Depression Screening in Pediatric Orthopedic Surgery Clinics and Identifying Patients At-Risk.

BACKGROUND: Up to 25% of youth experience a depressive episode by 18 years of age, leading the US Preventive Services Task Force to recommend depression screening within this population. This study aimed to understand the prevalence of depression identified within pediatric orthopedic clinics compared with primary care clinics after the implementation of a screening program and present data on the prevalence of moderate-severe depression across specific pediatric orthopedic clinics, characterizing and identifying specific populations at higher risk. METHODS: A retrospective review was performed to identify all patients screened using the 2-item and 9-item versions of the Patient Health Questionnaire (PHQ-2/PHQ-9) and the Columbia-Suicide Severity Rating Scale over a 2-year period (October 2018 to January 2021) within pediatric primary care and orthopaedic clinics. Demographic and clinical characteristics were collected. Statistical analysis was performed to compare scores between orthopedic and primary care clinics, as well as between the different pediatric orthopedic subspecialties and included χ 2 test, ANOVA, and logistic regression. RESULTS: There were 32,787 unique adolescent patients screened in primary care clinics, with an additional 14,078 unique adolescent patients screened in orthopaedic clinics, leading to a 30% increase in the overall number of patients receiving depression screening. 5.2% of patients in primary care pediatric clinics screened positive for moderate-severe depression versus 2.0% in pediatric orthopaedic clinics ( P <0.001). 2.7% of primary care patients were at risk of self-harm compared with 0.8% of orthopedic patients ( P <0.001). Within orthopaedic subspecialty clinics, the spine patients were at the highest risk of moderate-severe depression (3.5%), significantly higher than both the sports (1.4%, P =0.006) and patients with acute fracture (1.3%, P <0.001). CONCLUSIONS: This study demonstrates the high incidence of patients screening positive for depression in pediatric and adolescent orthopaedic clinics. By identifying high-risk clinics and patient groups, health care systems can apply a more practical approach and appropriately deploy behavioral health specialists for timely counseling and treatment discussions. LEVEL OF EVIDENCE: Level-III.

Breaking the Rules in Three Dimensions: What to Expect After a Thoracic-only Fusion With Structural Thoracic and Thoracolumbar Curves.

OBJECTIVE: Despite guidelines to fuse both thoracic and thoracolumbar/lumbar (TH/L) curves in patients with structural curves in both regions, a thoracic-only fusion allows preservation of lumbar motion segments. The purpose of this study was to assess the 2-year postoperative three-dimensional (3D) radiographic and clinical outcomes of patients with double or triple major (thoracic curves >TH/L curves) structural curves who underwent a thoracic-only fusion. METHODS: A prospective adolescent idiopathic scoliosis registry was queried for double or triple major curves undergoing thoracic-only posterior fusion and a minimum 2-year follow-up. 3D reconstructions were generated from bi-planar radiographs. Paired sample t tests were used to assess differences in the coronal, sagittal, and axial planes pre and postoperatively, as well as Scoliosis Research Society Questionnaire-22 scores. Pearson correlations were utilized to identify variables related to spontaneous lumbar derotation. RESULTS: Twenty-two patients met the inclusion criteria. Both thoracic [61 ± 10 degrees to 20 ± 9 degrees ( P < 0.001)] and lumbar curves [41 ± 7 degrees to 22±7 degrees ( P < 0.001)] had significant coronal improvement and T5 to T12 kyphosis improved from 7 ± 14 degrees to 23 ± 8 degrees ( P < 0.001). The thoracic apical translation was significantly improved postoperatively (4.7 ± 1.5 to 0.5 ± 1 cm, P < 0.001), but the lumbar apical translation was unchanged (-1.7 ± 0.6 to -1.7±0.8 cm, P = 0.94). Scoliosis Research Society Questionnaire-22 scores significantly improved by 2 years postoperative. CONCLUSIONS: Unlike the 3D correction observed in nonstructural TH/L curves after thoracic-only fusion, patients with double or triple major curves demonstrated only spontaneous coronal correction of the lumbar curve, whereas the sagittal and axial planes were not significantly improved. These radiographic parameters did not negatively affect subjective or clinical outcomes at minimum 2-year follow-up. LEVEL OF EVIDENCE: Level IV-therapeutic.

From PHQ-2 to SRS-22: how a depression screening tool relates to SRS scores in patients with adolescent idiopathic scoliosis.

