Timing of intraoperative neurophysiological monitoring (IONM) recovery and clinical recovery after termination of pediatric spinal deformity surgery due to loss of IONM signals.

BACKGROUND CONTEXT: Intraoperative neurophysiological monitoring (IONM) is used to reduce the risk of spinal cord injury during pediatric spinal deformity surgery. Significant reduction and/or loss of IONM signals without immediate recovery may lead the surgeon to acutely abort the case. The timing of when monitorable signals return remains largely unknown. PURPOSE: The goal of this study was to investigate the correlation between IONM signal loss, clinical examination, and subsequent normalization of IONM signals after aborted pediatric spinal deformity surgery to help determine when it is safe to return to the operating room. STUDY DESIGN/SETTING: This is a multicenter, multidisciplinary, retrospective study of pediatric patients (<18 years old) undergoing spinal deformity surgery whose surgery was aborted due to a significant reduction or loss of IONM potentials. PATIENT SAMPLE: Sixty-six patients less than 18 years old who underwent spinal deformity surgery that was aborted due to IONM signal loss were enrolled into the study. OUTCOME MEASURES: IONM data, operative reports, and clinical examinations were investigated to determine the relationship between IONM loss, clinical examination, recovery of IONM signals, and clinical outcome. METHODS: Information regarding patient demographics, deformity type, clinical history, neurologic and ambulation status, operative details, IONM information (eg, quality of loss [SSEPs, MEPs], laterality, any recovery of signals, etc.), intraoperative wake-up test, postoperative neurologic exam, postoperative imaging, and time to return to the operating were all collected. All factors were analyzed and compared with univariate and multivariate analysis using appropriate statistical analysis. RESULTS: Sixty-six patients were enrolled with a median age of 13 years [IQR 11-14], and the most common sex was female (42/66, 63.6%). Most patients had idiopathic scoliosis (33/66, 50%). The most common causes of IONM loss were screw placement (27/66, 40.9%) followed by rod correction (19/66, 28.8%). All patients had either complete bilateral (39/66, 59.0%), partial bilateral (10/66, 15.2%) or unilateral (17/66, 25.8%) MEP loss leading to termination of the case. Overall, when patients were returned to the operating room 2 weeks postoperatively, nearly 75% (40/55) had monitorable IONM signals. Univariate analysis demonstrated that bilateral SSEP loss (p=.019), bilateral SSEP and MEP loss (p=.022) and delayed clinical neurologic recovery (p=.008) were significantly associated with having unmonitorable IONM signals at repeat surgery. Multivariate regression analysis demonstrated that delayed clinical neurologic recovery (> 72 hours) was significantly associated with unmonitorable IONM signals when returned to the operating room (p=.006). All patients ultimately made a full neurologic recovery. CONCLUSIONS: In children whose spinal deformity surgery was aborted due to intraoperative IONM loss, there was a strong correlation between combined intraoperative SSEP/MEP loss, the magnitude of IONM loss, the timing of clinical recovery, and the time of electrophysiological IONM recovery. The highest likelihood of having a prolonged postoperative neurological deficit and undetectable IONM signals upon return to the OR occurs with bilateral complete loss of SSEPs and MEPs.

Analysis of 5,070 consecutive pedicle screws placed utilizing robotically assisted surgical navigation in 334 patients by experienced pediatric spine deformity surgeons: surgical safety and early perioperative complications in pediatric posterior spinal fusion.

