Lower socioeconomic status is not associated with severity of adolescent idiopathic scoliosis: a matched cohort analysis.

PURPOSE: Assessing the influence of socioeconomic status (SES) on the severity of adolescent idiopathic scoliosis (AIS) on initial presentation to the spinal surgeon remains a challenge. The area deprivation index (ADI) is a validated measure of SES that abstracts multiple domains of disadvantage into a single score. We hypothesized that patients with low SES (high ADI) present to the orthopedic clinic with more advanced curve pathology. METHODS: We retrospectively reviewed patients diagnosed with AIS. Subjects were assigned ADI scores based on Zip codes. Matched cohorts of high and low ADI were generated using propensity scores. Bivariate and multivariate analyses were performed to identify factors impacting the magnitude of the curve at presentation. RESULTS: A total of 425 patients with appropriate imaging were included. After matching, the study population was 69.2% female and 92.3% Black. The mean BMI percentile was 61.9. Medicaid covered 57.3% of subjects, and 42.7% had commercial insurance. The mean ADI was 55.5. The mean Cobb angle at presentation was 33.6 degrees. Cobb angle was significantly greater among female patients (36.0 degrees vs 28.0) and among patients with greater BMI percentile (ß = 0.127), but was not significantly associated with ADI, race, or insurance type. ADI was not associated with the rate of surgery. CONCLUSION: ADI is not predictive of curve severity in pediatric patients presenting to the clinic for AIS. Female sex and BMI are independently associated with advanced curvature. Public health workers, primary care providers, and surgeons should remain aware of the complex interactions of socioeconomic factors, BMI and sex when addressing barriers to timely care. LEVEL OF EVIDENCE: Prognostic Level III.

Complications following posterior spinal fusion for adolescent idiopathic scoliosis: a retrospective cohort study using the modified Clavien-Dindo-Sink system.

PURPOSE: Published complication rates after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) range from 1 to 22%. Complications are often minor and may be underestimated in registries. This study describes complications of PSF for AIS, classifies them according to a Clavien-Dindo-Sink (CDS) system, and investigates risk factors for occurrence of a complication. METHODS: This retrospective cohort study at two academic centers included all AIS patients aged 10-18 who underwent primary PSF 4/2014-12/2019. Data included demographics, comorbidities, curve magnitude, Lenke classification, levels osteotomized/fused, implant density, 90-day emergency department visits, readmissions, reoperations, and complications as defined by Harms Study Group. RESULTS: Among 424 patients, mean age was 14.7, mean BMI 22, 77% were female, and 57% had no comorbidities. There were 270 complications (0.64 per patient); 198 patients (47%) had ≥ 1 complication; and 63 patients (15%) had CDS grade ≥ II complications (deviation from standard postoperative course). Complications not related to persistent pain occurred in 103 patients (24%). Ninety-three percent of complications did not require readmission or reoperation (CDS I-II). Within 90 days, 8% presented to an ED, 2% required readmission, and 2% required reoperation. Common complications were back pain > 6 weeks postoperatively (26%), surgical site complications (7%), and ileus/prolonged constipation (3%). Risk factors for experiencing any complication were BMI ≥ 34 (OR 3.44) and Lenke 6 curve (OR 1.95). CONCLUSION: One in four AIS patients experiences a complication not related to persistent pain after primary PSF, higher than rates published from self-reported registries. Obesity and Lenke 6 curve may increase risk. While most do not require readmission or surgery, 15% of patients have their postoperative course altered by complications. LEVEL OF EVIDENCE: III-retrospective cohort study.

Complications With Surgical Treatment of Pediatric Supracondylar Humerus Fractures: Does Surgeon Training Matter?