PURPOSE: The aim of our study was to determine the relationship between Patient Health Questionnaire (PHQ) scores-a simple, validated depression screening tool-and Scoliosis Research Society (SRS)-22 questionnaire scores in patients with idiopathic scoliosis (IS). METHODS: IS patients screened for depression with the PHQ-2 who completed the SRS-22 over a 2-year period were reviewed. If PHQ-2 scores were positive (> 3), the more comprehensive PHQ-9 was administered. Median SRS-22 scores between positive and negative PHQ screens were compared. Nonparametric correlation between PHQ and SRS-22 Mental Health (MH) domain was performed. The ability of the MH domain to discriminate between patients with positive versus negative screens and patients with moderate-severe depression risk versus no-mild risk was evaluated with ROC analysis. RESULTS: 521 patients were included. Patients with + PHQ-2 screens had significantly lower total and individual domain SRS scores, especially within the MH domain (4.0 vs. 3.2). For those with moderate-severe depression risk, total and individual domain scores were also significantly lower (MH domain, 4.0 vs. 3.0, p < 0.05). A weak, but significant correlation was observed between the PHQ and MH domain scores (rho = 0.32, p < 0.001). A cut-off of ≥ 3.6 on the MH domain demonstrated sensitivity of 0.75 and specificity of 0.86 for identifying patients at no-mild risk for depression. CONCLUSION: Recognizing mental health conditions is critical to successful IS treatment as psychosocial conditions can negatively affect treatment outcomes. IS patients scoring < 3.6 on the SRS-22 MH domain should be considered for depression screening due to an increased risk of moderate-severe depression.

Who gets staged surgery in severe pediatric and adolescent spine deformity?

BACKGROUND: There is significant debate regarding the indications of staged surgery for severe adolescent spinal deformity, and the factors associated with the decision to perform staged compared to same-day surgery have not been previously investigated. Thus, the purpose of this study was to determine which factors were most strongly associated with this decision. METHODS: A prospective multicenter registry of adolescent patients with severe spinal deformity was reviewed. Two cohorts were identified: those who underwent a planned staged surgical procedure for deformity correction and those who underwent a same-day procedure. Patients who underwent an unplanned staged procedure secondary to complications during the initial procedure were excluded. Comparisons were made between these cohorts with respect to preoperative patient and radiographic variables to determine which factors were associated with the decision to perform a staged procedure. Surgical data was also compared to evaluate for differences in the intraoperative management of staged versus same-day patients. RESULTS: Two hundred and twenty-nine patients with severe spinal deformities were identified. Forty patients (17%) underwent a planned staged procedure and 189 patients (80%) underwent a same-day procedure. On univariate analysis of preoperative variables, patients who underwent staged surgery had a significantly younger age at surgery, greater major curve magnitude, greater major curve AVT to CSVL, lesser thoracic spine height, greater radiographic trunk shift, and a greater proportion of patients undergoing revision surgery (as opposed to primary correction) compared to those who underwent a planned single-stage procedure. Multivariate logistic regression of pre-operative variables showed that age < 16 years, maximum cobb angle ≥ 120 degrees, major curve AVT to CSVL of ≥ 3.5 cm, and revision surgery were independently associated with the decision to perform a staged procedure. Intraoperatively, patients in the staged cohort more frequently underwent combined anterior and posterior procedures, grade 4 or higher Schwab osteotomies, and had a greater number of levels fused. CONCLUSION: There is substantial variability with respect to the decision to perform surgery for severe adolescent spine deformities in a staged versus same-day fashion. This large analysis of prospectively collected data is the first to describe the factors most strongly associated with the decision to perform a staged procedure and may help guide the surgical decision-making for these patients.

Fifteen Years of Spinal Fusion Outcomes in Children With Cerebral Palsy: Are We Getting Better?

STUDY DESIGN: Retrospective multicenter study. OBJECTIVE: We reviewed 15-year trends in operative factors, radiographic and quality of life outcomes, and complication rates in children with cerebral palsy (CP)-related scoliosis who underwent spinal fusion. SUMMARY OF BACKGROUND DATA: Over the past two decades, significant efforts have been made to decrease complications and improve outcomes of this population. MATERIALS AND METHODS: We retrospectively reviewed a multicenter registry of pediatric CP patients who underwent spinal fusion from 2008 to 2020. We evaluated baseline and operative, hospitalization, and complication data as well as radiographic and quality of life outcomes at a minimum 2-year follow-up. RESULTS: Mean estimated blood loss and transfusion volume declined from 2.7±2.0 L in 2008 to 0.71±0.34 L in 2020 and 1.0±0.5 L in 2008 to 0.5±0.2 L in 2020, respectively, with a concomitant increase in antifibrinolytic use from 58% to 97% (all, P <0.01). Unit rod and pelvic fusion use declined from 33% in 2008 to 0% in 2020 and 96% in 2008 to 79% in 2020, respectively (both, P <0.05). Mean postoperative intubation time declined from 2.5±2.6 to 0.42±0.63 days ( P< 0.01). No changes were observed in preoperative and postoperative coronal angle and pelvic obliquity, operative time, frequency of anterior/anterior-posterior approach, and durations of hospital and intensive care unit stays. Improvements in the Caregiver Priorities and Child Health Index of Life with Disabilities postoperatively did not change significantly over the study period. Complication rates, including reoperation, superficial and deep surgical site infection, and gastrointestinal and medical complications remained stable over the study period. CONCLUSIONS: Over the past 15 years of CP scoliosis surgery, surgical blood loss, transfusion volumes, duration of postoperative intubation, and pelvic fusion rates have decreased. However, the degree of radiographic correction, the rates of surgical and medical complications (including infection), and health-related quality of life measures have broadly remained constant.

