The first described case of Lodderomyces elongisporus meningitis.

We describe the first documented case of meningitis caused by Lodderomyces elongisporus. Identification of L. elongisporus was made on the basis of an arachnoid biopsy with pathology samples sent for fungal internal transcribed spacer sequencing after multiple central nervous system (CNS) fungal culture specimens were negative. After final diagnosis, treatment was transitioned from amphotericin to fluconazole, which, combined with insertion of lumbar drain followed by a permanent ventriculopleural shunt, resulted in significant clinical improvement. Our report reviews the literature of (1) cases of L. elongisporus, which almost exclusively describe fungemia or endocarditis; (2) CNS infections caused by Candida parapsilosis, an organism with which L. elongisporus was previously conflated; and (3) management of fungal meningitis-associated hydrocephalus.

Les chercheurs décrivent le premier cas répertorié de méningite causée par le Lodderomyces elongisporus. Ils ont dépisté le L. elongisporus après avoir effectué une biopsie de l'arachnoïde et envoyé les prélèvements pathologiques au séquençage de l'espaceur transcrit interne fongique après l'obtention de multiples cultures fongiques négatives. Après le diagnostic définitif, le traitement d'amphotéricine a été remplacé par du fluconazole qui, combiné à l'insertion d'un drain lombaire suivie par l'installation d'une dérivation ventriculopleurale permanente, a favorisé une amélioration clinique évidente. L'analyse bibliographique a permis d'extraire 1) des cas de L. elongisporus, qui ont été observés presque exclusivement dans des cas de fongémie auparavant, 2) des infections du système nerveux central causées par le Candida parapsilosis, un organisme avec lequel le L. elongisporus a déjà été confondu et 3) la prise en charge de l'hydrocéphalie associée à la méningite fongique.

Factors Affecting Length of Stay Following 3-Column Spinal Osteotomies in Pediatric Patients.

STUDY DESIGN: A retrospective analysis. OBJECTIVES: Length of stay (LOS) is one of the important indicators for the quality of patient care. Although perioperative complications are known to be associated with longer LOS in general, little has been understood regarding LOS after 3-column spinal osteotomy for the rigid spinal deformity in pediatric population. The main objective of the article is to identify factors affecting the LOS in pediatric patients undergoing 3-column posterior spinal osteotomies. METHODS: Following research ethics approval, a retrospective review was performed of 35 consecutive posterior 3-column spinal osteotomies performed on pediatric patients in a single academic institution. Patients' demographic data, preoperative comorbidities, details of operative procedures, intraoperative complications, and postoperative complications were investigated, and LOS was compared among the groups. RESULTS: The mean LOS was 9.0 days, and the median LOS was 7 days (range = 4-23 days). Low body weight and syndromic deformity were associated with longer LOS. Operation time ≥6 hours and total perioperative fluid administration greater than or equal to twice the estimated blood volume were associated with longer LOS. Among postoperative complications, those with respiratory complication had prolonged stay. CONCLUSIONS: Preoperative low body weight and syndromic scoliosis had longer LOS after 3-column osteotomies. Excessive fluid administration and respiratory complications were associated with longer LOS.

The prevalence of pathological findings identified by next day abdominal ultrasound in patients discharged from the emergency department.

OBJECTIVE: A common strategy for managing emergency department (ED) patients with low-risk abdominal pain is to discharge them home and arrange for next day outpatient ultrasound for further assessment. The objective was to determine the proportion of outpatient ultrasounds with findings requiring intervention within 14 days. METHODS: This was a retrospective chart review of non-pregnant patients ages 18 to 40 years, presenting to an academic ED (annual census 65,000) with an abdominal complaint for whom the emergency physician arranged an outpatient (next day) abdominal ultrasound. RESULTS: Of the 299 included patients, 252 (84.3%) were female and mean (SD) age was 28.4 (6.0) years. Twenty-three (7.7%) patients had ultrasounds requiring intervention within 14 days of imaging. Of these, eight (34.8%) had appendicitis, five (21.7%) had cholecystitis, four (17.4%) had urological pathology, three (13.0%) had gynecological pathology, and three (13.0%) had gastrointestinal diagnoses. Of note, 14 (60.9%) patients requiring follow-up or intervention within 14 days had symptoms that improved or resolved at the time of the outpatient ultrasound. For the 277 (92.6%) patients not requiring intervention, 117 (42.2%) had improved, 89 (32.1%) were unchanged, 50 (18.1%) had resolved, and 5 (1.8%) had worsened symptoms at the time of the follow-up ultrasound. Of the non-intervention patients, 13 (4.7%) went on to have alternative imaging, including magnetic resonance imaging, computed tomography, and a sonohysterogram. CONCLUSIONS: Next-day ultrasound imaging remains a good way of identifying patients with serious pathology not appreciated at the time of their ED visit.

