation discriminante et de critère, les scores CPOT et les autoévaluations des patients concernant l'intensité de la douleur ont été collectés de manière prospective par un évaluateur au chevet du patient avant, pendant et après une procédure non nociceptive et nociceptive le lendemain de la chirurgie. Les réactions comportementales des patients ont été enregistrées sur vidéo au chevet du patient et visionnées rétrospectivement par deux des évaluateurs vidéo indépendants pour examiner la fiabilité des scores CPOT inter-évaluateurs et intra-évaluateurs.Résultats: La validation discriminante a été confirmée par l'obtention de scores plus élevés à l'échelle CPOT pendant la procédure nociceptive que pendant la procédure non nociceptive. La validation de critère a été confirmée par une corrélation positive modérée entre les scores sur l'échelle CPOT et l'intensité de la douleur autoévaluée par les patients pendant la procédure nociceptive. Un score-seuil ≥ 2 sur l'échelle CPOT a été associé à la sensibilité et la spécificité maximales (61,3 % et 94,1 %, respectivement). Les analyses de fiabilité ont révélé une concordance faible à modérée entre les évaluateurs de chevet et les évaluateurs vidéo, et une cocordance modérée à excellente parmi les évaluateurs vidéo.Conclusions: Ces résultats indiquent que le CPOT peut être un outil valide pour détecter la douleur chez les enfants patients de l'unité de soins hospitaliers postopératoires aigus après une fusion rachidienne postérieure.

Scoliosis in osteogenesis imperfecta: results of posterior spinal fusion in 39 patients.

PURPOSE: To evaluate the outcomes of scoliosis corrective surgery in Osteogenesis Imperfecta (OI) patients with primarily pedicles screw fixation in terms of correcting and maintaining the correction of the spinal deformity, and to assess for several peri-operative parameters and complications associated with this surgical treatment. METHODS: Retrospective case series of 39 consecutive patients with OI treated surgically for scoliosis. The surgeries were performed between 2002 and 2020 by three different surgeons. All patients' medical peri-operative and post-operative charts were evaluated. Radiological assessment was performed by evaluation of the pre-operative, immediate post-operative and last follow-up plain radiographs. RESULTS: There were 20 females and 19 males included in this review with a mean age of 14 years (range, 6-20 years) at the time of surgery. The median follow-up time was 7.9 years. The mean pre-operative cobb angle (CA) of the major curve was 76.5 degrees (SD ± 18.9), decreasing to 42.6 (SD ± 17.4) in the long-term post-operative follow-up (P < 0.001). A total of 21 adverse events in 16 patients were noted. Only 4 patients required subsequent invasive surgical treatment or prolonged hospital stay. All other patients were treated conservatively with no lasting complication. CONCLUSION: Scoliosis surgical correction in OI patients seems to yield acceptable results, with maintained coronal plane surgical correction in the long-term follow-up. Even though a high peri-operative complications rate is observed in this series, there were no long-term sequelae or lasting complications. LEVEL OF EVIDENCE: Level IV, Case series.

Phenotyping Chronic Musculoskeletal Pain in Male and Female Adolescents: Psychosocial Profiles, Somatosensory Profiles and Pain Modulatory Profiles.

PURPOSE: A major limitation in treatment outcomes for chronic pain is the heterogeneity of the population. Therefore, a personalized approach to the assessment and treatment of children and adolescents with chronic pain conditions is needed. The objective of the study was to subgroup pediatric patients with chronic MSK pain that will be phenotypically different from each other based on their psychosocial profile, somatosensory function, and pain modulation. PATIENTS AND METHODS: This observational cohort study recruited 302 adolescents (10-18 years) with chronic musculoskeletal pain and 80 age-matched controls. After validated self-report questionnaires on psychosocial factors were completed, quantitative sensory tests (QST) and conditioned pain modulation (CPM) were performed. RESULTS: Three psychosocial subgroups were identified: adaptive pain (n=125), high pain dysfunctional (n=115), high somatic symptoms (n=62). Based on QST, four somatosensory profiles were observed: normal QST (n=155), thermal hyperalgesia (n=98), mechanical hyperalgesia (n=34) and sensory loss (n=15). Based on CPM and temporal summation of pain (TSP), four distinct groups were formed, dysfunctional central processing group (n=27) had suboptimal CPM and present TSP, dysfunctional inhibition group (n=136) had suboptimal CPM and absent TSP, facilitation group (n=18) had optimal CPM and present TSP, and functional central processing (n=112) had optimal CPM and absent TSP. A significant association between the psychosocial and somatosensory profiles. However, no association was observed between the psychosocial or somatosensory profiles and pain modulatory profiles. CONCLUSION: Our results provide evidence that adolescents with chronic musculoskeletal pain are a heterogenous population comprising subgroups that may reflect distinct mechanisms and may benefit from different treatment approaches. The combination of screening self-reported questionnaires, QST, and CPM facilitate subgrouping of adolescents with chronic MSK pain in the clinical context and may ultimately contribute to personalized therapy.

