In-office Maximal Voluntary Ventilation Testing Demonstrates Pulmonary Improvement Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

OBJECTIVE: Pulmonary function can be impaired in patients with adolescent idiopathic scoliosis (AIS). Maximal voluntary ventilation (MVV) has been shown to be more strongly correlated with major coronal curve, and a more easily obtained measurement of pulmonary function, than forced vital capacity (FVC). We evaluated changes in pulmonary function using these 2 measures in patients with AIS in relation to changes in major coronal curves over time. METHODS: Forty-seven patients with AIS with thoracic curves ≥10 degrees performed pulmonary function tests using the Carefusion MicroLoop Spirometer at enrollment and 1 year later. Major coronal curve worsening >5 degrees was considered curve progression. RESULTS: At enrollment, 47 patients had a mean major coronal curve of 38 degrees (range: 10 to 76 degrees). One year later, 17 patients had undergone posterior spinal fusion, 9 had curve progression >5 degrees, and 21 had no progression. MVV and major coronal curve were negatively correlated (r = -0.36, P = 0.01) at enrollment. After fusion, the major coronal curve improved by a mean of 41 degrees, and MVV improved by 23% (P < 0.01), but FVC did not improve significantly (6%, P = 0.29). In stable curves, MVV improved 12% (P = 0.01) and FVC improved 9% (P = 0.007). In patients without surgery whose curves progressed an average of 11 degrees, there was no significant change in MVV or FVC (P > 0.44). CONCLUSION: This is the first study using office-based spirometry in an orthopaedic clinic showing improved pulmonary function with posterior spinal fusion and growth in patients with AIS. It is notable that MVV improved after spinal fusion, but FVC did not, as MVV appears to be a more sensitive measurement for the assessment of pulmonary function in these patients. LEVEL OF EVIDENCE: Level II.

Painful bruising: Gynecology, hematology, or just pill bias? A case report.

A 23-year-old woman, G0, presented to the emergency department with painful bruising of the legs shortly after starting an oral contraceptive pill. The presumed diagnosis was pill-induced ecchymosis, and she was instructed to discontinue the medication. Her bruising resolved. However, the working diagnosis was later questioned as the patient had used other oral contraceptive pills in the past without any adverse reaction. In addition, there is robust literature associating these medications with thrombosis, not bruising. The patient later disclosed that she had concomitantly started an oral hair supplement along with her oral contraceptive pill. Analysis of the supplement contents revealed that it contained extract of Aesculus hippocastanum, a herbal anticoagulant, making this a much more plausible explanation for the ecchymosis. She then resumed the original oral contraceptive pill alone without any reaction. The case highlights how cognitive bias resulted in a misdiagnosis. Specifically, this case introduces the concept of pill bias, as the patient's unexplained bruising was presumed to be a result of her use of an oral contraceptive despite the lack of evidence to support this claim. This bias has the potential to impact clinical decision-making and lead to clinical errors.

High Satisfaction in Adolescent Idiopathic Scoliosis Patients on Enhanced Discharge Pathway.

BACKGROUND: Recently, there have been several reports of using an enhanced discharge pathway following posterior spinal fusion (PSF) in patients with adolescent idiopathic scoliosis (AIS). No previous studies have prospectively examined patient satisfaction of patients with AIS using an enhanced discharge pathway. The purpose of this study was to evaluate patient satisfaction with an enhanced discharge pathway for PSF and whether patients felt that their length of stay was appropriate. METHODS: Patients with AIS undergoing PSF were prospectively enrolled. At their first postoperative clinic visit, patients were administered a survey regarding their experience. RESULTS: Of the 46 patients enrolled (mean age, 14 y), 1 was discharged on postoperative day (POD) 2, 33 were discharged on POD 3, 9 were discharged on POD 4, and 3 were discharged on POD 5. Eighty (37/46) of patients felt that they were discharged at an appropriate time, whereas 20% (9/46) felt they were discharged too early. Patients who felt they were discharged at an appropriate time (mean, 3.2 d) had a trend toward shorter stays than those who felt they were discharged too early (mean, 3.7 d). Overall patient satisfaction of hospital stay was high with a mean of 9 on a 10-point scale (range, 1 to 10). There was no correlation between length of stay and patient satisfaction (P=0.723). Patients who felt they were discharged early had a significantly higher mean FACES pain scores than those who felt they were discharged about right both as inpatients (mean, 4.8 vs. 3.4; P=0.0319) and at their first postoperative clinic visit (5.4 vs. 2.9; P=0.004). CONCLUSIONS: Eighty percent of patients with AIS who underwent PSF felt that the time of discharge was appropriate with an enhanced discharge pathway. There was no correlation between patient satisfaction and length of stay. LEVEL OF EVIDENCE: Level II.

A Comparison of Maximal Voluntary Ventilation and Forced Vital Capacity in Adolescent Idiopathic Scoliosis Patients.