PURPOSE: This study evaluates the intraoperative and short-term complications associated with robotically assisted pedicle screw placement in pediatric posterior spinal fusion (PSF) from three surgeons at two different institutions. METHODS: We retrospectively reviewed 334 pediatric patients who underwent PSF with robotic-assisted navigation at 2 institutions over 3 years (2020-2022). Five thousand seventy robotically placed screws were evaluated. Data collection focused on intraoperative and early postoperative complications with minimum 30-day follow-up. Patients undergoing revision procedures were excluded. RESULTS: Intraoperative complications included 1 durotomy, 6 patients with neuromonitoring alerts not related to screw placement, and 62 screws (1.2%) with documented pedicle breaches, all of which were revised at time of surgery. By quartile, pedicle breaches statistically declined from first quartile to fourth quartile (1.8% vs. 0.56%, p < 0.05). No breach was associated with neuromonitoring changes or neurological sequelae. No spinal cord or vascular injuries occurred. Seventeen postoperative complications occurred in eleven (3.3%) of patients. There were five (1.5%) patients with unplanned return to the operating room. CONCLUSION: Robotically assisted pedicle screw placement was safely and reliably performed on pediatric spinal deformity by three surgeons across two centers, demonstrating an acceptable safety profile and low incidence of unplanned return to the operating room.

What Do We C in Children With Scurvy? A Case Series Focused on Musculoskeletal Symptoms.

OBJECTIVES: Vitamin C deficiency in children commonly presents with musculoskeletal symptoms such as gait disturbance, refusal to bear weight, and bone or joint pain. We aimed to identify features that could facilitate early diagnosis of scurvy and estimate the cost of care for patients with musculoskeletal symptoms related to scurvy. METHODS: We conducted a retrospective chart review of patients at a single site with diagnostic codes for vitamin C deficiency, ascorbic acid deficiency, or scurvy. Medical records were reviewed to identify characteristics including presenting symptoms, medical history, and diagnostic workup. The Pediatric Health Information System was used to estimate diagnostic and hospitalization costs for each patient. RESULTS: We identified 47 patients with a diagnosis of scurvy, 49% of whom had a neurodevelopmental disorder. Sixteen of the 47 had musculoskeletal symptoms and were the focus of the cost analysis. Three of the 16 had moderate or severe malnutrition, and 3 had overweight or obesity. Six patients presented to an emergency department for care, 11 were managed inpatient, and 3 required critical care. Diagnostic workups included MRI, computed tomography, echocardiogram, endoscopy, lumbar puncture, and/or EEG. Across all patients evaluated, the cost of emergency department utilization, imaging studies, diagnostic procedures, and hospitalization totaled $470 144 (median $14 137 per patient). CONCLUSIONS: Children across the BMI spectrum, particularly those with neurodevelopmental disorders, can develop vitamin C deficiency. Increased awareness of scurvy and its signs and symptoms, particularly musculoskeletal manifestations, may reduce severe disease, limit adverse effects related to unnecessary tests/treatments, and facilitate high-value care.

Intraoperative neuromonitoring predicts postoperative deficits in severe pediatric spinal deformity patients.

PURPOSE: To evaluate intraoperative monitoring (IOM) alerts and neurologic deficits during severe pediatric spinal deformity surgery. METHODS: Patients with a minimum Cobb angle of 100° in any plane or a scheduled vertebral column resection (VCR) with minimum 2-year follow-up were prospectively evaluated (n = 243). Preoperative, immediate postoperative, and 2-year postoperative neurologic status were reported. Radiographic data included preoperative and 2-year postoperative coronal and sagittal Cobb angles and deformity angular ratios (DAR). IOM alert type and triggering event were recorded. SRS-22r scores were collected preoperatively and 2-years postoperatively. RESULTS: IOM alerts occurred in 37% of procedures with three-column osteotomy (n = 36) and correction maneuver (n = 32) as most common triggering events. Patients with IOM alerts had greater maximum kyphosis (101.4° vs. 87.5°) and sagittal DAR (16.8 vs. 12.7) (p < 0.01). Multivariate regression demonstrated that sagittal DAR independently predicted IOM alerts (OR 1.05, 95% CI 1.02-1.08) with moderate sensitivity (60.2%) and specificity (64.8%) using a threshold value of 14.3 (p < 0.01). IOM alerts occurred more frequently in procedures with new postoperative neurologic deficits (17/24), and alerts with both SSEP and TCeMEP signals were associated with new postoperative deficits (p < 0.01). Most patients with new deficits experienced resolution at 2 years (16/20) and had equivalent postoperative SRS-22r scores. However, patients with persistent deficits had worse SRS-22r total score (3.8 vs. 4.2), self-image subscore (3.5 vs. 4.1), and function subscore (3.8 vs. 4.3) (p ≤ 0.04). CONCLUSION: Multimodal IOM alerts are associated with sagittal kyphosis, and predict postoperative neurologic deficits. Most patients with new deficits experience resolution of their symptoms and have equivalent 2-year outcomes. LEVEL OF EVIDENCE: II.