Risk of early complication following anterior vertebral body tethering for idiopathic scoliosis.

PURPOSE: The purpose of this study was to determine peri-operative morbidity associated with anterior vertebral body tethering (aVBT) for idiopathic scoliosis. METHOD: Of 175 patients treated with aVBT, 120 patients had 2 year follow up and were included in this study. Prospectively collected clinical and radiographic data was analyzed retrospectively. RESULTS: Pre-operatively, the mean patient age was 12.6 year (8.2-15.7 year), Risser 0-3, with main thoracic scoliosis 51.2° (40-70°). Immediately post-operative, scoliosis improved to 26.9° (6-53°; p < 0.05), at 1-year post-operative was 23.0° (- 11 to 50°; p < 0.01 vs immediate post-op) and at 2-year post-operative was 27.5° (- 5 to 52; p = 0.64 vs immediate post-op). Pre-operative T5-T12 kyphosis was 16.0° (- 23 to 52°), post-operative was 16.9° (- 7 to 44°), at 1-year was 17.5° (- 14 to 61°) and at 2-year was 17.0° (- 10 to 50°; p = 0.72 vs pre-op). All patients underwent thoracoscopic approach, EBL 200 ml (20-900 ml), surgical time 215.3 min (111-472 min), anesthesia time 303.5 min (207-480 min), ICU stay of 0.2 day (0-2 days), and post-operative hospital stay 4.5 days (2-9 days). During the in-hospital peri-operative period, there were no unplanned return to the operating room (UPROR) and there was a 0.8% rate of complication: one pneumothorax requiring reinsertion of chest tube. By 90 days post-operative, there was no UPROR and a 5% rate of complication. Five additional patients developed complications after discharge: one CSF leak treated with blood patch injection in the clinic and resolved, two pleural effusions requiring chest tubes, one superficial wound infection and one pneumonia treated with outpatient antibiotics. By 1-year post-op, there was a 1.7% rate of UPROR and 8.3% rate of complication. Four additional patients developed complications beyond 90 days: two upper limb paresthesia required outpatient medical management, one CSF leak which initially treated blood patch injection in the clinic initially which then required UPROR, and one compensatory lumbar curve add on that was treated with extension of the tether. By 2-years post-op, there was a 6.7% rate of UPROR and 15.8% rate of complication. 9 additional complications developed after 1 year. One curve progression, one keloid scar, one right leg weakness, 4 cable failures and 2 curve overcorrections. CONCLUSION: This large, multicenter series of aVBT demonstrated a 15.8% complication rate and a 6.7% UPROR rate at 2 year post-operatively. This early study during the learning curve of aVBT found higher rates of CSF leaks and overall complications than would be expected for PSFI at 1 year post-operatively and a higher rate of overall complications and of UPROR than would be expected for PSFI at 2 year post-operatively. As is common with new procedures, the complication rate may fall with further experience.

Musculoskeletal deformities after thoracic surgery in children: An observational long-term follow-up study.

PURPOSE: This study reports the incidence, severity, and predictors of musculoskeletal deformities (MD), including scoliosis and chest wall anomalies, following thoracic procedures in children. METHODS: Children younger than 14 years who had thoracic surgery between 1997 and 2012 and had no other predispositions to MD, underwent longitudinal follow-ups with dedicated musculoskeletal examination performed in an esophageal atresia, orthopedic, or research clinic. Incidence of MD was calculated, and logistic regression methods were used to determine independent predictors, including sex, gestational age, age at procedure, serratus anterior muscle division, and chest tube placement. RESULTS: The study cohort consisted of 104 patients followed for a median of 10.8 years (range 3-21). A total of 56 MD developed in 41 patients (39%), including scapular winging (24; 23%), scoliosis (17; 16%), and chest wall anomalies (15; 14%). The majority of MD were subclinical, with only 8 patients [8% (6 thoracotomies, 2 thoracoscopies)] requiring intervention. Among patients who underwent thoracotomies (93, 89%), serratus anterior muscle division was the only significant predictor of the development of MD [OR 8.9; 95% CI 2.8-32.6]. CONCLUSION: Musculoskeletal deformities develop in a significant proportion of children following thoracic surgery, but most are subclinical. A muscle-sparing technique decreases the incidence of these deformities. TYPE OF STUDY: Prospective Cohort Study. LEVEL OF EVIDENCE: Level II.