STUDY DESIGN: Prospective, single center. OBJECTIVE: To compare maximal voluntary ventilation (MVV) and forced vital capacity (FVC) testing in the outpatient scoliosis clinic to determine their relative feasibility and sensitivity in assessing pulmonary function in the AIS population. SUMMARY OF BACKGROUND DATA: Evidence of compromised pulmonary function in patients with severe AIS is well established. The American Thoracic Society (ATS) has established criteria for the reliability and accuracy of pulmonary function tests (PFTs), including MVV and FVC. METHODS: A total of 91 AIS patients with thoracic curves of 20° or greater were enrolled in the orthopedic clinic. Patients performed PFTs using the CareFusion MicroLoop Spirometer. MVV and FVC values were collected. Results were considered reliable or "passing" when ATS spirometer guidelines were met. RESULTS: Eighty-seven of the 91 patients (96%) met ATS criteria for the MVV test and 43 of the 91 patients (47%) met criteria for the FVC test. Both MVV (r = -0.41, p < .01) and FVC (r = -0.37, p = .01) were significantly correlated with thoracic Cobb angle. The percentile predicted (%predicted) MVV (r = -0.24, p = .03) and %predicted FVC (r = -0.32, p = .04) were also significantly correlated with thoracic Cobb angle. Of those who passed both tests (42/91 patients), 26% had abnormal MVV results with normal FVC results, and 5% had abnormal FVC results with normal MVV results. CONCLUSION: MVV and FVC correlated closely with Cobb angle. Twice as many AIS patients could perform an MVV test compared with an FVC test. MVV seems to be a more practical and sensitive PFT than FVC for assessing the pulmonary function of AIS patients in the orthopedic clinic setting. LEVEL OF EVIDENCE: Level II.

Psychological Effects of the SRS-22 on Girls With Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Prospective, randomized control study. OBJECTIVES: To determine whether the SRS-22r (SRS-22) has a negative effect on the body image of females with adolescent idiopathic scoliosis (AIS) using the Body Appreciation Scale (BAS). SUMMARY: The SRS-22 is a validated questionnaire designed by the Scoliosis Research Society (SRS) to assess outcomes of scoliosis patients. Parents and nursing staff have expressed concern that the questionnaire may incite body image concerns when administered to teenagers with AIS. METHODS: Female AIS patients were prospectively enrolled and randomly assigned to the study or control group. Patients were being observed, braced, or planning operative intervention. Patients in the study group were administered the SRS-22, followed by the BAS. Patients in the control group were administered only the BAS. The BAS is scored from 13 to 65, with higher scores indicating a more positive body image. RESULTS: 45 females were enrolled and assigned to study group (n = 24, SRS-22+BAS) or control group (n = 21, BAS only). There were no differences between the groups in age (p = .55) or Cobb angle (p = .21). There were no differences in overall BAS scores between study (mean = 55.9, range 31-65) and control group participants (mean = 54.2, range 42-64, p = .56). SRS-22 questions and BAS scores had multiple correlations. A higher BAS score is associated with the following SRS-22 questions: being a happy person in the last 6 months, feeling calm and peaceful during the past 6 months, and feeling attractive with one's current back condition. A lower BAS score is associated with the following SRS-22 questions: being down in the dumps, feeling downhearted and blue, and feeling that one's back condition affects personal relationships. CONCLUSION: Similar BAS scores were observed between the study and control group. Despite concerns regarding the potential negative impact of the SRS-22, taking the questionnaire was not observed to negatively affect patients' body image. LEVEL OF EVIDENCE: Level II.

Pain is the Greatest Preoperative Concern for Patients and Parents Before Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Prospective cross-sectional study. OBJECTIVE: To evaluate patients' and parents' concerns so they can be addressed with appropriate preoperative counseling. SUMMARY OF BACKGROUND DATA: Despite much research on outcomes for posterior spinal fusion (PSF) in adolescent idiopathic scoliosis (AIS), little is available about preoperative fears or concerns. METHODS: Patients with AIS undergoing PSF, their parents, and surgeons were prospectively enrolled and asked to complete a survey on their fears and concerns about surgery at their preoperative appointment. RESULTS: Forty-eight patients and parents completed surveys. Four attending pediatric spine surgeons participated and submitted 48 responses. Mean age of patients was 14.2 years. On a scale of 0 to 10, mean level of concern reported by parents (6.9) was higher than that reported by patients (4.6). Surgeons rated the procedure's complexity on a scale of 0 to 10 and reported a mean of 5.2. Neither patients' nor parents' level of concern correlated with the surgeons' assessment of the procedure's complexity level (R = 0.19 and 0.12, P = 0.20 and P = 0.42, respectively). Top three concerns for patients were pain (25%), ability to return to activities (21%), and neurologic injury (17%). Top three concerns for parents were pain (35%), neurologic injury (21%), and amount of correction (17%). Top three concerns for surgeons were postoperative shoulder balance (44%), neurologic injury (27%), and lowest instrumented vertebrae selection (27%). Patients reported the same concerns 23% of the time as parents, and 17% of the time as surgeons. Parents and surgeons reported the same concerns 21% of the time. CONCLUSION: Pain was the greatest concern for both patients and parents but was rarely listed as a concern by surgeons. Parent and patient level of concern did not correlate to the surgeon's assessment of the procedure's complexity. Neurologic injury was a top concern for all groups, but otherwise there was little overlap between physician, patient, and parent concerns. LEVEL OF EVIDENCE: 3.