Baclofen pumps do not increase risk of complications following spinal fusion.

PURPOSE: To assess the complication risks associated with intrathecal baclofen (ITB) pumps in cerebral palsy (CP) patients undergoing posterior spinal fusion (PSF) and to determine if timing of pump implantation before or during PSF impacts the risk of complications. METHODS: A prospectively collected multicenter database was retrospectively reviewed to identify CP patients undergoing PSF from 2008 to 2023. Patients were divided into 2 cohorts: those with an ITB pump (ITB cohort) and those without (non-ITB cohort). The ITB cohort was further categorized by placement of the pump prior to or during PSF. Cohorts were then compared in terms of postoperative complications, perioperative complications, and need for revision surgery. RESULTS: Four hundred six patients (ITB n = 79 [53 prior to, 26 during PSF], non-ITB n = 326) were included in this analysis. At an average follow-up of 4.0 years (range 2-10 years), there were no significant differences between the ITB and non-ITB cohorts in the rate of perioperative complications (5.0% vs 6.5%, p = 0.80), revision surgeries (2.5% vs 4.6%, p = 0.54), or any complication type, regardless of whether pumps were placed prior to or during PSF, aside from longer surgical times in the latter group. CONCLUSION: Complication rates are similar for ITBs placed prior to and during PSF. Patients with spastic CP may safely be treated with ITB pumps without increased risks of complication or further reoperation/revision following PSF. LEVEL OF EVIDENCE: Level III.

Does radiographic calibration affect linear radiographic measurements in a large pediatric spine registry?

PURPOSE: Large registries are increasingly at the forefront of modern pediatric spine research, with manual, centralized, trained radiographic measurement serving as the gold standard for spine research. However, there is limited data regarding the reliability of registry measurements which may be subject to differences in radiographic calibration. We undertook this study to evaluate reliability of T1-T12 height, L1-S1 height, and coronal balance measurements for a large registry of early onset scoliosis patients. METHODS: Three trained technicians from the Pediatric Spine Study Group measured 43 radiographs for T1-T12, L1-S1, and coronal balance using 3 different calibration techniques. All radiographs were AP views of patients with magnetically controlled growing rods with known diameters. The calibration techniques used a pre-export manually drawn line, a digital automatically generated computerized marker, and the diameter of a magnetically controlled growing rod. The intraclass correlation coefficient (ICC) was calculated to determine reliability. RESULTS: 1161 measurements were performed. For each of the three raters, coronal balance, T1-T12 height and L1-S1 height had excellent agreement regardless of the calibration technique (alpha 0.93-1.0). Among the parameters, coronal balance had the worst inter-rater reliability, whereas there was excellent interrater reliability regarding T1-T12 height and L1-S1 height (alpha 0.91-0.99). CONCLUSION: There was excellent agreement among reviewers and between the 3 different calibration techniques. While calibration using rod diameter served as the gold standard, this data shows that other standard calibration methods were adequate and achieved excellent reliability for registry radiographs.

Is spinal height gain associated with rod orientation and the use of cross-links in magnetically controlled growing rods in early-onset scoliosis?

Optimal orientation for magnetically controlled growing rods (MCGRs) is unclear. The objective of this study was to investigate associations of rod orientation with implant-related complications (IRCs) and spinal height gains. Using an international early-onset scoliosis (EOS) database, we retrospectively reviewed 57 patients treated with dual MCGRs from May 2013 to July 2015 with minimum 2-year follow-up. Outcomes of interest were IRCs and left/right rod length gains and thoracic (T1-T12) and spinal (T1-S1) heights. We compared patients with two rods lengthened in the cephalad ( standard; n  = 18) versus opposite ( offset; n  = 39) directions. Groups did not differ in age, sex, BMI, duration of follow-up, EOS cause, ambulatory status, primary curve magnitude, baseline thoracic height, or number of distractions/year. We compared patients whose constructs used ≥1 cross-link (CL group; n  = 22) versus no CLs (NCL group; n  = 35), analyzing thoracic height gains per distraction ( α  = 0.05). Offset and standard groups did not differ in left or right rod length gains overall or per year or in thoracic or spinal height gain. Per distraction, the CL and NCL groups did not differ significantly in left or right rod length or thoracic or spinal height gain. Complications did not differ significantly between rod orientation groups or between CL groups. MCGR orientation and presence of cross-links were not associated with differences in rod length gain, thoracic height, spinal height, or IRCs at 2-year follow-up. Surgeons should feel comfortable using either MCGR orientation. Level of evidence: 3, retrospective.

Perioperative Complications and Health-related Quality of Life Outcomes in Severe Pediatric Spinal Deformity.