Accuracy of EOS Imaging Technology in Comparison to Computed Tomography in the Assessment of Vertebral Rotational Orientation in Instrumented Spines in Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective radiographic reliability study. OBJECTIVE: The aim of this study was to assess the validity of EOS 3D imaging technology in the determination of vertebral rotations in the spine of patients with previous instrumentation. SUMMARY OF BACKGROUND DATA: There is a lack of evidence on the accuracy of vertebral rotational measurement using EOS 3D morphological analysis in the instrumented spine. METHODS: A retrospective review of 31 patients with adolescent idiopathic scoliosis (AIS) who underwent instrumented fusion and postoperative computed tomography (CT) scans of the spine was performed. Vertebral rotations of the apex vertebra, the uppermost (UIV) and lowermost (LIV) instrumented vertebra, the noninstrumented vertebra one level cranial to the UIV (UIV + 1) and one level caudal to LIV (LIV + 1) were determined using EOS 3D reconstruction. The vertebral rotation was also measured using reformatted CT axial images. Relative vertebral rotational difference (VRD) were calculated for UIV to apex, UIV + 1 to apex, LIV to apex, LIV + 1 to apex, UIV to LIV and UIV + 1 to LIV + 1. Paired t tests were used to compare the VRD measured using the two different imagining modalities. For values where P > 0.05, the Bland-Altman plot was used to assess the agreement between the measures. Interclass correlation (ICC) was used to determine interobserver and intraobserver reliabilities of EOS and CT measurements. RESULTS: EOS analysis of relative VRD was found to be significantly different from that of CT for UIV to apex (P = 0.006) and UIV + 1 to apex (P = 0.003). No significant differences were found for LIV to apex (P = 0.06), LIV + 1 to apex (P = 0.06), UIV to LIV (P = 0.59) and UIV + 1 to LIV + 1 (P = 0.64). However, Bland-Altman plots showed that agreement was poor, and variance was beyond acceptable. ICC showed good interobserver and good to very good intraobserver reliability for EOS. CONCLUSION: EOS 3D morphological analysis of VRD in the instrumented levels of the spine demonstrated significant difference and unacceptable variance in comparison to CT measurement.Level of Evidence: 4.

Toll-like receptor involvement in adolescent scoliotic facet joint degeneration.

Facet joint osteoarthritis is prevalent in young patients with adolescent idiopathic scoliosis (AIS) and might contribute to back pain. Toll-like receptors (TLR) have been linked to cartilaginous tissue degeneration but their involvement in facet joint osteoarthritis in AIS patients is still unknown. We compared baseline gene expression levels of TLRs -1, -2, -4, and -6 in scoliotic and non-scoliotic chondrocytes and found higher expression levels in scoliotic chondrocytes with significantly higher TLR2 levels. Furthermore, TLR expression correlated strongly and significantly with inflammatory and catabolic markers in scoliotic but not in non-scoliotic chondrocytes. TLR activation with a synthetic TLR2/6 agonist resulted in a robust induction and release of pro-inflammatory and catabolic factors which exacerbated proteoglycan loss in scoliotic but not in non-scoliotic cartilage. We also detected a higher abundance of alarmins including S100A8/9 and biglycan in scoliotic cartilage. Finally, the small-molecule antagonists Sparstolonin B and o-Vanillin reduced catabolism following induction with naturally occurring alarmins and the synthetic TLR2/6 agonist. The high baseline expression, robust responsiveness and strong and significant correlation with proteases and pro-inflammatory cytokines suggest that TLRs are key regulators of facet joint degeneration in AIS. Blocking their activity could therefore potentially modify disease progression.

