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Study Design: Retrospective study.Objective: To assess the learning curve of a dual attending surgeon strategy in severe adolescent idiopathic scoliosis patients.Summary Of Background Data: The advantages of a dual attending surgeon strategy in improving the perioperative outcome in scoliosis surgery had been reported. However, the learning curve of this strategy in severe scoliosis had not been widely studied.Methods: A total of 105 patients with adolescent idiopathic scoliosis with Cobb angle of 90° or greater, who underwent posterior spinal fusion using a dual attending surgeon strategy were recruited. Primary outcomes were operative time, total blood loss, allogeneic blood transfusion requirement, length of hospital stay from time of operation and perioperative complications. Cases were sorted chronologically into group 1: cases 1 to 35, group 2: cases 36 to 70, and group 3: case 71 to 105. Mean operative time (≤193.3 min), total blood loss (≤1612.2 mL), combination of both and allogeneic blood transfusion were the selected criteria for receiver operating characteristic analysis of the learning curve.Results: The mean Cobb angle was 104.5° ± 12.3°. The operative time, total blood loss, and allogeneic blood transfusion requirement reduced significantly for group 1 (220.6 ± 54.8 min; 2011.3 ± 881.8 mL; 12 cases) versus group 2 (183.6 ± 36.7 min; 1481.6 ± 1035.5 mL; 3 cases) and group 1 versus group 3 (175.6 ± 38.4 min; 1343.7 ± 477.8 mL; 3 cases) (P < 0.05). There were six perioperative complications. Fifty-seven cases were required to achieve the preset criteria (mean operative time and mean total blood loss) (area under the curve 0.740; P < 0.001; sensitivity 0.675; specificity 0.662).Conclusion: There was significant improvement in operative time and total blood loss when comparing group 1 versus group 2 and group 1 versus group 3. The cut-off point for the learning curve was 57 cases when the preset criteria were fulfilled (≤193.3 min operative time and ≤1612.2 mL of total blood loss).Level of Evidence: 4. [ABSTRACT FROM AUTHOR]

Study Design: Prospective study.Objective: To determine the parents'/patients' perception on the informed consent process prior to posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) patients.Summary Of Background Data: Understanding parents/patients perspective on the process is important in order to achieve the goal of consent and prevent medico-legal implications.Methods: Fifty AIS patients operated between August 2019 and November 2019 were prospectively recruited. Parents'/patients' perceptions on three sections were evaluated: the process of the informed consent, specific operative risk which they were most concerned with and the accountability of surgeons for the surgical risks. These data were ranked and scored using a 5-point Likert Scale. Preferences were reported in mean and standard deviation. Differences in terms of preferences were studied using One-way analysis of variance (ANOVA) analysis and deemed significant when P < 0.05.Results: There were 30 females (60.0%) and 20 males (40.0%) with a mean age of 41.8 ± 10.6 years. Majority of parents/patients preferred the inform consent to be explained more than once (P = 0.021), once during clinic consultation and once during admission (4.2 ± 1.0). Consent taking by both attending surgeons was preferred (4.5 ± 0.6) compared with other healthcare providers, P < 0.001. Death (60.0%) and neurological deficit (30.0%) were the two most concerned surgical risks. Parents/patients would still hold the surgeon accountable for any complications despite signing the informed consent and they felt that surgeons were directly responsible for screw-related injuries (3.9 ± 0.9), neurological injury (3.8 ± 0.9), and intraoperative bleeding (3.7 ± 0.9).Conclusion: Parents/patients preferred the attending surgeons to personally explain the informed consent, more than once with the use of visual aid. They would still hold the surgeons accountable when complications occur despite acceptance of the informed consent.Level Of Evidence: 2. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective study.Objective: The primary objective of this study was to assess the conformity of the radiological neck and shoulder balance parameters throughout a follow-up period of more than 2 years.Summary Of Background Data: Postoperative shoulder and neck imbalance are undesirable features among Adolescent Idiopathic Scoliosis patients who underwent Posterior Spinal Fusion. There are many clinical and radiological parameters used to assess this clinical outcome. However, we do not know whether these radiological parameters conform throughout the entire follow-up period.Methods: This was a retrospective study done in a single academic institution. Inclusion criteria were patients with scoliosis who underwent posterior