The Effect of Implant Density on Adolescent Idiopathic Scoliosis Fusion: Results of the Minimize Implants Maximize Outcomes Randomized Clinical Trial.

BACKGROUND: Severe adolescent idiopathic scoliosis (AIS) can be treated with instrumented fusion, but the number of anchors needed for optimal correction is controversial. METHODS: We conducted a multicenter, randomized study that included patients undergoing spinal fusion for single thoracic curves between 45° and 65°, the most common form of operatively treated AIS. Of the 211 patients randomized, 108 were assigned to a high-density screw pattern and 103, to a low-density screw pattern. Surgeons were instructed to use ≥1.8 implants per spinal level fused for patients in the high-implant-density group or ≤1.4 implants per spinal level fused for patients in the low-implant-density group. The primary outcome measure was the percent correction of the coronal curve at the 2-year follow-up. The power analysis for this trial required 174 patients to show equivalence, defined as a 95% confidence interval (CI) within a ±10% correction margin with a probability of 90%. RESULTS: In the intention-to-treat analysis, the mean percent correction of the coronal curve was equivalent between the high-density and low-density groups at the 2-year follow-up (67.6% versus 65.7%; difference, -1.9% [95% CI: -6.1%, 2.2%]). In the per-protocol cohorts, the mean percent correction of the coronal curve was also equivalent between the 2 groups at the 2-year follow-up (65.0% versus 66.1%; difference, 1.1% [95% CI: -3.0%, 5.2%]). A total of 6 patients in the low-density group and 5 patients in the high-density group required reoperation (p = 1.0). CONCLUSIONS: In the setting of spinal fusion for primary thoracic AIS curves between 45° and 65°, the percent coronal curve correction obtained with use of a low-implant-density construct and that obtained with use of a high-implant-density construct were equivalent. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

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.

Medical complications and health-related quality of life in complex pediatric spine deformities exceeding 100 degrees or treated by 3CO.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To determine the incidence of medical complications in the pediatric population aged 10-20 years with baseline deformities exceeding 100 degrees or who had 3CO at surgery. Severe pediatric spine deformity poses a great challenge to the treating physician and carries a high complication rate. Pulmonary complications are among the most life threatening. The onus is on the treating surgeon to identify patients who are high risk and institute measures to mitigate the risk for successful outcomes. METHOD: Data of 251/311pts from FOX pediatric database from 17 international sites was queried for incidence of major medical complications. Comparative analysis was done to determine the impact of such complications on HRQoL using paired t-test. Risk factors associated with medical complications were assessed using Firth logistic regression. RESULTS: 251/311pts had min 2 year f/u. 142F/109 M, average age 14.61years (10-20). Etiologies included 96 Cong,94 Idiopathic, 14-Post TB, 12-NM,12-NF,10-syndromic,8 others. Curve types included Scoliosis-121, Kyphoscoliosis 72, Kyphosis 58. Coronal and sag cobb avg 88° ± 41.47 and 91.92° ± 39.17, respectively. Deformity apices were in the thoracic region in 88% of patients. Pre-op co-morbidities included 54 (21.5%) cardiopulmonary; 7(2.79%) Genitounrinary;13 (5.18%) GI;13 (5.18%) Anxiety/depression; neurological 24 (9.56%). HGT was utilized in 103pts (41%) at an average duration of 68 days. Mean OR time was 459 min, blood loss averaged 1465 ml. VCR was performed in 120(47.81%), PSO in 16 pts (6.37%), SPO in 145pts (57.77%), Thoracoplasty in 132 pts (52.8%). 96% had blood and other blood products transfusion (FFP and platelets). There were 35 post-op medical complications occurring in 29pts (11.6%). Event-specific cumulative incidence was 24 (9.6%) pulmonary, 5(2.0%) gastrointestinal, 3(1.2%) cardiovascular, 1(0.4%) genitourinary and 1(0.4%) other complication. There was no mortality. Osteotomy grade was found to be an independent predictor of pulmonary complication. Despite significant improvement in baseline SRS total and Domain scores at 2 year FU irrespective of medical complication, the improvement in SRS scores were blunted in the complication group. CONCLUSION: Medical complications are common among pediatric patients undergoing complex spine surgery for severe deformity. However, medical complications can be managed successfully. Although baseline HRQoL improved irrespective of medical complication status, clinical differences in the magnitude of the changes in HRQoL were observed in some domains.