OBJECTIF: L'une des conduites souvent tenues devant les douleurs abdominales à faible risque au service des urgences (SU) est de retourner les patients à domicile et de fixer un rendez-vous à la clinique externe pour une échographie d'évaluation à effectuer le lendemain. L'étude visait donc à déterminer la proportion de patients soumis à une échographie en consultation externe, qui ont dû subir une intervention dans les 14 jours suivants. MÉTHODE: Il s'agit d'un examen rétrospectif de dossiers de patients et de patientes non enceintes, âgés de 18 à 40 ans, ayant consulté dans un SU d'hôpital d'enseignement (65 000 selon le recensement annuel) pour des douleurs abdominales qui ont motivé l'urgentologue à fixer un rendez-vous à la clinique externe (le lendemain) pour une échographie abdominale. RÉSULTATS: Au total, 299 patients ont été retenus, dont 252 femmes (84,3%), et l'âge moyen (écart type) était de 28,4 ans (6,0). Parmi ceux qui ont été soumis à une échographie, 23 patients (7,7%) ont dû subir une intervention au cours des 14 jours suivant l'examen par imagerie. Sur ce nombre, 8 (34,8%) souffraient d'appendicite, 5 (21,7%), de cholécystite; 4 (17,4%), de troubles urinaires; 3 (13,0%), de troubles gynécologiques; et 3 (13,0%) de troubles gastro-intestinaux. Point à souligner, chez 14 patients (60,9%) qui ont eu besoin d'un suivi ou d'une intervention dans les 14 jours suivants, les symptômes s'étaient atténués ou avaient disparu complètement au moment de l'échographie en consultation externe. Chez les 277 autres patients (92,6%) qui n'ont pas eu à subir d'intervention, 117 (42,2%) ont vu leurs symptômes diminuer; 89 (32,1%), rester inchangés; 50 (18,1%), disparaître; et 5 (1,8%) s'intensifier au moment de l'échographie de suivi. Parmi ceux qui n'ont pas subi d'intervention, 13 (4,7%) ont été soumis à d'autres examens par imagerie, notamment à un examen par résonance magnétique, à une tomodensitométrie ou à une échographie utérine. CONCLUSION: Une échographie effectuée le lendemain demeure une bonne conduite à tenir devant des manifestations pathologiques sérieuses mais non reconnues au moment de la consultation au SU.

Evaluation of a Web-based Educational Program to Teach the Identification and Management of Alcohol Withdrawal in the Emergency Department.

BACKGROUND: Ideal management of alcohol withdrawal syndrome (AWS) incorporates a symptom-driven approach, where patients are regularly assessed using a standardized scoring system (Clinical Institute Withdrawal Assessment for Alcohol-Revised [CIWA-Ar]) and treated according to severity. Accurate administration of the CIWA-Ar requires experience, yet there is no training program to teach this competency. The objective of this study was to develop and evaluate a curriculum to teach clinicians how to accurately assess and treat AWS. METHODS: This was a three-phase education program consisting of a series of e-learning modules containing core competency material, an in-person seminar to orient learners to high-fidelity simulation, and a summative evaluation in an objective structured clinical examination setting using a standardized patient. To determine the impact of the AWS curriculum, we recorded how often the CIWA-Ar was appropriately applied in the emergency department (ED) before and after training. A CIWA-Ar protocol breach was defined as inappropriate administration of benzodiazepines (CIWA-Ar < 10) and failure to administer benzodiazepines when required (CIWA-Ar ≥ 10). ED length of stay, amount of benzodiazepines administered in the ED, discharge prescriptions, and unit doses (take-away bottle of four tablets) of benzodiazepine given were recorded. RESULTS: Seventy-four ED nurses completed the curriculum over an 8-week period. In the 5 months prior to the educational program delivery, we identified 144 of 565 (25.5%) CIWA-Ar protocol breaches, compared to 64 of 547 (11.7%) in the 5 months after training (∆13.8%, 95% confidence interval [CI] = 9.3%-18.3%). Program completion resulted in a reduction in the median total dose of diazepam administered in the ED (40 mg vs. 30 mg, ∆10 mg, 95% CI = 0-20 mg) and no change was detected in ED length of stay and benzodiazepines prescribed. CONCLUSIONS: Completion of this curriculum resulted in better compliance with the CIWA-Ar protocol by those who administer the CIWA-Ar; however, changes in inappropriate benzodiazepine prescribing practice will require future interdisciplinary initiatives.

