Variation in care among spinal deformity surgeons: results of a survey of the Shriners hospitals for children.

STUDY DESIGN: Survey. OBJECTIVE: To understand the variation in scoliosis surgery and perioperative care among spinal deformity surgeons. SUMMARY OF BACKGROUND DATA: While variation in care has been well described in many spinal disorders, the degree of variation has not been described for spinal deformity. METHODS: Clinical histories and radiographs of 4 typical spinal deformity patients were sent to spinal deformity surgeons for review. The cases consisted of idiopathic thoracolumbar, double major, and right thoracic curves and a neuromuscular lumbar curve. The survey queried choice of surgical approach, levels fused and instrumented, type of instrumentation, preoperative testing, intraoperative neurologic monitoring, blood and antibiotic use, and postoperative care, including pain control and patient mobilization. Cost estimates for each case were obtained from the individual hospitals' pricing. RESULTS: There was wide variation in the specific fusion levels and instrumentation for the idiopathic curves. The variation was greatest for the thoracolumbar curve. The double major and right thoracic curves differed primarily in their choice of instrumenting secondary curves. The neuromuscular curve had the least variation. Costs estimates were widely disparate between centers. Perioperative care had much less disparity. CONCLUSIONS: Agreement appears common in areas with readily identifiable outcomes such as shorter length of stay and rapid postoperative mobilization. However, agreement is poor in areas where outcomes are difficult to measure and require long-term follow-up such as instrumentation fusion and levels.

Recognition and management of autonomic dysreflexia in pediatric spinal cord injury.

BACKGROUND: Autonomic dysreflexia (AD) is a well-documented complication of spinal cord injury (SCI) at or above the T6 level. However, research into AD has focused primarily on the adult. Because research that involves children with SCI is scarce, current guidelines may not be appropriate for children. Therefore, many episodes of AD may be unrecognized or inappropriately treated. To address this issue, Shriners Hospitals for Children undertook the development of a protocol specific to children and adolescents. METHOD: A task force was developed to look at current literature on AD and blood pressure in children. Utilizing this literature and consensus among the task force members, the tools necessary to treat children with SCI at risk for AD were developed. RESULTS: The task force developed several products intended to assist in the recognition and management of AD. These include an event flow sheet for recording incidents of AD, a letter for the child's school or primary care physician that provides a brief summary of AD and the child's baseline blood pressure, and a policy/protocol with 2 age-specific algorithms to standardize interventions across the 3 Shriners Hospitals in the United States with SCI programs (California, Illinois, and Pennsylvania). CONCLUSION: The Shriners Hospitals for Children Task Force on Autonomic Dysreflexia in Children with Spinal Cord Injury has developed several tools specific to children. However, many questions remain to be answered concerning blood pressure norms and the clinical presentation of AD in children.