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.

UK Higher Education staff experiences of moral injury during the COVID-19 pandemic.

Jonathan Shay argued that social, relational, and institutional contexts were central to understanding moral injury and conceptualised moral injury as a normative response to the betrayal of an individual's understanding of what is right by a more senior/authoritative "other". Using the conceptual lens of moral injury, this paper investigates academic staff experiences of HE during the COVID-19 pandemic and explores the rapid transition back to face-to-face teaching that took place in autumn 2020. To collect data, we used an online survey that opened in January 2021 and ran until the end of March 2021. A total of 663 complete questionnaires were received across the survey period. The questionnaire was comprised of ten topic-related questions, each of which included follow-up sub-questions and also invited participants to write in additional information. The majority of participants felt that during the course of the COVID-19 pandemic, they had acted in ways that put their own health and wellbeing at risk. Of those who had acted in ways that put their health and wellbeing at risk, they believed that their senior management were the most responsible for them acting in such ways, followed by the UK government. Qualitative data showed a systemic absence of leadership in the sector during the time, a sense of betrayal of staff and students by senior management and the government, and feelings of compulsion to act in ways which put lives at risk. On the basis of these results, we argue that there could be synergies between the situation facing healthcare staff and academics during the pandemic. Many of the experiences of HE academic staff during the pandemic reported to us in this research are resonant with the concepts of betrayal and moral injury and resulted in affective responses which we understand here in relation to feelings of guilt, shame, and anger, leading ultimately to poor mental health and wellbeing. This paper discusses implications for the HE sector going forward.

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.

Reduced complication rate with simultaneous detethering and spinal deformity correction surgery compared to staged surgeries in patients with early onset scoliosis.

PURPOSE: In patients with early onset scoliosis (EOS) and intraspinal anomalies, surgery may be necessary for both the tethered spinal cord (TSC) and spinal deformity. The purpose of this study was to determine if there is a difference in complications when TSC release and surgery for spinal deformity correction (SDC) are performed separately compared simultaneously. METHODS: EOS patients with TSC who underwent detethering and SDC surgeries were identified through a multicenter registry. Patients were stratified into two groups. The simultaneous cohort consisted of patients receiving both detethering and SDC surgeries in a single anesthetic event on the same day, and the staged cohort consisted of patients undergoing detethering and SDC on two separate occasions. Postoperative complications up to 180 days for either surgery were assessed. RESULTS: Twenty five (65.8%) patients were staged and 13 (34.2%) underwent a simultaneous approach. Percent curve correction following SDC surgery did not significantly differ between the groups (p = 0.36). Within 90 days postoperatively, 16 complications in 11 patients (44.0%) occurred in the staged group, whereas no complications occurred in the simultaneous cohort (p = 0.006). From 90-days to 180-days postoperatively, 4 additional complications in 3 patients (12.0%) occurred in the staged group, with no complications reported in the same timeframe for the simultaneous cohort. CONCLUSION: To our knowledge, this is the largest multicenter comparative study to date, and it suggests that a simultaneous approach can be performed safely for EOS patients undergoing detethering and SDC surgeries, with a potentially lower risk profile than the traditional staged approach to these pathologies. LEVEL OF EVIDENCE: Level III.