STUDY DESIGN: Prospective multicenter cohort study. OBJECTIVE: To evaluate perioperative complications and mid-term outcomes for severe pediatric spinal deformity. SUMMARY OF BACKGROUND DATA: Few studies have evaluated the impact of complications on health-related quality of life (HRQoL) outcomes in severe pediatric spinal deformity. METHODS: Patients from a prospective, multicenter database with severe pediatric spinal deformity (minimum of 100 degree curve in any plane or planned vertebral column resection (VCR)) with a minimum of 2-years follow-up were evaluated (n=231). SRS-22r scores were collected preoperatively and at 2-years postoperatively. Complications were categorized as intraoperative, early postoperative (within 90-days of surgery), major, or minor. Perioperative complication rate was evaluated between patients with and without VCR. Additionally, SRS-22r scores were compared between patients with and without complications. RESULTS: Perioperative complications occurred in 135 (58%) patients, and major complications occurred in 53 (23%) patients. Patients that underwent VCR had a higher incidence of early postoperative complications than patients without VCR (28.9% vs. 16.2%, P =0.02). Complications resolved in 126/135 (93.3%) patients with a mean time to resolution of 91.63 days. Unresolved major complications included motor deficit (n=4), spinal cord deficit (n=1), nerve root deficit (n=1), compartment syndrome (n=1), and motor weakness due to recurrent intradural tumor (n=1). Patients with complications, major complications, or multiple complications had equivalent postoperative SRS-22r scores. Patients with motor deficits had lower postoperative satisfaction subscore (4.32 vs. 4.51, P =0.03), but patients with resolved motor deficits had equivalent postoperative scores in all domains. Patients with unresolved complications had lower postoperative satisfaction subscore (3.94 vs. 4.47, P =0.03) and less postoperative improvement in self-image subscore (0.64 vs. 1.42, P =0.03) as compared to patients with resolved complications. CONCLUSION: Most perioperative complications for severe pediatric spinal deformity resolve within 2-years postoperatively and do not result in adverse HRQoL outcomes. However, patients with unresolved complications have decreased HRQoL outcomes.

Late Infection After Spinal Fusion for Adolescent Idiopathic Scoliosis: Implant Exchange Versus Removal.

BACKGROUND: Late infection after posterior spinal arthrodesis for adolescent idiopathic scoliosis (AIS) is the leading cause of late revision. While implant removal and antibiotic therapy are usually curative, patients may experience deformity progression. The goal of this study was to compare outcomes after implant exchange (IE) or removal (IR) to treat late-onset (≥1 y postoperative) deep surgical site infection (SSI) after spinal arthrodesis in patients with AIS. METHODS: Using a multicenter AIS registry, patients who underwent posterior spinal fusion between 2005 and 2019 and developed late deep SSI treated with IE or IR were identified. Radiographic, surgical, clinical, and patient-reported outcomes at most recent follow-up were compared. RESULTS: Of 3,705 patients, 47 (1.3%) developed late infection 3.8±2.2 years (range 1 to 9.7 y) after index surgery. Mean follow-up after index surgery was 6.1 years, with 2.8 years (range 25 to 120 mo) of follow-up after revision surgery. Twenty-one patients were treated with IE and 26 with IR. At the latest follow-up, average major-curve loss of correction (1° vs 9°, P <0.001) and increase in kyphosis (1° vs. 8°, P =0.04) were smaller in the IE group than in the IR group. Two IR patients but no IE patients had reoperation. Patients who underwent IE had higher Scoliosis Research Society 22-Item Patient Questionnaire (SRS-22) total scores (4.38 vs. 3.81, P =0.02) as well as better subscores for self-image, function, and satisfaction at the latest follow-up than those who underwent IR only. There were no significant between-group differences in operative duration, estimated blood loss, length of hospital stay, or changes in SRS-22 total scores. No patient had a subsequent infection during the follow-up period. CONCLUSIONS: When treating late-onset deep SSI after posterior spinal fusion for AIS, single-stage IE is associated with better maintenance of major curve correction, sagittal profile, and patient-reported outcomes and fewer reoperations compared with IR, with no significant differences in blood loss, operative duration, or length of stay. No time interval from index surgery to IR was observed where the corrected deformity remained stable. Both techniques were curative of infection. LEVEL OF EVIDENCE: Level III.

When to Perform Fusion Short of the Pelvis in Patients with Cerebral Palsy?: Indications and Outcomes.