INTRODUCTION: National trends reveal increased transfers to referral hospitals for surgical management of pediatric supracondylar humerus (SCH) fractures. This is partly because of the belief that pediatric orthopaedic surgeons (POs) deliver improved outcomes compared with nonpediatric orthopaedic surgeons (NPOs). We compared early outcomes of surgically treated SCH fractures between POs and NPOs at a single center where both groups manage these fractures. METHODS: Patients ages 3 to 10 undergoing surgery for SCH fractures from 2014 to 2020 were included. Patient demographics and perioperative details were recorded. Radiographs at surgery and short-term follow-up assessed reduction. Primary outcomes were major loss of reduction (MLOR) and iatrogenic nerve injury (INI). Complications were compared between PO-treated and NPO-treated cohorts. RESULTS: Three hundred and eleven fractures were reviewed. POs managed 132 cases, and NPOs managed 179 cases. Rate of MLOR was 1.5% among POs and 2.2% among NPOs (P=1). Rate of INI was 0% among POs and 3.4% among NPOs (P=0.041). All nerve palsies resolved postoperatively by mean 13.1 weeks. Rates of reoperation, infection, readmission, and open reduction were not significantly different. Operative times were decreased among POs (38.1 vs. 44.6 min; P=0.030). Pin constructs were graded as higher quality in the PO group, with a higher mean pin spread ratio (P=0.029), lower rate of "C" constructs (only 1 "column" engaged; P=0.010) and less frequent crossed-pin technique (P<0.001). Multivariate analysis revealed minimal positive associations only for operative time with MLOR (odds ratio=1.021; P=0.005) and INI (odds ratio=1.048; P=0.009). CONCLUSIONS: Postsurgical outcomes between POs and NPOs were similar. Rates of MLOR were not different between groups, despite differences in pin constructs. The NPO group experienced a marginally higher rate of INI, though all injuries resolved. Pediatric subspecialty training is not a prerequisite for successfully treating SCH fractures, and overall value of orthopaedic care may be improved by decreasing transfers for these common injuries. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

When Is a Growth-friendly Strategy Warranted? A Matched Comparison of Growing Rods Versus Primary Posterior Spinal Fusion in Juveniles With Early-onset Scoliosis.

BACKGROUND: In 7 to 11-year-old juveniles with severe early-onset scoliosis (EOS) the optimal surgical option remains uncertain. This study compares growing rods (GRs) followed by definitive posterior spinal fusion (PSF) versus primary PSF in this population. We hypothesized that the thoracic height afforded by GRs would be offset by increased rigidity, more complications, and more operations. METHODS: This retrospective comparative study included EOS patients aged 7.0 to 11.9 years at index surgery treated with GR→PSF or primary PSF during 2013 to 2020. Primary outcomes were thoracic height gain (ΔT1-12H), major curve, complications, and total operations. Primary PSFs were matched with replacement 1-to-n to GR→PSFs by age at index, etiology, and major curve. RESULTS: Twenty-eight GR→PSFs met criteria: 19 magnetically controlled GRs and 9 traditional GRs. Three magnetically controlled GRs were definitively explanted without PSF due to complications. The remaining 25 GR→PSFs were matched to 17 primary PSFs with 100% etiology match, mean Δ major curve 1 degree, and mean Δ age at index 0.5 years (PSFs older). Median ΔT1-12H pre-GR to post-PSF was 4.7 cm with median deformity correction of 37%. Median ΔT1-12H among primary PSFs was 1.9 cm with median deformity correction of 62%. GR→PSFs had mean 1.8 complications and 3.4 operations. Primary PSFs had mean 0.5 complications and 1.3 operations. Matched analysis showed adjusted mean differences of 2.3 cm greater ΔT1-12H among GR→PSFs than their matched primary PSFs, with 25% less overall coronal deformity correction, 1.2 additional complications, and 2.2 additional operations per patient. CONCLUSIONS: In juveniles aged 7 to 11 with EOS, on average GRs afford 2 cm of thoracic height over primary PSF at the cost of poorer deformity correction and additional complications and operations. Primary PSF affords an average of 2 cm of thoracic height gain; if an additional 2 cm will be impactful then GRs should be considered. However, in most juveniles the height gained may not warrant the iatrogenic stiffness, complications, and additional operations. Surgeons and families should weigh these benefits and harms when choosing a treatment plan. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