Ten-year follow-up of Lenke 5 curves treated with spinal fusion.

INTRODUCTION: Patients with surgically treated Lenke 5 curves require at least partial fusion of the lumbar spine. The implications of lumbar fusion remain unknown as long-term follow-up is sparse. METHODS: A retrospective review of a prospectively collected registry of patients with Lenke 5 curves treated with spinal fusion was performed. Clinical and radiographic outcomes as well as SRS-22 scores were collected at 2- and 10-year follow-up. RESULTS: 54 of 247 available patients met all inclusion criteria [26 treated with posterior spinal fusion (PSF) and 28 with anterior spinal fusion (ASF)]. Preoperative lumbar curve magnitude was 45.1 ± 8.4° and corrected to 14.0 ± 7.2° (p < 0.001). A 3.3 ± 7.3° increase in curve size was noted at final follow-up (p < 0.008) with 20.3% of patients having a loss of correction (LOC)of 10° or more. Thoracic curve correction and kyphosis were stable at 10-year follow-up. End vertebrae angulation improved from 11.2 ± 23.2° to 0.96 ± 6.4° (p = 0.004) and translation improved from 2.5 ± 2.9 to 0.92 ± 1.5 cm (p = 0.008) with no LOC. Disc wedging below the lower instrumented vertebrae increased from 0.3 ± 4.9° to 2.8 ± 4.4° (p < 0.001) with no change at 10 years. SRS-22 self-image and satisfaction improved from post-operative to final follow-up. No patient required a second operation. CONCLUSIONS: Both ASF and PSF showed durable results at 10-year follow-up with no obvious difference between approaches. 20% of patients had a LOC > 10°; this did not correlate with pain or need for revision surgery. Disc wedging was stable. Selection of LIV did not correlate with pain scores. LEVEL OF EVIDENCE: Level III.

Male High School Students' Perceptions of Nursing as a Professional Career Choice: Nursing Pathway Project.

AIM: The aim of this study was to understand male high school students' perceptions of nursing as a professional career choice. BACKGROUND: Nursing is predominantly female, with male nurses accounting for less than 10 percent of the nursing workforce. METHOD: A 32-item descriptive survey that contained demography items and constructs of the theory of planned behavior was administered to 820 high school students from a large Pacific Northwest school district. RESULTS: Male students scored higher (less positive) relative to female students on all scales. When gay and bisexual male students were compared to female students, there was no statistically significant difference. Gay and bisexual male students scored significantly lower (more positive) than straight male students. CONCLUSION: Self-identified female individuals and self-identified gay and/or bisexual male individuals have a more positive perception of the nursing profession than other self-identified male individuals. Nurse educators should work with high schools, schools of nursing, and nursing professional organizations to implement strategies to recruit male high school students.

Uncorrected Pelvic Obliquity Is Associated With Worse Health-related Quality of Life (HRQoL) in Children and Their Caregivers at the End of Surgical Treatment for Early Onset Scoliosis (EOS).