Adolescent idiopathic scoliosis: evaluating perioperative back pain through a simultaneous morphological and biomechanical approach.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) has been associated with diminished postural stability and a greater prevalence of back pain. Currently, the literature is lacking information on the effect of spinal fusion on both postural stability and its association with back pain. Our objectives were to evaluate the postsurgical effect of spinal morphological changes on static standing balance and assess the influence of these alterations on reported pain throughout the perioperative period. METHODS: Twenty consecutive AIS patients schedule to undergo spinal fusion surgery were recruited and followed prospectively at the Shriners Hospitals for Children-Canada. Data was collected at the preoperative, 6 weeks and 6 months postoperative visits. Spinal morphology data was collected through 3D reconstructed simultaneous standing biplanar radiographs using the SterEOS software. Postural balance was assessed through Moticon© sensor insoles and analyzed through their software. The data was simultaneously collected as part of the Global Biomechanical and morphological Assessment. Pain was evaluated through self-reported questionnaires. RESULTS: Morphological curve parameters were significantly reduced after surgery. Balance parameters did not change significantly throughout the perioperative period with the exception of the Center of Pressure of the left foot medial/lateral transient shift (P = 0.017) at 6 weeks. Of note, preoperative balance parameters were associated with the degree of right thoracic Cobb angles (P = 0.029 R = 0.528). Pain scores significantly improved 6 weeks and 6 months after the surgery. Pain intensity diminished in the thoracic and lumbar spine but worsen in the neck region at the 6 weeks and 6 months postoperative time points (P = 0.044). Greater residual Cobb angle difference between Mid thoracic and Thoracolumbar/Lumbar curves was associated with greater pain severity at 6 weeks postop (P < 0.005). In addition, greater residual thoracic deformity was associated with significant pain severity 6 months after surgery (P < 0.05). CONCLUSIONS: Improved spinal morphology of postsurgical AIS patients has no significant impact on their static standing balance. Suggesting that other factors apart from the spinal morphology may contribute to AIS patients' balance during stance. Although balance did not influence pain severity, spinal morphology and its correction appear to have influenced the intensity and location of back pain.

Management of common elective paediatric orthopaedic conditions during the COVID-19 pandemic: the Montreal experience.

PURPOSE: To explore safe delays for the treatment of common paediatric orthopaedic conditions when faced with a life-threatening pandemic, COVID-19, and to propose a categorization system to address this question. METHODS: Review of the literature related to acceptable delays for treatment of common orthopaedic conditions, experience of healthcare professionals from low resource communities and expertise of experienced surgeons. RESULTS: Guidelines for the management of cancellations of elective surgeries during a period of resource reallocation are proposed. Elective cases must not be postponed indefinitely as adverse outcomes may result. Triage of waiting lists should include continuous monitoring of the patient and close communication with families despite social distancing and travel restrictions. Telehealth becomes a necessity. Common orthopaedic conditions are triaged into four groups according to urgency and safe and acceptable delay. Categories proposed are Emergent (life and limb threatening conditions), Urgent (within seven days), Semi-elective (postponed for three months) and Elective (postponed for three to 12 months). In total, 25 common orthopaedic conditions are reviewed and categorized. CONCLUSION: Given the uncertainty within healthcare during a pandemic, it is necessary to determine acceptable delays for elective conditions. We report our experience in developing guidelines and propose categorizing elective cases into four categories, based on the length of delay. Telemedicine plays a key role in determining the gravity of each situation and hence the amount of delay. These guidelines will assist others dealing with elective cases in the midst of a crisis. This paper initiates a coordinated effort to develop a consensus statement on safe delays.Published without peer review.

Back pain in adolescents with idiopathic scoliosis: the contribution of morphological and psychological factors.