Patients with scoliosis secondary to cerebral palsy (CP) are often treated with posterior spinal fusion (PSF) with or without pelvic fixation. We sought to establish criteria to guide the decision of whether or not to perform fusion "short of the pelvis" in this population, and to assess differences in outcomes. Methods: Using 2 prospective databases, we analyzed 87 pediatric patients who underwent PSF short of the pelvis from 2008 to 2015 to treat CP-related scoliosis and who had ≥2 years of follow-up. Preoperative radiographic and clinical variables were analyzed for associations with unsatisfactory correction (defined as pelvic obliquity of ≥10°, distal implant dislodgement, and/or reoperation for increasing deformity at 2- or 5-year follow-up). Continuous variables were dichotomized using the Youden index, and a multivariable model of predictors of unsatisfactory correction was created using backward stepwise selection. Finally, radiographic, health-related quality-of-life, and clinical outcomes of patients with fusion short of the pelvis who had neither of the 2 factors associated with unsatisfactory outcomes were compared with those of 2 matched-control groups. Results: Deformity correction was unsatisfactory in 29 of 87 patients with fusion short of the pelvis. The final model included preoperative pelvic obliquity of ≥17° (odds ratio [OR], 6.8; 95% confidence interval [CI], 2.3 to 19.7; p < 0.01) and dependent sitting status (OR, 3.2; 95% CI, 1.1 to 9.9; p = 0.04) as predictors of unsatisfactory correction. The predicted probability of unsatisfactory correction increased from 10% when neither of these factors was present to a predicated probability of 27% to 44% when 1 was present and to 72% when both were present. Among matched patients with these factors who had fusion to the pelvis, there was no association with unsatisfactory correction. Patients with independent sitting status and pelvic obliquity of <17° who had fusion short of the pelvis had significantly lower blood loss and hospital length of stay, and better 2-year health-related quality-of-life scores compared with matched controls with fusion to the pelvis. Conclusions: In patients with scoliosis secondary to CP, pelvic obliquity of <17° and independent sitting status are associated with a low risk of unsatisfactory correction and better 2-year outcomes when fusion short of the pelvis is performed. These may be used as preoperative criteria to guide the decision of whether to perform fusion short of the pelvis in patients with CP. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical Outcomes of Cerebral Palsy Patients With Scoliosis and Lumbar Hyperlordosis: A Comparative Analysis With 2-year Minimum Follow-up.

STUDY DESIGN: Retrospective review of a prospectively collected multicenter database. OBJECTIVE: To compare outcomes of patients with cerebral palsy (CP) who undergo surgery for scoliosis with normal lordosis (NL) versus hyperlordosis. SUMMARY OF BACKGROUND DATA: Surgical correction of scoliosis with lumbar hyperlordosis is challenging. Hyperlordosis may confer higher perioperative morbidity, but this is not well understood. MATERIALS AND METHODS: A multicenter database was queried for CP patients who underwent surgery from 2008 to 2017. The minimum follow-up was 2 years. Two groups were identified: lumbar lordosis <75° (NL) versus ≥ 75° hyperlordosis (HL). Perioperative, radiographic, and clinical outcomes were compared. RESULTS: Two hundred seventy-five patients were studied: 236 NL and 39 HL (-75 to -125°). The mean age was 14.1 years, and 52.4% were male. Patients with hyperlordosis had less cognitive impairment (76.9% vs. 94.0%, P =0.008) and higher CPCHILD scores (59.4 vs. 51.0, P =0.003). Other demographics were similar between the groups. Patients with hyperlordosis had greater lumbar lordosis (-90.5 vs. -31.5°, P <0.001) and smaller sagittal vertical axis (-4.0 vs. 2.6 cm, P <0.001). Patients with hyperlordosis had greater estimated blood loss (2222.0 vs. 1460.7 mL, P <0.001) but a similar perioperative complication rate (20.5% vs. 22.5%, P =0.787). Significant correction of all radiographic parameters was achieved in both groups. The HL group had postoperative lumbar lordosis of -68.2° and sagittal vertical axis of -1.0 cm. At a 2-year follow-up, patients with hyperlordosis continued to have higher CPCHILD scores and gained the greatest benefit in overall quality of life measures (20.0 vs. 6.1, P =0.008). The reoperation rate was 10.2%: implant failure (3.6%), pseudarthrosis (0.7%), and wound complications (7.3%). There were no differences in the reoperation rate between the groups. CONCLUSION: Surgical correction of scoliosis with hyperlordosis is associated with greater estimated blood loss but similar radiographic results, perioperative morbidity, and reoperation rate as normal lordosis. Patients with hyperlordosis gained greater overall health benefits. Correction of ≥25% of hyperlordosis seems satisfactory. LEVEL OF EVIDENCE: 3.

Posterior cervical spinal fusion in the pediatric population using modern adult instrumentation - clinical outcome and safety.

PURPOSE: Traditionally, less rigid fixation techniques have been applied to the pediatric cervical spine. There is a lack of long-term outcome data for rigid fixation techniques. The purpose of this study was to define the clinical outcome and safety of posterior instrumented fusion in the pediatric population using adult posterior instrumentation. METHODS: A multicenter, retrospective review of pediatric patients who underwent posterior cervical fusion using a 3.5 mm posterior cervical system for any indication was performed. Outcome parameters included complications, revision and fusion rates, operative time (OR), blood loss, and postoperative neurologic status. Outcomes were compared between patient groups (posterior only versus anterior/posterior approach, short versus intermediate versus long fusion, and between different etiologies) using Mann-Whitney and chi-square test. RESULTS: Seventy-nine patients with a mean age of 9.9 years and mean follow-up of 2.8 years were included. At baseline 44 (56%) had an abnormal neurologic exam. Congenital deformities and basilar invagination were the most common indications for surgery. Posterior-only surgery was performed in 71 (90%) cases; mean number of levels fused was 4 (range 1-15). Overall, 4 (5%) operative complications and 4 (5%) revisions were reported at an average postoperative time of 2.6 years. Neurologic status remained unchanged in 74%, improved in 23%, and worsened in 3%. When comparing outcome measures between the various groups, 2 significant differences were found: OR was longer in the anterior/posterior approach group and decline of neuro status was more frequent in the long fusion group. CONCLUSION: Posterior cervical fusion with an adult 3.5 mm posterior cervical system was safe in this cohort of 79 pediatric patients irrespective of surgical technique, fusion length, and etiology, resulting in a high fusion and low complication/revision rate.