BACKGROUND: While largely of concern in nonambulatory patients, pelvic obliquity (PO) can be found in many patients with early onset scoliosis (EOS) and may remain following surgery. However, its association with health-related quality of life (HRQoL) in children and their caregivers at the end of treatment is not well understood. The purpose of this study was to investigate the association between residual PO and HRQoL in children and their caregivers at the end of surgical treatment in ambulatory patients with EOS. METHODS: In this retrospective cohort study, a multicenter EOS registry was queried to identify ambulatory patients who underwent definitive posterior spinal fusion (PSF) from 2012 to 2019. Patients with fusions extending to the pelvis were excluded. PO was measured at least 1 year following PSF. HRQoL, Parental Burden, Financial Burden, and Satisfaction were assessed through the 24-Item Early Onset Scoliosis Questionnaire (EOSQ-24) also at a minimum of 1 year following PSF. RESULTS: A total of 155 patients (12.5±2.1 y, 73.5% female) were included. Etiology distribution was 30.3% congenital, 12.9% neuromuscular, 21.3% syndromic, and 35.5% idiopathic. In congenital patients, those with residual PO >8 degrees had worse Satisfaction by 23.2 points compared with those with PO ≤8 degrees. In neuromuscular patients, those with residual PO >7 degrees had worse HRQoL by 16.1 points and Parental Burden by 22.3 points compared with their counterparts. In syndromic patients, those with residual PO >8 degrees had worse HRQoL by 14.8 points, Parental Burden by 16.4 points, and Satisfaction by 21.2 points compared with their counterparts. In idiopathic patients, those with >9 degrees of residual PO had worse HRQoL by 15.0 points and Financial Burden by 26.8 points compared with their counterparts. CONCLUSIONS: Remaining PO at the end of surgical treatment is associated with worse HRQoL in ambulatory children and their caregivers. These results suggest that correction of PO should remain a primary goal of treatment in patients with EOS undergoing surgery. LEVEL OF EVIDENCE: Level II-multicenter retrospective cohort study investigating prognosis.

Modified Clavien-Dindo-sink classification system for adolescent idiopathic scoliosis.

PURPOSE: The Clavien-Dindosink (CDS) classification system provides more treatment-focused granularity than subjective methods of describing surgical complications; however, it has not been validated in posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). The purpose of this study was to modify the CDS system for application in patients with AIS undergoing PSF to assess its inter- and intra-rater reliability for describing complications faced by this population. METHODS: A review of all complications specific to patients with AIS captured in a large multicenter international database was performed. All complications were classified according to CDS, modified by addition of "prolonged initial hospital stay" as a criterion for Grade II. A survey of this complication list and an additional 20 clinical vignettes (sent out on two occasions) was sent to nine spinal deformity surgeons. Weighted kappa values were used to determine inter- and intra-rater reliability. RESULTS: The Fleiss κ value for interrater reliability among 5 respondents grading all AIS complications was 0.8 (very good). For each grade, interrater reliability was very good, with an overall range of 0.8-1. The overall kappa value for intrarater reliability among eight respondents grading 20 vignettes was between 0.6 (good) and 0.9 (very good). CONCLUSION: The modified CDS classification system has very good interrater and intrarater reliability in describing complications following PSF in patients with AIS. This system may be of greater utility for reporting outcomes than a "major" versus "minor" complication system and can serve as a valuable tool for improving surgical practices and patient outcomes in this population. LEVEL OF EVIDENCE: IV case series.

Baclofen Pump Use: Complications After Growth-friendly Instrumentation for Early-onset Scoliosis.

BACKGROUND: Patients with early-onset scoliosis (EOS) and spasticity may receive treatment with an intrathecal baclofen pump. We assessed how baclofen pumps are associated with the odds of complications and secondary interventions after growth-friendly (GF) spine surgery for EOS and analyzed infectious complications within the pump cohort. METHODS: Using a prospectively maintained, international multicenter database, we studied patients with neuromuscular EOS with baclofen pumps who underwent GF spine surgery from 2002 through 2019 (n=25). Baclofen pumps were implanted before GF instrumentation in 18 patients, during in 2 patients, and after in 5 patients. Patients with existing pumps at initial GF spine surgery were matched 1:3 with 54 patients (control group) without pumps according to treatment center, year of surgery, diagnosis, surgery type, and preoperative curve magnitude. Univariate analysis and multivariate logistic regression were performed to compare complications and secondary interventions between the 2 cohorts. RESULTS: Patients with baclofen pumps had 4.8 times the odds [95% confidence interval (CI): 1.5-16] of experiencing any complication within 1 year after initial GF spine surgery compared with controls. During mean follow-up of 6.9±4.3 years, they had 4.7 times the odds (95% CI: 1.3-16) of deep surgical site infection and 5.6 times the odds (95% CI: 1.2-26) of spinal rod removal after any complication. Differences in rates of mechanical complication, such as rod migration and breakage, were nonsignificant between the 2 groups. For the 9 patients (50%) with pumps who experienced infections, the most common microorganisms were Staphylococcus aureus (4 patients) and Pseudomonas aeruginosa (2). The pump/catheter was revised or removed, in addition to antibiotic therapy or surgical irrigation and debridement, in 2 patients. CONCLUSIONS: Among patients with neuromuscular EOS, those with baclofen pumps are much more likely to experience complications within 1 year after GF spine surgery. They are also more likely to have deep surgical site infections, with S. aureus and P. aeruginosa being the most common causative organisms, and to require spinal rod removal. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Pain Neuroscience Education Delivered by a Student Physical Therapist for a Patient with Persistent Musculoskeletal Pain.