Risk Factors for Postoperative Coronal Balance in Adult Spinal Deformity Surgery.

STUDY DESIGN: A retrospective case-control study. OBJECTIVES: To determine factors influencing the ability to achieve coronal balance following spinal deformity surgery. METHODS: Following institutional ethics approval, the radiographs of 47 patients treated for spinal deformity surgery with long fusions to the pelvis, were retrospectively reviewed. The postoperative measurements included coronal balance, L4 tilt, and L5 tilt, levels fused, apical vertebral translation and maximum Cobb angle. L4 and L5 tilt angles were measured between the superior endplate and the horizontal. Sagittal parameters including thoracic kyphosis, lumbar lordosis, pelvic incidence, and sagittal vertical axis were recorded. Coronal balance was defined as the distance between the central sacral line and the mid body of C7 being ≤40 mm. Surgical factors, including levels fused, use of iliac fixation with and without connectors, use of S2A1 screws, interbody devices, and osteotomies. Statistical tests were performed to determine factors that contribute to postoperative coronal imbalance. RESULTS: Of the 47 patients reviewed, 32 were balanced after surgery and 14 were imbalanced. Coronal balance was 1.30 cm from center in the balanced group compared to 4.83 cm in the imbalanced group (P < .01). Both L4 and L5 tilt were statistically different between the groups. Gender and the use of transverse connectors differed between the groups but not statistically. CONCLUSIONS: In adult spinal deformity patients undergoing primary fusions to the pelvis, the ability to level the coronal tilt of L4 and L5 had the greatest impact on the ability to achieve coronal balance in this small series. A larger prospective series can help validate this important finding.

Cognitive Rest and Graduated Return to Usual Activities Versus Usual Care for Mild Traumatic Brain Injury: A Randomized Controlled Trial of Emergency Department Discharge Instructions.

OBJECTIVES: It is estimated that 15%-25% of patients with a mild traumatic brain injury (MTBI) diagnosed in the emergency department (ED) will develop postconcussive syndrome. The objective of this study was to determine if patients randomized to graduated return to usual activity discharge instructions had a decrease in their Post-Concussion Symptom Score (PCSS) 2 weeks after MTBI compared to patients who received usual care MTBI discharge instructions. METHODS: This was a pragmatic, randomized trial of adult (18-64 years) patients of an academic ED (annual census 60,000) diagnosed with MTBI occurring within 24 hours of ED visit. The intervention group received cognitive rest and graduated return to usual activity discharge instructions, and the control group received usual care discharge instructions that did not instruct cognitive rest or graduated return. Patients were contacted by text message or phone 2 and 4 weeks post-ED discharge and asked to complete the PCSS, a validated, 22-item questionnaire, to determine if there was a change in their symptoms. Secondary outcomes included change in PCSS at 4 weeks, number follow-up physician visits, and time off work/school. RESULTS: A total of 118 patients were enrolled in the study (58 in the control group and 60 in the intervention). The mean (±SD) age was 35.2 (±13.7) years and 43 (36.4%) were male. There was no difference with respect to change in PCSS at 2 weeks (10.5 vs. 12.8; ∆2.3, 95% confidence interval [CI] = 7.0 to 11.7) and 4 weeks post-ED discharge (21.1 vs 18.3; ∆2.8, 95% CI = 6.9 to 12.7) for the intervention and control groups, respectively. The number of follow-up physician visits and time off work/school were similar when the groups were compared. Thirty-eight (42.2%) and 23 (30.3%) of patients in this cohort had ongoing MTBI symptoms (PCSS > 20) at 2 and 4 weeks, respectively. CONCLUSIONS: Results from this study suggest graduated return to usual activity discharge instructions do not impact rate of resolution of MTBI symptoms 2 weeks after ED discharge. Given that patients continue to experience symptoms 2 and 4 weeks after MTBI, more investigation is needed to determine how best to counsel and treat patients with postconcussive symptoms.

T12 Sagittal Tilt Predicts Thoracic Kyphosis.