Myelopathic Patients Undergoing Severe Pediatric Spinal Deformity Surgery Can Improve Neurologic Function to That of Non-Myelopathic Patients by 1-Year Postoperative.

STUDY DESIGN: Multi-center, prospective, observational cohort. OBJECTIVE: To compare myelopathic vs. non-myelopathic ambulatory patients in short- and long-term neurologic function, operative treatment, and patient-reported outcomes. METHODS: Pediatric deformity patients from 16 centers were enrolled with the following inclusion criteria: aged 10-21 years-old, a Cobb angle ≥100° in either the coronal or sagittal plane or any sized deformity with a planned 3-column osteotomy, and community ambulators. Patients were dichotomized into 2 groups: myelopathic (abnormal preoperative neurologic exam with signs/symptoms of myelopathy) and non-myelopathic (no clinical signs/symptoms of myelopathy). RESULTS: Of 311 patients with an average age of 14.7 ± 2.8 years, 29 (9.3%) were myelopathic and 282 (90.7%) were non-myelopathic. There was no difference in age (P = 0.18), gender (P = 0.09), and Risser Stage (P = 0.06), while more patients in the non-myelopathic group had previous surgery (16.1% vs. 3.9%; P = 0.03). Mean lower extremity motor score (LEMS) in myelopathic patients increased significantly compared to baseline at every postoperative visit: Baseline: 40.7 ± 9.9; Immediate postop: 46.0 ± 7.1, P = 0.02; 1-year: 48.2 ± 3.7, P < 0.001; 2-year: 48.2 ± 7.7, P < 0.001). The non-myelopathic group had significantly higher LEMS immediately postoperative (P = 0.0007), but by 1-year postoperative, there was no difference in LEMS between groups (non-myelopathic: 49.3 ± 3.6, myelopathic: 48.2 ± 3.7, P = 0.10) and was maintained at 2-years postoperative (non-myelopathic: 49.2 ± 3.3, myelopathic: 48.2 ± 5.7, P = 0.09). Both groups improved significantly in all SRS domains compared to preoperative, with no difference in scores in the domains for pain (P = 0.12), self-image (P = 0.08), and satisfaction (P = 0.83) at latest follow-up. CONCLUSION: In severe spinal deformity pediatric patients presenting with preoperative myelopathy undergoing spinal reconstructive surgery, myelopathic patients can expect significant improvement in neurologic function postoperatively. At 1-year and 2-year postoperative, neurologic function was no different between groups. While non-myelopathic patients had significantly higher postoperative outcomes in SRS mental-health, function, and total-score, both groups had significantly improved outcomes in every SRS domain compared to preoperative.

Current trends in surgical magnitude of neuromuscular scoliosis curves: a study of 489 operative patients with non-ambulatory cerebral palsy.

PURPOSE: A curve magnitude at which posterior spinal fusion (PSF) is indicated for children with cerebral palsy (CP) scoliosis is not defined. We sought to evaluate whether agreement exists for a curve magnitude at which PSF is undertaken for CP scoliosis and to evaluate outcomes by quartile of curve magnitude and flexibility at time of fusion. METHODS: A prospective multicenter pediatric spine database was queried for patients with a Gross Motor Function Classification Scale (GMFCS) IV or V who underwent PSF for CP scoliosis. Demographics, surgical indications, and correlations between curve magnitude, postoperative radiographic outcomes, and Caregiver's Priorities and Child Health Index of Life and Disabilities (CPCHILD) scores were evaluated for patients with at least 2 years of follow-up. RESULTS: 489 patients from 15 sites were analyzed. Median major Cobb angle at time of PSF was 87° and significantly varied by site (p < 0.001). Median Cobb angle on flexibility studies was 55° and median percent correction on flexibility studies was 36.3%. Severity of the curve at surgery correlated significantly with lower overall quality of life and CPCHILD score (p < 0.05). Larger residual curves correlated with larger operative curves (p < 0.001) and decreased flexibility on preoperative flexibility studies (p < 0.001), although postoperative CPCHILD scores did not differ by curve size or flexibility at time of fusion or by size of residual curve (p > 0.05). CONCLUSION: The median curve magnitude is large and there is substantial variability in curve size of CP scoliosis at time of fusion, although clinical outcomes are not negatively influenced by larger operative magnitudes. Further study should aim to narrow surgical indications by defining unacceptable radiographic outcomes. LEVEL OF EVIDENCE: Level III.