instrumented spinal fusion with pedicle screw fixation and attended all scheduled follow-ups for at least 24 months postoperatively. Radiological shoulder parameters were measured from both preoperative antero-posterior and postoperative antero-posterior radiographs. Lateral shoulder parameters were: Radiographic Shoulder Height, Clavicle Angle (Cla-A), Clavicle-Rib Intersection Difference, and Coracoid Height Difference. Medial shoulder and neck parameters were: T1 Tilt and Cervical Axis (CA).Results: The radiographs of 50 patients who had surgery done from November 2013 to November 2015 were analyzed. Mean age of this cohort was 16.3 ± 7.0 years. There were 38 (76%) female patients and 12 (24%) male patients. Mean final follow-up was 38.6 ± 5.8 months. When conformity assessment of the radiological parameter using the interclass coefficient correlation was done, we found that all parameters had significant correlation (P < 0.05). T1 tilt (0.78) had good reliability, CA (0.47), Clavicle-Rib Intersection Difference (0.43), and Coracoid Height Difference (0.40) had moderate reliability and Radiographic Shoulder Height (0.22) and Cla-A (0.13) had poor reliability.Conclusion: All the radiological shoulder and neck balance parameters studied were conformed and suitable to be used to assess the patient postoperatively. Amongst these radiological parameters, T1 tilt followed by CA recorded to be the most reliable parameters over time.Level Of Evidence: 4. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective study.Objective: To investigate the association between postoperative upper instrumented vertebrae (UIV) tilt angle with postoperative medial shoulder and neck imbalance.Summary Of Background Data: Studies had found that current recommendations for UIV selection were not predictive of good postoperative shoulder balance.Methods: A total of 98 patients with adolescent idiopathic scoliosis with Lenke 1/2 curves who underwent posterior spinal fusion between 2013 and 2014 with minimum follow-up of 2 years were recruited. Radiological parameters: UIV tilt angle, T1 tilt, cervical axis, and clavicle angle were measured preoperatively, postoperatively, and at final follow-up.Results: Mean age was 16.2 ± 6.2 years. Mean follow-up was 37.9 ± 6.5 months. There were 73.5% Lenke 1 and 26.5% Lenke 2 curves. Significant factors affecting postoperative T1 Tilt were postoperative UIV tilt angle, preoperative T1 tilt, and preoperative UIV tilt angle. Postoperative UIV tilt angle and preoperative cervical axis were significant factors affecting cervical axis at final follow-up. UIV level was not significant independent factor that affected postoperative T1 tilt and cervical axis. There was strong correlation between postoperative UIV tilt angle and T1 tilt for the whole cohort (P < 0.001), when UIV was at T2 (P < 0.001), T3 (P < 0.001), and T4 (P < 0.001). Postoperative UIV tilt angle also had significant correlation with cervical axis when UIV was at T2 (P = 0.021) and T3 (P = 0.009).Conclusion: Postoperative UIV tilt angle was an independent factor, which had significant correlation with postoperative T1 tilt and cervical axis measurement. There was strong correlation between postoperative UIV tilt angle and T1 tilt for the whole cohort, when UIV was at T3 and T4. There was very strong correlation between postoperative UIV tilt angle and T1 tilt when UIV was at T2. There was also moderate and significant correlation between postoperative UIV tilt angle and cervical axis for the whole cohort.Level Of Evidence: 2. [ABSTRACT FROM AUTHOR]

Study Design: Randomized controlled trial.Objective: The present study investigated the effectiveness of chewing gum on promoting faster bowel function and its ability to hasten recovery for patients with adolescent idiopathic scoliosis (AIS) after posterior spinal fusion (PSF) surgery.Summary Of Background Data: Sham feeding with chewing gum had been reported to reduce the incidence of postoperative ileus by accelerating recovery of bowel function.Methods: We prospectively recruited and randomized 60 patients with AIS scheduled for PSF surgery into treatment (chewing gum) and control group. The patient-controlled anesthesia usage, wound pain score, abdominal pain score, nausea score, and abdominal girth were assessed and recorded at 12, 24, 36, 48, and 60 hours postoperatively. The timing for the first fluid intake, first oral intake, sitting up, walking, first flatus after surgery, first bowel opening after surgery, and duration of hospital stay were also assessed and recorded.Results: We found that there were no significant differences (P > 0.05) in patient-controlled anesthesia usage, wound pain score, abdominal pain score, nausea score, and abdominal girth between treatment (chewing gum) and control groups. We also found that there were no significant difference (P > 0.05) in postoperative recovery