The Prevalence of Bacterial Infection in Patients Undergoing Elective ACDF for Degenerative Cervical Spine Conditions: A Prospective Cohort Study With Contaminant Control.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: To determine the prevalence of bacterial infection, with the use of a contaminant control, in patients undergoing anterior cervical discectomy and fusion (ACDF). METHODS: After institutional review board approval, patients undergoing elective ACDF were prospectively enrolled. Samples of the longus colli muscle and disc tissue were obtained. The tissue was then homogenized, gram stained, and cultured in both aerobic and anaerobic medium. Patients were classified into 4 groups depending on culture results. Demographic, preoperative, and postoperative factors were evaluated. RESULTS: Ninety-six patients were enrolled, 41.7% were males with an average age of 54 ± 11 years and a body mass index of 29.7 ± 5.9 kg/m2. Seventeen patients (17.7%) were considered true positives, having a negative control and positive disc culture. Otherwise, no significant differences in culture positivity was found between groups of patients. However, our results show that patients were more likely to have both control and disc negative than being a true positive (odds ratio = 6.2, 95% confidence interval = 2.5-14.6). Propionibacterium acnes was the most commonly identified bacteria. Two patients with disc positive cultures returned to the operating room secondary to pseudarthrosis; however, age, body mass index, prior spine surgery or injection, postoperative infection, and reoperations were not associated with culture results. CONCLUSION: In our cohort, the prevalence of subclinical bacterial infection in patients undergoing ACDF was 17.7%. While our rates exclude patients with positive contaminant control, the possibility of contamination of disc cultures could not be entirely rejected. Overall, culture results did not have any influence on postoperative outcomes.

Delayed Diagnosis of Tandem Spinal Stenosis: A Retrospective Institutional Review.

BACKGROUND: Tandem spinal stenosis (TSS) is defined as simultaneous spinal stenosis in the cervical, thoracic, and/or lumbar regions and may present with both upper and lower motor neuron symptoms, neurogenic claudication, and gait disturbance. Current literature has focused mainly on the prevalence of TSS and treatment methods, while the incidence of delayed TSS diagnosis is not well defined. The purpose of this study was to determine the incidence of delayed TSS diagnosis at our institution and describe the clinical characteristics commonly observed in their particular presentation. METHODS: Following institutional review board approval, an institutional billing database review was performed for patients who underwent a spinal decompression procedure between 2006 and 2016. Thirty-three patients who underwent decompression on 2 separate spinal regions within 1 year were included for review. Patients with delayed diagnosis of TSS following the first surgery were differentiated from those with preoperative diagnosis of TSS. RESULTS: TSS requiring surgical decompression occurred in 33 patients, with the incidence being 2.06% in this cohort. Fifteen patients received a delayed diagnosis after the first surgical decompression (45%) and were found to have a longer interval between decompressions (7.6 ± 2.1 months versus 4.01 ± 3 months, P = .0004). Patients undergoing lumbar decompression as the initial procedure were more likely to have a delayed diagnosis of TSS (8 versus 2 patients, P = .0200). The most common presentation of delayed TSS was pain and myelopathic symptoms that persisted after decompressive surgery. CONCLUSION: TSS should remain within the differential diagnosis for patients at initial presentation of spinal stenosis. In addition, suspicion of TSS should be heightened if preoperative symptoms fail to expectedly improve following decompression even if overt myelopathic signs are not present. LEVEL OF EVIDENCE: 4.

Effect of forced-air warming blanket position in elective lumbar spine surgery: Intraoperative body temperature and postoperative complications.