Developing consensus for the management of pediatric cervical spine disorders and stabilization: a modified Delphi study.

OBJECTIVE: Cervical spine disorders in children are relatively uncommon; therefore, paradigms for surgical and nonsurgical clinical management are not well established. The purpose of this study was to bring together an international, multidisciplinary group of pediatric cervical spine experts to build consensus via a modified Delphi approach regarding the clinical management of children with cervical spine disorders and those undergoing cervical spine stabilization surgery. METHODS: A modified Delphi method was used to identify consensus statements for the management of children with cervical spine disorders requiring stabilization. A survey of current practices, supplemented by a literature review, was electronically distributed to 17 neurosurgeons and orthopedic surgeons experienced with the clinical management of pediatric cervical spine disorders. Subsequently, 52 summary statements were formulated and distributed to the group. Statements that reached near consensus or that were of particular interest were then discussed during an in-person meeting to attain further consensus. Consensus was defined as ≥ 80% agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). RESULTS: Forty-five consensus-driven statements were identified, with all participants willing to incorporate them into their practice. For children with cervical spine disorders and/or stabilization, consensus statements were divided into the following categories: A) preoperative planning (12 statements); B) radiographic thresholds of instability (4); C) intraoperative/perioperative management (15); D) postoperative care (11); and E) nonoperative management (3). Several important statements reaching consensus included the following recommendations: 1) to obtain pre-positioning baseline signals with intraoperative neuromonitoring; 2) to use rigid instrumentation when technically feasible; 3) to provide postoperative external immobilization for 6-12 weeks with a rigid cervical collar rather than halo vest immobilization; and 4) to continue clinical postoperative follow-up at least until anatomical cervical spine maturity was reached. In addition, preoperative radiographic thresholds for instability that reached consensus included the following: 1) translational motion ≥ 5 mm at C1-2 (excluding patients with Down syndrome) or ≥ 4 mm in the subaxial spine; 2) dynamic angulation in the subaxial spine ≥ 10°; and 3) abnormal motion and T2 signal change on MRI seen at the same level. CONCLUSIONS: In this study, the authors have demonstrated that a multidisciplinary, international group of pediatric cervical spine experts was able to reach consensus on 45 statements regarding the management of pediatric cervical spine disorders and stabilization. Further study is required to determine if implementation of these practices can lead to reduced complications and improved outcomes for children.

Beware of open triradiate cartilage: 1 in 4 patients will lose > 10° of correction following posterior only fusion.

PURPOSE: As 2-year follow-up may not be sufficient to assess the risk of curve progression following fusion in immature patients with adolescent idiopathic scoliosis (AIS), this study reports on 5-year outcomes of AIS patients, factoring in maturity and surgical approach, to determine whether immature patients are at risk of continued curve progression beyond 2 years. METHODS: A multicenter database was reviewed for AIS patients who underwent spinal fusion with pedicle screw fixation and who had both 2 and 5-year follow-up. Radiographic and SRS-22 scores were compared between three groups: open triradiate cartilage-posterior fusion (OTRC-P), OTRC-combined anterior/posterior fusion (OTRC-APSF), and closed TRC (CTRC, matched to OTRC-P group). RESULTS: 142 subjects were included (67 OTRC-P, 8 OTRC-APSF, 67 CTRC). Main curve type (p = 0.592) and size (p = 0.117) were not different between groups at all timepoints. Compensatory curve size was similar at all timepoints for OTRC-P and CTRC, with a slight increase for OTRC-APSF from immediate postoperative to 5 years. At 5 years, OTRC-P had > 10° loss of correction in 25% of patients, which was greater than in the CTRC (6%) and OTRC-APSF (0%) groups (p = 0.002). No significant differences were found in loss of correction of the compensatory curve or in SRS-22 scores between groups. CONCLUSIONS: Compared to those with CTRC and those treated with anterior/posterior fusion, patients with OTRC treated with posterior fusion had an increased risk of main curve progression greater than 10°, with some continued loss of correction after 2 years. This did not appear to affect patient-reported outcomes.

Definitive fusions are better than growing rod procedures for juvenile patients with cerebral palsy and scoliosis: a prospective comparative cohort study.