STUDY DESIGN: Retrospective review and analysis of lateral long cassette radiographs. OBJECTIVE: The purpose of this paper is to assess whether certain radiographic features routinely seen on lumbar radiographs can predict a structural thoracic deformity. SUMMARY OF BACKGROUND DATA: Obtaining proper sagittal alignment is an essential factor contributing to favorable clinical outcomes following spinal deformity surgery. The majority of patients treated with lumbar fusions do not undergo long cassette radiographs, and therefore physicians must rely upon clinical examination to determine the presence of a structural thoracic kyphotic deformity. METHODS: A total of 193 consecutive lateral long cassette radiographs of outpatients without prior spine surgery presenting to a spine surgeon were independently reviewed. Statistical analysis was performed on sagittal parameters that included the T12 slope, pelvic incidence, sacral slope, T2-T12 and T5-T12 kyphosis, and T12-S1 lordosis, and correlated with patient demographics. RESULTS: The age of the patient combined with the sagittal slope of T12 can be used to assess a patient's risk of having a structural thoracic deformity defined in this series as >35 degrees from T5 to T12 and >40 degrees from T2 to T12. Based on our findings, for a given 20-year-old patient, the threshold T12 sagittal angle was about 17-18 degrees. This angle decreased 2-3 degrees per decade so that the threshold value was 12-13 degrees by age 40, 7-9 degrees by age 60, and 3-4 degrees by age 80. CONCLUSION: Age and the sagittal slope of the 12th thoracic vertebra are effective predictors of kyphosis between T2-T12 and T5-T12. This information may be used to determine the need for long cassette radiographs to further examine the possible presence of kyphotic deformity in the thoracic spine. LEVEL OF EVIDENCE: Level IV.

The Deformity Angular Ratio: Does It Correlate With High-Risk Cases for Potential Spinal Cord Monitoring Alerts in Pediatric 3-Column Thoracic Spinal Deformity Corrective Surgery?

STUDY DESIGN: A retrospective analysis. OBJECTIVE: The purpose of this study was to determine whether the deformity angular ratio (DAR) can reliably assess the neurological risks of patients undergoing deformity correction. SUMMARY OF BACKGROUND DATA: Identifying high-risk patients and procedures can help ensure that appropriate measures are taken to minimize neurological complications during spinal deformity corrections. Subjectively, surgeons look at radiographs and evaluate the riskiness of the procedure. However, 2 curves of similar magnitude and location can have significantly different risks of neurological deficit during surgery. Whether the curve spans many levels or just a few can significantly influence surgical strategies. Lenke et al have proposed the DAR, which is a measure of curve magnitude per level of deformity. METHODS: The data from 35 pediatric spinal deformity correction procedures with thoracic 3-column osteotomies were reviewed. Measurements from preoperative radiographs were used to calculate the DAR. Binary logistic regression was used to model the relationship between DARs (independent variables) and presence or absence of an intraoperative alert (dependent variable). RESULTS: In patients undergoing 3-column osteotomies, sagittal curve magnitude and total curve magnitude were associated with increased incidence of transcranial motor evoked potential changes. Total DAR greater than 45° per level and sagittal DAR greater than 22° per level were associated with a 75% incidence of a motor evoked potential alert, with the incidence increasing to 90% with sagittal DAR of 28° per level. CONCLUSION: In patients undergoing 3-column osteotomies for severe spinal deformities, the DAR was predictive of patients developing intraoperative motor evoked potential alerts. Identifying accurate radiographical, patient, and procedural risk factors in the correction of severe deformities can help prepare the surgical team to improve safety and outcomes when carrying out complex spinal corrections. LEVEL OF EVIDENCE: 3.

A quantitative evaluation of alcohol withdrawal tremors.

This paper evaluates the relation between Alcohol Withdrawal Syndrome tremors in the left and right hands of patients. By analyzing 122 recordings from 61 patients in emergency departments, we found a weak relationship between the left and right hand tremor frequencies (correlation coefficient of 0.63). We found a much stronger relationship between the expert physician tremor ratings (on CIWA-Ar 0-7 scale) of the two hands, with a correlation coefficient of 0.923. Next, using a smartphone to collect the tremor data and using a previously developed model for obtaining estimated tremor ratings, we also found a strong correlation (correlation coefficient of 0.852) between the estimates of each hand. Finally, we evaluated different methods of combining the data from the two hands for obtaining a single tremor rating estimate, and found that simply averaging the tremor ratings of the two hands results in the lowest tremor estimate error (an RMSE of 0.977). Looking at the frequency dependence of this error, we found that higher frequency tremors had a much lower estimation error (an RMSE of 1.102 for tremors with frequencies in the 3-6Hz range as compared to 0.625 for tremors with frequencies in the 7-10Hz range).