BACKGROUND: Perioperative hypothermia is linked to multiple postoperative complications including increased surgical bleeding, surgical site infection, myocardial events, and increased length of hospital stay. The purpose of this study is to determine the effects of forced-air warming blanket position, above the shoulders versus under the trunk/legs, on intraoperative core body temperature and perioperative complications in elective lumbar spine surgery. METHODS: After IRB approval, patients were enrolled in a consecutive fashion and randomized to either upper body (Group I) or lower body (Group II) groups. Primary outcomes were intraoperative body temperature, incidence of hypothermia, postoperative complications, and infection. Secondary outcomes included blood loss, operative time, and length of stay. RESULTS: Seventy-four patients were included (Group I, 38; Group II, 36, mean age 60.7 years, 54% of male). Average patient follow-up was 69 ± 33.6 days in Group I and 67 ± 34.6 days in Group II. Average intraoperative body temperature was 35.7 in Group I and 35.8 in Group II (P = 0.27). Incidence of critical hypothermia (T < 35°C) was 18.4% and 11.1% in Groups I and II, respectively (P = 0.52). Incidence of mild hypothermia (T: 35°C-36°C) was 34.2% and 30.56% in Groups I and II, respectively (P = 0.81). Separately, pooled analysis comparing average body temperature and incidence infection demonstrated a relationship between mild hypothermia and infection (P = 0.03). CONCLUSION: Compared to using a lower body Bair Hugger under the patient, using standard upper body Bair Hugger may be associated with increased surgical site infection. Given equivalent body warming, we recommend using the lower body Bair Hugger to avoid infection.

Biomechanical evaluation of lumbar lateral interbody fusion for the treatment of adjacent segment disease.

BACKGROUND CONTEXT: Adjacent segment disease (ASD) is a well-known complication after lumbar fusion. Lumbar lateral interbody fusion (LLIF) may provide an alternative method of treatment for ASD while avoiding the morbidity associated with revision surgery through a traditional posterior approach. This is the first biomechanical study to evaluate the stability of lateral-based constructs for treating ASD in existing multilevel fusion model. PURPOSE: We aimed to evaluate the biomechanical stability of anterior column reconstruction through the less invasive lateral-based interbody techniques compared with traditional posterior spinal fusion for the treatment of ASD in existing multilevel fusion. STUDY DESIGN/SETTING: Cadaveric biomechanical study of laterally based interbody strategies for treating ASD. METHODS: Eighteen fresh-frozen cadaveric specimens were nondestructively loaded in flexion, extension, and lateral bending. The specimens were randomized into three different groups according to planned posterior spinal instrumented fusion (PSF): group 1: L5-S1, group 2: L4-S1, and group 3: L3-S1. In each group, ASD was considered the level cranial to the upper-instrumented vertebrae (UIV). After testing the intact spine, each specimen underwent PSF representing prior fusion in the ASD model. The adjacent segment for each specimen then underwent (1) Stand-alone LLIF, (2) LLIF + plate, (3) LLIF + single screw rod (SSR) anterior instrumentation, and (4) LLIF + traditional posterior extension of PSF. In all conditions, three-dimensional kinematics were tracked, and range of motion (ROM) was calculated for the comparisons. RESULTS: ROM results were expressed as a percentage of the intact spine ROM. LLIF effectively reduces ROM in all planes of ROM. Supplementation of LLIF with plate or SSR provides further stability as compared with stand-alone LLIF. Expansion of posterior instrumentation provides the most substantial stability in all planes of ROM (p <.05). All constructs demonstrated a consistent trend of reduction in ROM between all the groups in all bending motions. CONCLUSIONS: This biomechanical study suggests potential promise in exploring LLIF as an alternative treatment of ASD but reinforces previous studies' findings that traditional expansion of posterior instrumentation provides the most biomechanically stable construct.

Outcomes of multilevel vertebrectomy for spondylodiscitis.