parameters, which were the first fluid intake, first oral intake, sitting up after surgery, walking after surgery, first flatus after surgery, first bowel opening after surgery, and duration of hospital stay between both groups. The wound pain was the worst at 12 hours postoperatively, which progressively improved in both groups. The abdominal pain progressively worsened to the highest score at 48 hours in the treatment group and 36 hours in the control group before improving after that. The pattern of severity and recovery of wound pain and abdominal pain was different.Conclusion: We found that chewing gum did not significantly reduce the abdominal pain, promote faster bowel function, or hasten patient recovery.Level Of Evidence: 1. [ABSTRACT FROM AUTHOR]

Study Design: Prospective study.Objective: To evaluate the perioperative outcome of posterior spinal fusion in adolescent idiopathic scoliosis (AIS) patients comparing a single attending surgeon strategy (G1) versus a dual attending surgeon strategy (G2).Summary Of Background Data: The complication rate for surgical correction in AIS is significant. There are no prospective studies that investigate dual attending surgeon strategy for posterior spinal fusion in AIS.Methods: A total of 60 patients (30 patients in each arm) were recruited. The patients were comparable for age, gender, Lenke classification, major Cobb angle magnitude, and number of fusion levels. The anesthetic, surgical, and postoperative protocol was standardized. The outcome measures included the operative duration, blood loss, postoperative hemoglobin, need for transfusion, morphine usage, duration of hospital stay, intraoperative lactate levels, and pH. The timing of the operation at six critical stages of the operation was recorded.Results: The mean operative time for G2 was 173.6 ± 27.0 minutes versus 248.0 ± 49.9 minutes in G1 (P < 0.000). Mean blood loss in G2 was 0.92 ± 0.4 L and 1.25 ± 0.6 L in G1 (P < 0.05). None of the patients in G2 required any allogenic transfusion. Four patients in G1 (13.3%) required allogenic blood product transfusion. The day 2 postoperative hemoglobin levels in both groups were similar, but this was taken after blood product transfusion in G1. The amount of morphine usage was 20.4 ± 11.5 mg in G2 and 42.5 ± 24.0 mg in G1 (P < 0.000). G2 patients had a shorter hospital stay. One patient in G1 had superficial wound infection. G2 was faster than G1 during exposure, instrumentation, facetectomy, and bone grafting.Conclusion: The involvement of two attending surgeons significantly reduced operative time, blood loss, need for allogenic blood transfusion, patient-controlled analgesia morphine requirement and led to faster patient recovery during the perioperative period.Level Of Evidence: 2. [ABSTRACT FROM AUTHOR]

Study Design: Prospective clinical study.Objective: To analyze the amount of blood loss at different stages of Posterior Instrumented Spinal Fusion (PSF) surgery in adolescent idiopathic scoliosis (AIS) patients.Summary Of Background Data: Knowing the pattern of blood loss at different surgical stages may enable the surgical team to formulate a management strategy to reduce intraoperative blood loss.Methods: One hundred AIS patients who underwent PSF from January 2013 to December 2014 were recruited. The operation was divided into six stages; stage 1-exposure, stage 2-screw insertion, stage 3-release, stage 4-correction, stage 5-corticotomies and bone grafting, and stage 6-closure. The duration and blood loss at each stage was documented. The following values were calculated: total blood loss, blood loss per estimated blood volume, blood loss per minute, blood loss per vertebral level fused, and blood loss per minute per vertebral level fused.Results: There were 89 females and 11 males. The mean age was 17.0 ± 5.8 years old. Majority (50.0%) were Lenke 1 curve type. The mean preoperative major Cobb angle was 64.9 ± 15.0°. The mean number of levels fused was 9.5 ± 2.3 levels. The mean operating time was 188.5 ± 53.4 minutes with a mean total blood loss 951.0 ± 454.0 mLs. The highest mean blood loss occurred at stage 2 (301.0 ± 196.7 mL), followed by stage 4 (226.8 ± 171.2 mL) and stage 5 (161.5 ± 146.6 mL). The highest mean blood loss per minute was at stage 5 (17.1 ± 18.3 mL/min), followed by stage 3 (12.0 ± 10.8 mL/min). The highest mean blood loss per vertebral levels fused was at stage 2 (31.0 ± 17.7 mL/level), followed by stage 4 (23.9 ± 18.1 mL/level) and stage 5 (16.6 ± 13.3 mL/level).Conclusion: All stages were significant contributors to the total blood loss except exposure (stage 1) and closure (stage 6). Blood loss per minute and blood loss per minute per level was highest during corticotomies (stage 5), followed by release (stage 3). However, the largest amount of total blood loss occurred during screw insertion (stage 2).Level Of Evidence: 2. [ABSTRACT FROM AUTHOR]