Comparison of pedicle subtraction and Smith-Petersen osteotomies in correcting thoracic kyphosis when closed with a central hook-rod construct.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: To demonstrate the effectiveness of hook-rod constructs in closing thoracic osteotomies safely and effectively. SUMMARY OF BACKGROUND DATA: The outcomes of hook-rod instrumentation in osteotomies for the correction of kyphosis at the lumbar region of the spine have been described. Little literature exists on the outcomes at the thoracic level. METHODS: The radiographs and clinical scores of 38 patients who underwent pedicle subtraction osteotomy or Smith-Petersen osteotomy in the thoracic spine with the osteotomies closed using a central rod were retrospectively reviewed. Measurements included osteotomy angle, thoracic kyphosis (T2-T12), and maximum kyphosis. Perioperative and long-term complications were reviewed. RESULTS: Thirty-eight patients underwent thoracic level osteotomies. There were 8 males and 30 females with a mean age of 51.9 years (range, 18-76 yr) at the time of surgery. The mean construct length was 13.2 levels (4-25). Kyphosis correction was equal in the 2 groups. In the pedicle subtraction osteotomy group, a mean of 24.7° (4°-47°) correction was obtained through the osteotomies compared with 24.0° (9°-65°) in the Smith-Petersen osteotomy group. Correction per osteotomy was 23.7° (4°-47°) in the pedicle subtraction osteotomy group compared with 11.8° (2.8°-46.0°) in the Smith-Petersen osteotomy group. No difference in the amount of correction achieved at the different regions of the thoracic spine was observed with either type of osteotomy with central rod closure. CONCLUSION: Central hook-rod constructs provide a safe and effective means of closing thoracic osteotomies and result in good correction of rigid sagittal plane deformities. LEVEL OF EVIDENCE: 4.

Modified T4 hemivertebrectomy for persistent high left shoulder after surgery for double thoracic scoliosis.

STUDY DESIGN: Case report. OBJECTIVE: To surgically regain shoulder balance in patients with adolescent idiopathic scoliosis after loss of alignment after posterior fusion for Lenke II deformity correction. SUMMARY OF BACKGROUND DATA: Shoulder balance is known to have a large effect on patient satisfaction after deformity correction. Previous studies have outlined guidelines for determining levels of instrumentation to prevent postoperative high left shoulder. However, to our knowledge, no study has provided instructions on how to correct coronal imbalance in patients with previously fused scoliosis. We describe a case using a T4 unilateral pedicle subtraction osteotomy and contralateral Smith-Petersen osteotomy to treat high left shoulder in a patient who had previously undergone posterior instrumented fusion for adolescent idiopathic scoliosis. METHODS: The radiographs and clinical charts were reviewed for a 17-year-old female patient treated with a revision fusion and modified T4 hemivertebrectomy for a persistently high left shoulder after previous correction of a Lenke II idiopathic scoliosis. RESULTS: A reduction in the T1 tilt angle from 19.2° to 10.1° and an improvement in the coronal Cobb angle of the proximal thoracic curve from 37° to 17° were obtained. Shoulder balance was greatly improved. CONCLUSION: A proximal thoracic partial vertebrectomy with unilateral pedicle subtraction osteotomy and contralateral Smith-Petersen osteotomy is a technique that can be used to successfully correct fixed shoulder imbalance after posterior instrumented fusion of a double thoracic adolescent idiopathic scoliosis. LEVEL OF EVIDENCE: N/A.

Tension Pneumothorax as a Complication of Inadvertent Pleural Tears During Posterior Spinal Surgery.

OBJECTIVE: To review and expose the occurrences of tension pneumothorax as a result of pleural tear during posterior spinal surgery. METHODS: Intraoperative reports were retrospectively reviewed for 2 patients who underwent posterior spinal fusion and experienced pleural tear and subsequent tension pneumothorax. Surgical decisions for recognition and treatment were also reviewed. RESULTS: Unrecognized pleural tearing led to the formation of tension pneumothorax in both patients studied. Onset of respiratory signs and symptoms were delayed, occurring in the recovery room for the first patient and intraoperatively for the second. Both patients were successfully treated with conversion to open pneumothorax and placement of chest tubes. CONCLUSIONS: Tension pneumothorax is a complication that can arise during posterior thoracic spinal surgery as a result of an inadvertent pleural tear. Awareness of this potentially fatal complication will greatly help in the timely recognition and treatment of this condition if this situation occurs. The authors recommend a low threshold for chest tube placement in patients with known or suspected pleural tears or in patients with undiagnosed respiratory failure undergoing posterior thoracic spine surgery.