BACKGROUND Persistent pain is one of the most common reasons individuals seek healthcare in the United States, costing $635 billion annually. At present, the medical literature outlines many treatments for persistent pain. Pain neuroscience education (PNE) is described in the literature as an educational intervention for patients with persistent pain that can be applied by a physical therapist. There is limited research on the application of PNE by a student physical therapist; however, this case report offers a unique opportunity to examine outcomes for this intervention when applied by a student physical therapist in conjunction with manual therapy and therapeutic exercise. CASE REPORT This case report examined the outcomes of PNE for a 65-year-old patient with a long-standing history of low back, cervical, shoulder, knee, and foot pain. Interventions included 7 sessions of PNE over 4 weeks delivered by a student physical therapist, in combination with manual therapy and exercise prescribed by a licensed physical therapist. Outcomes measured were fear avoidance belief questionnaire, visual analog scale, Tampa scale of kinesiophobia, neurophysiology of pain questionnaire, neck disability index, and Oswestry disability index. CONCLUSIONS Outcomes included clinically significant decreases in subjective pain level, and kinesiophobia; however, there was only a minimal decrease in fear avoidance and no decrease in perceived disability. This case report provides preliminary evidence that positive outcomes can be achieved when PNE is delivered by a student physical therapist combined with manual therapy and therapeutic exercise from an expert clinician for patients with persistent musculoskeletal pain.

Treatment of Kyphosis Arising Secondary to Laminectomy and Irradiation in the Pediatric Population.

The effects of radiation therapy and laminectomy on the growing spine have been well documented. Due to compromised bone quality after irradiation, spinal fusion has a high failure rate. The aim of this study was to evaluate treatment of post-laminectomy and post-irradiation kyphosis in children using a vascularized rib graft (VRG) to augment anterior spinal fusion and posterior spinal fusion. Data were collected retrospectively from electronic medical records for all patients treated at a single institution for post-laminectomy and post-irradiation kyphosis who underwent VRG to augment spinal fusions done between December 2003 and August 2015. Five patients were included in the analysis. Imaging studies were analyzed by 2 senior pediatric orthopedic surgeons and a pediatric orthopedic surgery fellow. The outcome for all 5 patients who underwent VRG were considered successful at most recent clinical follow-up. Success was defined as the following: complete fusion evident through computed tomography scan, no implant failure, and no kyphosis progression. Follow-up ranged from 21 to 63 months. One patient experienced 2 complications: esophageal tear and deep infection. Spinal fusion with a VRG is a viable treatment option for children who have developed kyphosis following laminectomy and irradiation. On long-term follow-up, there has been no evidence of progression of kyphosis for patients who were treated with VRG in either the primary fusion procedure or in subsequent revision procedures. A VRG provides a non-irradiated, vascularized bone graft to bridge the irradiated segments, increasing the stability of the spine. [Orthopedics. 2021;44(4):e563-e569.].

Ultrasonic Bone Scalpel (USBS) Does Not Reduce Blood Loss During Posterior Spinal Fusion (PSF) in Patients with Adolescent Idiopathic Scoliosis (AIS): Randomized Clinical Trial.