PURPOSE: To define the relationship between 3D radiological features, psychological factors, and back pain prevalence and intensity in patients with adolescent idiopathic scoliosis (AIS). METHODS: Consecutive AIS patients answered self-reported questionnaires and underwent simultaneous posterior-anterior and lateral scans of the spine (EOS Imaging, Paris, France). 3D reconstructions of the spine and pelvis reported 18 parameters in the coronal, sagittal, and axial plane. RESULTS: Hundred and twenty-four patients with AIS were included in the study. Overall, 90% of AIS patients reported having some back pain over the last 6 months and 85.8% over the last 30 days. Pain intensity in the last month was reported to be mild in 37.5%, moderate in 31.8%, moderate to severe in 24.3%, and severe in 6.54% of cases. Location of back pain was associated with location of main curve (P = 0.036). Low back pain was associated with higher lumbar apical AVR and lower lumbar lordosis (P < 0.05). Independent risk factors for back pain in AIS were pain catastrophizing (B = 0.061, P = 0.035), poorer self-reported state of mental health (B = - 0.872, P = 0.023), decreased thoracic kyphosis (B = - 0.033, P = 0.044) and greater pelvic asymmetry (B = 0.146, P = 0.047). There was a significant association between self-reported pain intensity in the last 24 h and levels of catastrophizing. Pain catastrophizing level influenced the relationship between deformity severity and pain intensity. In low catastrophizers, there was a significant association between greater deformity severity and higher pain levels. CONCLUSIONS: Back pain in AIS is multifactorial and associated with psychological and morphological parameters. Pain catastrophizing is an important construct in AIS-related pain and should be taken into consideration when evaluating these patients.

A novel growing rod technique to treat early-onset scoliosis (EOS): a step-by-step 2D surgical video.

Early-onset scoliosis (EOS) correction techniques have evolved slowly over the past 40 years and still remain a challenge for the spine surgeon. Avoiding spinal fusion in these patients is key to decreasing morbidity and mortality in this population. Current treatments for EOS include both conservative and surgical options. The authors present the modified Luqué technique that has been performed at their institution for the past decade. This modified technique relies on Luqué's principle, but with newer "gliding" implants through a less disruptive approach. The goal of this technique is to delay fusion as long as possible, with the intent to prevent deformity progression while preserving maximal growth. Normally, these patients will have definitive fusion surgery once they have reached skeletal maturity or as close as possible. Out of 23 patients until present (close to 4-year follow-up), the authors have not performed any revision due to implant failure. Three patients have undergone final fusion as the curve progressed (one patient, 4 years out, had final fusion at age 12 years; two other patients had final fusion at 3 years). These implants, which have the CE mark in Europe, are available in Canada via a special access process with Health Canada. The implants have not yet been submitted to the FDA, as they are waiting on clinical data out of Europe and Canada. In the following video the authors describe the modified Luqué technique step-by-step. The video can be found here: https://youtu.be/k0AuFa9lYXY.

Treatment of Femur Neck Fracture in Children with Osteogenesis Imperfecta: Two Case Reports.

CASE: We present 2 cases of femoral neck fracture (FNF) in patients with osteogenesis imperfecta (OI) with a previously placed intramedullary nail (IMN). Case 1: A 12-year-old girl who sustained a right FNF after spine surgery. Case 2: An 18-year-old boy who sustained a right FNF after IMN of the left side. Both patients underwent our modified surgical technique as described below. Both patients recovered well overall. CONCLUSIONS: FNF in patients with OI poses a significant challenge especially in the presence of an IMN. Here, we describe a surgical technique that provides stable fixation with a less stress riser effect by bypassing the screws and a previously placed nail.

Evidence of impaired pain modulation in adolescents with idiopathic scoliosis and chronic back pain.

BACKGROUND CONTEXT: Although 40% of adolescent idiopathic scoliosis (AIS) patients present with chronic back pain, the pathophysiology and underlying pain mechanisms remain poorly understood. We hypothesized that development of chronic pain syndrome in AIS is associated with alterations in pain modulatory mechanisms. PURPOSE: To identify the presence of sensitization in nociceptive pathways and to assess the efficacy of the diffuse noxious inhibitory control in patients with AIS presenting with chronic back pain. STUDY DESIGN: Cross-sectional study. PATIENT SAMPLE: Ninety-four patients diagnosed with AIS and chronic back pain. OUTCOME MEASURES: Quantitative sensory testing (QST) assessed pain modulation and self-reported questionnaires were used to assess pain burden and health-related quality of life. METHODS: Patients underwent a detailed pain assessment using a standard and validated quantitative sensory testing (QST) protocol. The measurements included mechanical detection thresholds (MDT), pain pressure threshold (PPT), heat pain threshold (HPT), heat tolerance threshold (HTT), and a conditioned pain modulation (CPM) paradigm. Altogether, these tests measured changes in regulation of the neurophysiology underlying the nociceptive processes based on the patient's pain perception. Funding was provided by The Louise and Alan Edwards Foundation and The Shriners Hospitals for Children. RESULTS: Efficient pain inhibitory response was observed in 51.1% of patients, while 21.3% and 27.7% had sub-optimal and inefficient CPM, respectively. Temporal summation of pain was observed in 11.7% of patients. Significant correlations were observed between deformity severity and pain pressure thresholds (p=.023) and CPM (p=.017), neuropathic pain scores and pain pressure thresholds (p=.015) and temporal summation of pain (p=.047), and heat temperature threshold and pain intensity (p=.048). CONCLUSIONS: Chronic back pain has an impact in the quality of life of adolescents with idiopathic scoliosis. We demonstrated a high prevalence of impaired pain modulation in this group. The association between deformity severity and somatosensory dysfunction may suggest that spinal deformity can be a trigger for abnormal neuroplastic changes in this population contributing to chronic pain syndrome.