PURPOSE: This study compared the outcomes of juvenile patients with cerebral palsy (CP) and scoliosis who underwent spinal fusion (SF) versus growing rod (GR) surgery. METHODS: Two prospective multicenter registries were queried for patients 8-10 years old with minimum 2-year follow-up who underwent SF or GR surgery (no MCGR). Demographics, radiographs, complications, and outcome scores were recorded. RESULTS: There were 35 patients in the SF and 15 in the GR group. The mean age at surgery was 10 and 9.3 years in the SF and GR groups, respectively (p = 0.004). In the SF group preoperatively, the major curve measured 86° and 80° in the GR group (p = 0.40). "Definitive" surgery in the GR group consisted of SF in 10, implant retention in three, and implant removal in two. The SF group had 60.8% and the GR group had 45.0% correction following "definitive" surgery (p = 0.03). In the SF group, 8 patients and in the GR group, 9 patients (SF = 22.9%, GR = 60.0%) had a complication (p = 0.01). In the SF group, two patients (5.7%) had reoperations for infection; eight patients (53.3%) in the GR group had reoperations for infection and implant complications (p < 0.001). In the SF group, 23/30 parents (76.6%) noted that the child's life "improved a lot." In the GR group, 3/6 parents (50.0%) noted they were "neutral" about their child's ability to do things, 2/6 (33.3%) were "very dissatisfied." CONCLUSIONS: SF treatment for juvenile patients with CP and scoliosis resulted in fewer complications and unplanned reoperations and better radiographic outcomes compared with GR. Quality of life improvements were also better in the SF group. LEVEL OF EVIDENCE: Level III.

Best Practice Guidelines for Surgical Site Infection in High-risk Pediatric Spine Surgery: Definition, Prevention, Diagnosis, and Treatment.

BACKGROUND: Prior "best practice guidelines" (BPG) have identified strategies to reduce the risk of acute deep surgical site infection (SSI), but there still exists large variability in practice. Further, there is still no consensus on which patients are "high risk" for SSI and how SSI should be diagnosed or treated in pediatric spine surgery. We sought to develop an updated, consensus-based BPG informed by available literature and expert opinion on defining high-SSI risk in pediatric spine surgery and on prevention, diagnosis, and treatment of SSI in this high-risk population. MATERIALS AND METHODS: After a systematic review of the literature, an expert panel of 21 pediatric spine surgeons was selected from the Harms Study Group based on extensive experience in the field of pediatric spine surgery. Using the Delphi process and iterative survey rounds, the expert panel was surveyed for current practices, presented with the systematic review, given the opportunity to voice opinions through a live discussion session and asked to vote regarding preferences privately. Two survey rounds were conducted electronically, after which a live conference was held to present and discuss results. A final electronic survey was then conducted for final voting. Agreement ≥70% was considered consensus. Items near consensus were revised if feasible to achieve consensus in subsequent surveys. RESULTS: Consensus was reached for 17 items for defining high-SSI risk, 17 items for preventing, 6 for diagnosing, and 9 for treating SSI in this high-risk population. After final voting, all 21 experts agreed to the publication and implementation of these items in their practice. CONCLUSIONS: We present a set of updated consensus-based BPGs for defining high-risk and preventing, diagnosing, and treating SSI in high-risk pediatric spine surgery. We believe that this BPG can limit variability in practice and decrease the incidence of SSI in pediatric spine surgery. LEVEL OF EVIDENCE: Not applicable.

Spontaneous Lumbar Curve Correction Following Vertebral Body Tethering of Main Thoracic Curves.

BACKGROUND: Growth modulation through anterior vertebral body tethering (AVBT) has emerged as a fusionless option for the treatment of progressive scoliosis. When tethering the main thoracic curve, the compensatory thoracolumbar/lumbar curve must correct indirectly as a result. The present study evaluated the response of these lumbar curves following AVBT of the main thoracic curves. METHODS: Patients who underwent thoracic AVBT and who had a minimum follow-up of 2 years were included. Magnitudes of the thoracic and lumbar curves were recorded preoperatively and at the first-erect and 2-year postoperative visits. Lumbar curves were further stratified according to their lumbar modifier (A, B, or C). Analysis of variance (ANOVA) and repeated-measures ANOVA were performed to compare correction rates, and the Pearson coefficient was utilized to determine the correlation between the tethered thoracic curve and uninstrumented lumbar curve magnitudes. RESULTS: A total of 218 patients were included. Thoracic curve correction was 40% at the first-erect visit and 43% at 2 years (p = 0.012). Lumbar correction was 30%, 26%, and 18% at the first-erect visit (p < 0.001 for all compared with preoperatively) and minimally changed at 31%, 26%, and 24% at 2 years for lumbar modifiers A, B, and C, respectively. A total of 118 patients (54%) showed thoracic curve improvement between the first-erect and 2-year visits. In a subgroup analysis, these patients had a correction in lumbar curve magnitude from preoperatively to the first-erect visit of 30%, 22%, and 16% for lumbar modifiers A, B, C, respectively, that increased to 42%, 34%, and 31% at 2 years, with strong correlation to thoracic correction at 2-year follow-up (r = 0.557, p < 0.001). CONCLUSIONS: Although there was immediate lumbar correction following AVBT of a main thoracic curve, further improvement following initial correction was only observed among patients with growth modulation of the thoracic curve. Considering all patients, the uninstrumented lumbar curve corrected 30% at 2 years and the instrumented thoracic curve corrected 40%. As indications for AVBT are refined, these data will provide insight into the response of the uninstrumented lumbar curve. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.