STUDY DESIGN: Randomized Clinical Trial. OBJECTIVE: The aim of this study was to compare the efficacy of USBS with standard-of-care surgical instruments during posterior spinal fusion (PSF) in patients with adolescent idiopathic scoliosis (AIS) by evaluating the difference in estimated blood loss per level fused (EBL/level). SUMMARY OF BACKGROUND DATA: PSF surgery for AIS is often associated with high blood loss. Use of an ultrasonic bone scalpel (USBS) has been proposed to reduce blood loss during scoliosis surgery. METHODS: This was a single-blinded (patient-blinded), randomized, controlled superiority trial. We randomized 66 patients with AIS undergoing PSF to the control group (osteotome) or the experimental group (USBS). The primary outcome was intraoperative EBL/level obtained from red blood cell salvage reports. One-year follow-up was available for 57 of 62 (92%) of patients. RESULTS: EBL/level averaged 35 and 39 mL/level in the experimental and control groups, respectively [adjusted mean difference USBS - osteotome -8 mL/level, 95% CI: -16.4 to 0.3 mL/level, P = 0.0575]. There was no difference in curve correction [adjusted mean difference: -1.7%, 95% CI: -7.0 to 3.6%, P = 0.5321] or operative time [adjusted mean difference: -3.55 minutes, 95% CI: -22.45 to 15.46 min, P = 0.7089] between groups. Complications requiring change in routine postoperative care were noted in eight patients: two occurred in patients assigned to the experimental group and six occurred in patients assigned to the control group. CONCLUSION: There was no clinically significant difference in total blood loss, EBL/level, or complications between the two groups. In contrast to reports from other centers, at our high-volume spine center, USBS did not lead to reduced blood loss during PSF for AIS. These results may not be generalizable to centers with longer baseline operative times or higher baseline average blood loss during PSF for AIS.Level of Evidence: 1.

New neurologic deficit and recovery rates in the treatment of complex pediatric spine deformities exceeding 100 degrees or treated by vertebral column resection (VCR).

STUDY DESIGN: Prospective multicenter international observational study. OBJECTIVE: To investigate incidence of new neurologic deficit (NND) and the long-term recovery patterns following complex pediatric spine deformity surgery. The SRS M&M reports identify pediatric patients as having higher rate of new neurologic deficit compared with adults, while congenital and neuromuscular deformities are associated with higher new neurologic risks. Very few studies have had the large numbers of pediatric patients with curves exceeding 100 deg to ascertain the new neurologic deficit (NND) rates and recovery patterns as it relates to curve laterality and diagnosis. METHOD: The FOX pediatric database from 17 international sites was queried for New Neurologic Deficit (NND) as characterized by change in American Spinal Injury Association (ASIA) Lower or Upper Extremity Motor Score. Recovery rates at specific intervals were recorded and related to the curve type and etiology. RESULTS: Data of 286 consecutive patients with normal pre-operative neurologic exams were reviewed. There were 160 females vs 125 males with an average age of 14.6 years. NND occurred in 27 patients (9.4%) in the immediate post-operative period. Diagnostic categories included idiopathic scoliosis (3 patients); idiopathic kyphoscoliosis(5 patients); congenital scoliosis (7 patients); congenital kyphoscoliosis (4 patients); congenital kyphosis (6 patients), other kyphosis (1 patient) and syndromic (1 patient). 1 patient was lost to follow-up (f/u) after discharge; 1 had chronic deficits at the first post-operative erect visit (from discharge to 9 months f/u) and was subsequently lost to follow-up; 2 patients were improving at 1-year f/u but lost to subsequent f/u. 16 patients had normal neurologic function by the time of the first post-operative erect visit, 21 patients at 1-year f/u and 21 patients at the 2-year f/u. 2 patients (0.69%) had improved NND at 2-year mark. CONCLUSION: A significant proportion of patients with complex spine deformity experience NND. However, significant improvement in neurologic function can be expected over time as seen in this study without additional surgical intervention in most cases. Congenital deformities accounted for 63% of the patients experiencing NND.