The use of fusion mass screws in revision spinal deformity surgery.

STUDY DESIGN: To report the use of a posterior based 'fusion mass screw' (FMS) as a primary or salvage fixation point in a revision spinal deformity following a previous posterior spinal fusion (PSF). Our experience of this technique in a case report and the clinical and radiological results are reported. OBJECTIVES: To describe the technique and uses of the FMS as a primary/salvage fixation point in osteotomies in previously arthrodesed spinal deformity surgery. Obtaining fixation points to correct and stabilize a spinal deformity with coronal and sagittal imbalance in a previously arthrodesed spine during revision surgery can be challenging. Several alternate pedicle fixation techniques and laminar screw techniques have been described in the literature. However, there is no description of these techniques in the presence of a spinal fusion with distorted anatomy. A pedicle screw placed coronally across a thick posterior fusion mass can provide an alternate method of fixation in these cases with complex anatomy. METHODS: Two cases of complex spinal deformity and corrective spinal osteotomies using fusion mass screws (FMSs) placed coronally across the posterior fusion mass are described. The first case is an 8-year-old patient with Marfan's syndrome who developed a crank shaft phenomenon and severe thoracolumbar kyphoscoliosis following a previous PSF. The second case is a 53-year-old patient with coronal imbalance following PSF as a child using Harrington instrumentation who developed distal degeneration with stenosis in her remaining mobile segments. Both patients underwent vertebral column resection and osteotomy closure plus stabilisation using FMS. The clinical and radiological results and technique for insertion of the FMS are described. CONCLUSION: In this report, we present a novel method of using posterior FMSs to achieve fixation and correction in cases of revision deformity surgery with difficult anatomy. While we feel pedicle screws are the gold standard in deformity correction, knowledge of alternatives such as the FMS can allow surgeons to achieve stable constructs when faced with challenging situations.

Responding to neuromonitoring changes in 3-column posterior spinal osteotomies for rigid pediatric spinal deformities.

STUDY DESIGN: Retrospective review of prospectively collected data on the neuromonitoring changes recorded during a consecutive series of cord level 3-column posterior spinal osteotomies for the correction of rigid pediatric spinal deformities in children between 2005 and 2012. OBJECTIVE: To review the neuromonitoring changes observed during the performance of these procedures, to highlight the high-risk steps, and to describe actions taken to avert major neurological injury. SUMMARY OF BACKGROUND DATA: Significant motor evoked potentials (MEP) changes are common during the performance of spinal osteotomies in children. The real-time intraoperative information provided by MEPs can provide the necessary information to direct key surgical decisions. METHODS: The neuromonitoring changes occurring during the performance of 37 3-column, cord level, posterior spinal osteotomies in 28 patients were recorded. The procedures were divided, for comparative purposes, into 2 groups based on the presence or absence of alerts. A decrease in somatosensory evoked potentials and transcranial MEPs greater than 50% of baseline was considered an alert. Alerts were classified chronologically as type I: prior to decompression, type II: occurring during decompression and bone resection, type III: occurring after osteotomy closure. RESULTS: Somatosensory evoked potential alerts occurred in 3 patients, all of whom had significant MEP alerts. There were 2 type I, 15 type II, and 6 type III MEP alerts. Increasing blood pressure improved MEPs in all with the exception of 8 type II and 4 type III. The unresponsive 8 type II alerts were treated with osteotomy closure with the expectation that spinal shortening would decompress the spinal cord and improve spinal cord perfusion. The unresponsive 4 type III alerts all responded to reopening, manipulation, and subsequent reclosure of the osteotomy either with a cage or less correction. There were 5 immediate postoperative motor deficits. No patient had a permanent deficit. CONCLUSION: Changes unresponsive to increasing blood pressure occurring during decompression and bone resection (type II) responded well to osteotomy closure. Unresponsive changes during osteotomy closure (type III) were treated successfully with opening the osteotomy, cage adjustment, and less correction.