Blood monoamines as potential biomarkers for conditioned pain modulation efficacy: An exploratory study in paediatrics.

BACKGROUND: Monoaminergic pathways are involved in the process of pain inhibition and facilitation. The objective of this study was to investigate the role of blood monoamines as biomarkers of conditioned pain modulation (CPM) efficacy. METHODS: One hundred and five paediatric patients with chronic back pain were enrolled in this observational study. The protocol involved dosage of plasma monoamines (dopamine, DOPA; serotonin, 5-HT; epinephrine, Epi; norepinephrine, NE; metanephrine, ME; and normetanephrine, NME) and clinical assessment (CPM, functional disability, pain, sleep quality, anxiety and depression). RESULTS: 5-HT and DOPA were positively correlated among each other and were both negatively correlated with Epi, ME, NE and NME. CPM presented a positive correlation with DOPA and 5-HT. On the other hand, Epi, ME, NE and NME correlated negatively with CPM. Different correlation coefficients were observed between genders, with stronger coefficients being observed in the male subpopulation. Stepwise regression controlling for age and gender indicated that ME (B = -0.987, SE(B) = 0.299, p = 0.002) was the only significant predictor for CPM efficacy. Higher blood ME was associated with poorer CPM efficacy. ME explained 53% of variation of CPM in males (R2  = 0.536, p < 0.0001) and 7% in females (R2  = 0.074, p = 0.014). In males, blood ME >15 pg/ml predicted inefficient CPM with 88.9% sensitivity and 83.3% specificity. CONCLUSIONS: Our findings suggest that ME can be a potential biomarker for CPM efficacy in paediatrics. Future studies are needed to assess the efficacy of tailored treatments for pain according to blood ME. SIGNIFICANCE: We were able to demonstrate an association between CPM and circulating monoamines. In the clinical setting, sampling ME could provide the clinician an idea of the individual's pain modulation potential. This may be particularly important for children with cognitive impairment, for whose CPM paradigm cannot be used.

Facet joint degeneration in adolescent idiopathic scoliosis.

Adolescent idiopathic scoliosis (AIS) is a poorly understood deformity of the thoracolumbar spine which affects the intervertebral discs (IVDs) and the articular facet joints. The knowledge concerning facet joints in this context is very limited, although facet joint degeneration is a known contributor of back pain. In this study, a comprehensive investigation was performed to characterize the facet joint chondrocytes and extracellular matrix within the scoliotic spine. Surgically removed articular facet joint tissues were collected from patients undergoing spinal corrective surgery for AIS deformities, while non-scoliotic articular facet joint tissues were obtained from cadaveric organ donors. Alterations in cartilage tissue structure were evaluated histologically with safranin-O fast green and a modified OARSI grading scale. Pro-inflammatory cytokines, matrix-degrading proteases, and fragmented matrix molecules associated with cartilage degradation were analyzed by immunohistochemistry and western blotting. Safranin-O fast green staining revealed that young scoliotic facet joints show clear signs of degeneration with substantial proteoglycan loss, similar to osteoarthritis (OA). The proteoglycan levels were significantly lower than in healthy asymptomatic non-scoliotic control individuals. In comparison to controls, scoliotic articular facets showed increased cell density, increased expression of the proliferation marker Ki-67, and higher expression of MMP-3, MMP-13, and IL-1ß. Expression and fragmentation of the small leucine-rich proteins (SLRPs) chondroadherin, decorin, biglycan, lumican, and fibromodulin were analyzed with western blot. Chondroadherin and decorin were fragmented in cartilage from patients with a curve greater than 70°, whereas biglycan and fibromodulin did not show curve-related fragmentation. AIS facet joint cartilage shows hallmarks of OA including proteoglycan loss, overexpression of pro-inflammatory mediators, increased synthesis of matrix-degrading proteases and fragmentation of SLRPs. As with patients with age-related OA, the premature joint degeneration seen in scoliotic patients is likely to contribute to the pain perceived in some individuals.