BACKGROUND CONTEXT: The incidence of pyogenic vertebral osteomyelitis (PVO) continues to increase in the United States, highlighting the need to recognize unique challenges presented by these cases and develop effective methods of surgical management. To date, no prior research has focused on the outcomes of PVO requiring two or more contiguous corpectomies. PURPOSE: To describe our experience in the operative management of PVO in 56 consecutive patients who underwent multilevel corpectomies (≥2 vertebral bodies) via a combined approach. STUDY DESIGN/SETTING: Single institution retrospective cohort review between January 2002 and December 2015. All patients had been treated at an academic tertiary referral center by one of two fellowship-trained orthopedic spine surgeons. PATIENT SAMPLE: Patient records were cross-referenced with International Classification of Diseases osteomyelitis codes and paravertebral abscess code. Inclusion criteria for the study were patients within the cohort who had adequate medical records for review, a minimum patient age of 18 years, active vertebral osteomyelitis as an indication for surgical intervention, a minimum of 1-year radiographic follow-up, and surgical intervention that included at least two complete vertebral corpectomies. Subsequently, 56 patients met the inclusion criteria and were reviewed for this retrospective analysis. OUTCOME MEASURES: Outcomes of interest were readmission and reoperation rates related to treatment of PVO, 30-day and 1-year mortality rates, radiographic outcomes, perioperative complications, infection control, and length of stay. METHODS: After obtaining approval from the Institutional Review Board, retrospective review was performed on records of all adults with PVO refractory to standard nonoperative treatment who underwent complete corpectomy of two or more contiguous vertebrae at a single institution between January 2002 and December 2015. This study was not funded, and no potential conflict of interest-associated biases were present. RESULTS: Fifty-six patients were identified (63% men; mean age 56.8 years; mean radiographic follow-up 2.8 years). Median length of stay was 13 days with nearly half readmitted (47%) after a median of 222.5 days after surgery. Twelve (22%) posterior revisions were required after a median 54 days for infection, painful or failed hardware, proximal junction kyphosis, adjacent level disease, or extension of the fusion. Thirty-day and 1-year mortality rates were 7.14% and 19.6%, respectively, with an infectious etiology as the most common cause of death. CONCLUSIONS: Multilevel vertebral corpectomy for treatment of refractory vertebral osteomyelitis is associated with relatively high rates of complications and mortality compared with historical controls for 1 or 2 level procedures. We found clinical resolution and absence of complications requiring return to the operating room in 75% of patients when complete extirpation of the involved vertebrae is achieved. Our findings suggest multilevel anterior corpectomies with posterior stabilization may be a reasonable surgical option when approaching patients with complicated spondylodiscitis.

Mortality Rates After Posterior C1-2 Fusion for Displaced Type II Odontoid Fractures in Octogenarians.

STUDY DESIGN: Retrospective cohort study OBJECTIVE.: To assess 30-day and 1-year mortality rates as well as the most common complications associated with posterior C1-2 fusion in an octogenarian cohort. SUMMARY OF BACKGROUND DATA: Treatment of unstable type II odontoid fractures in elderly patients can present challenges. Recent evidence indicates in patients older than 80 years, posterior C1-2 fusion results in improved survival as compared to other modes of treatment. METHODS: Retrospective analysis of 43 consecutive patients (25 female and 18 male; mean age 84.3 yr, range 80-89 yr; mean Charlson Comorbidity Index 1.4, (range 1-6); mean body mass index 24.8 ±â€Š4.2 kg/m, who underwent posterior C1-C2 fusion for management of unstable type II odontoid fracture by four fellowship trained spine surgeons at a single institution between January 2006 to June 2016. RESULTS: Mean fracture displacement was 5.1 ±â€Š3.6 mm and mean absolute value of angulation was 19.93°â€Š±â€Š12.93°. The most common complications were altered mental status (41.9%, n = 18), dysphagia (27.9%, n = 12) with 50% of those patients (6/12) requiring a feeding tube, and emergency reintubation (9.3%, n = 4). To the date of review completion, 25 of 43 patients expired (58.1%), median survival of 1.76 years from the date of surgery. Thirty-day and 1-year mortality rates were 2.3% and 18.6%, respectively. Patients who developed dysphagia were 14.5 times more likely to have expired at 1 year; dysphagia was also found to be significantly associated with degree of displacement. Fracture displacement was found to be associated with increased odds for 1-year mortality when accounting for age and requirement of a feeding tube. CONCLUSION: Posterior C1-2 fusion results in acceptably low mortality rates in octogenarians with unstable type II odontoid fractures when compared to nonoperative management mortality rates in current literature. Initial fracture displacement is associated with higher mortality rate in this patient population. LEVEL OF EVIDENCE: 4.