Combined pelvic and femoral reconstruction in children with cerebral palsy.

Objective The primary aim of this study was to determine the effect of age, femoral head migration, and ambulatory status on radiographic outcomes after combined pelvic and femoral reconstruction in children with cerebral palsy. The secondary aim was to evaluate the fate of the opposite hip after unilateral reconstruction. Methods A retrospective cohort study design of consecutive patients from 1995-2009 was used. The records were screened for patients who underwent varus derotational osteotomy and modified Dega osteotomy. Results Eighty-five hips in 71 patients were included. The mean age was 8.4 ± 3.2 years and the mean follow-up was 6.6 ± 3.1 years. The final measures were a mean migration index of 20% ± 15.58%, centre edge angle of 28.45° ± 15.98°, and Sharp's angle of 40.75° ± 8.5°. Those values were not correlated with age and the initial migration index. Nonambulatory status did not negatively affect hip stability. Final measurements of the contralateral hips were similar to the reconstructed hips, and the cumulative incidence for later reconstruction was 5.67%. Conclusions Regardless of age, preoperative displacement, and ambulation, the combined procedure provides durable radiographic improvement. In unilateral cases, there is a low risk of later deterioration of the opposite side.

Musculoskeletal deformities following neonatal thoracotomy: long-term follow-up of an esophageal atresia cohort.

BACKGROUND: Musculoskeletal deformities (MD), including scoliosis and chest wall anomalies, are potential long-term complications of neonatal thoracotomies. METHODS: We studied the incidence of MD in patients who underwent open repair of esophageal atresia between 1997 and 2012, had no other predisposition to MD, and subsequently received longitudinal follow-up in a multidisciplinary esophageal atresia clinic. Detailed chest wall and musculoskeletal exams were performed at each visit. Incident rate and incident rate ratios were used to determine the incidence of deformities. Logistic regression methods were used to test the effect of independent variables including sex, gestational age, muscle division, number of thoracotomies, and operative complications on the occurrence of MD. RESULTS: The study cohort consisted of 52 patients followed for a median of 8 (range 1-19) years. MD developed in 13 (25%), with an incident rate of 2.92 per 100 child-years. Division of the serratus anterior was associated with a significantly higher probability of developing MD (log-rank p=.0237) and was also a strong predictor of the same [OR 8.6 (95% CI 1.8-42.1)] after adjusting for possible confounders. CONCLUSIONS: Musculoskeletal deformities develop in a significant proportion of neonates following thoracotomy. A muscle-sparing technique decreases the incidence of these deformities. TYPE OF STUDY: Prospective Cohort Study. LEVEL OF EVIDENCE: II.

Preoperative Norepinephrine Levels in Cerebrospinal Fluid and Plasma Correlate With Pain Intensity After Pediatric Spine Surgery.

PURPOSE: Catecholamines were found to be involved in descending pain modulation and associated with perioperative pain. The purpose of the present study was to investigate the relationship between preoperative concentrations of catecholamines and postoperative pain intensity of pediatric patients. METHODS: Fifty adolescents with idiopathic scoliosis scheduled for elective spinal fusion surgery were enrolled in this prospective cohort study. Preoperative plasma and cerebrospinal fluid (CSF) samples were collected and analyzed by mass spectrometry. Pain intensity was assessed during the acute postoperative period and in the intermediate period. RESULTS: Preoperative plasma concentrations of norepinephrine (NE) and normetanephrine (NME), as well as the CSF concentration of NE, were significantly correlated with the presence of pain six weeks after surgery (r = 0.48, 0.50, and 0.50, respectively; p < .002). We also found that preoperative NE levels in CSF were significantly higher in patients reporting moderate to severe pain intensity than in patients with mild pain during the first day following surgery (0.268 ± 0.29 ng/mL vs. 0.121 ± 0.074 ng/mL, p = .01), as well as between patients reporting pain and painless patients at 6 weeks postsurgery (0.274 ± 0.282 ng/mL vs. 0.103 ± 0.046 ng/mL respectively, U = 69.5, p = .002). CONCLUSIONS: These results support the potential role of catecholamine levels in predicting postoperative pain intensity.