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Durability of outcomes following vertebral body tethering (VBT) is a concern and may be impacted by tether breakage (TB), which has been unstudied in a large cohort. We characterized TB rates and their impact on clinical outcomes in the largest single-surgeon series to date.Inclusion criteria were VBT patients with AIS, major Cobb angle ≤ 75°, and minimum 2-year follow-up (FU). TBs were identified on 1- and 2-year FU X-rays. TB rates between single-cord and double-cord tethers were evaluated using two-proportion z test. Curve correction rates and SRS-22 scores between patients with and without TB at 2 years were evaluated using Mann-Whitney U test.69 patients were included. By 2-year FU, 18 (27%) had experienced TB. TB primarily occurred in major (70%) versus minor curves and thoracolumbar tethers (75%) versus thoracic. TB rates between thoracolumbar single (32%) and double-cord tethers (30%) were not significantly different (p = 0.88). Mean major curve correction at 2-year FU was lower (p = 0.02) in patients with major curve TB (48° to 24°, 50%) versus those without (53°-21°, 60%). 2 patients (3%) required reoperation, 1 due to foraminal encroachment from a screw tip and 1 for curve progression with TB.TB rate was 27% at 2 years following VBT. Broken major curve tethers are associated with minor loss of correction that may not be clinically significant. TB rates are higher for thoracolumbar curvatures and double cords may not be protective against TB. Further study of long-term TB rates is imperative.IV.

To identify the prevalence and predictors of nonspecific back pain in primary thoracic adolescent idiopathic scoliosis (AIS) patients at 10 years after surgery. This was a case–control multi-center study. A query of patients who underwent surgical correction of major thoracic AIS between 1997 and 2007 with 10-year follow-up was reviewed. SRS-22 pain scores at 10 years were classified as below normal (≤ 2 standard deviations below average for controls of similar age/sex from published literature) or within/above the control range. One hundred and seventy-one patients with an average of 10.5 ± 0.8-years follow-up were included. Average age at surgery was 14 ± 2 years. The rate of pain was 23% for males and 11% for females (p = 0.08). Differences in age, 10-year SRS mental health score, and radiographic measures were noted. Of 12 patients who underwent revision surgery, 42% reported below normal pain scores versus 11% in cases without revision (p = 0.012). Classification and regression tree (CART) analysis identified 10-year thoracic curve magnitude and 10-year mental health scores as significant predictors. Thoracic Cobb of ≤ 26° at 10 years was associated with a 7% rate of below normal pain scores compared to 27.5% when the curve was > 26° (OR = 4.8, p 4.2 and 15% had more pain than normal if mental health score was ≤ 4.2 (OR 23, p 26°) at 10 years was the primary predictor of increased pain. For patients with less coronal deformity (

Determine the efficacy of intraoperative traction (IOT) on curve correction in AIS. A prospective, multicenter, longitudinal database identified patients with major thoracic AIS (Lenke 1–4) treated with surgery using IOT and follow-up of 2 years. These cases were matched to comparable cases treated without traction (non-IOT). All patients were treated with single-stage posterior only surgery with pedicle screw constructs. Perioperative, radiographic and clinical outcome data at 2 years post-op were compared between the groups. 104 cases treated with IOT were matched to 104 treated without IOT. Operating room time was significantly greater in the IOT group (339 vs. 306 min, p = 70° (IOT 72% vs. non-IOT 64%, p = 0.04). IOT was associated with a significant reduction in 2D T5–T12 kyphosis measurements (IOT − 6.5° vs non-IOT + 0.48°, p

Surgical treatment of Adolescent Idiopathic Scoliosis (AIS) involves healthy individuals with spinal deformity. Parents are responsible for surgical consent on behalf of their children, a burden which causes trepidation and concern. Therefore, explanation of operative risk is a critical component of informed consent and parent decision-making. We set out to quantify parental risk aversion (RA). RA questionnaires were administered preoperatively to parents of 58 AIS patients undergoing spinal fusion (SF). RA is the likelihood of a parent to consent to their child’s SF (1- least likely, 10- most) with increasing allotments of data about potential complications at each stage (S1-complication named, S2-explained, S3-incidence given, S4-all information). A statistically significant mean difference in answers for each stage was assessed using paired sample t test or Wilcoxon rank t test. Normality was assessed by performing Shapiro–Wilk test. AIS patients (age 14.2 years, 85% female, major curve 61°) were included. Mean scores for each of the stages were 4.4 ± 3.1, 4.9 ± 3.1, 6.5 ± 3.0, 6.6 ± 3.0, respectively. Highest and lowest RA were reported for death and infection, respectively. The greatest increase in likelihood to proceed with surgery was seen after education on malposition of implants and on death, 2.6 and 2.5, respectively (p

Prospective cohort review. To compare two AIS databases to determine if a performance improvement-based surgeon group has different outcomes compared to a national database. The American College of Surgeon’s National Quality Improvement Program (ACS-NSQIP) and a surgeon study group (SG) collect prospective data on AIS surgery outcomes. NSQIP offers open enrollment to all institutions, and SG membership is limited to 15 high-volume institutions, with a major initiative to improve surgeon performance. While both provide important outcome benchmarks, they may reflect outcomes that are not relatable nationwide. The ASC-NSQIP Pediatric Spine Fusion and SG database were queried for AIS 30- and 90-day complication data for 2014 and 2015. Prospective enrollment and a dedicated site coordinator with rigorous data quality assurance protocols existed for both registries. Outcomes were compared between groups with respect to superficial and deep surgical site infections (SSI), neurologic injury, readmission, and reoperation. There were a total of 2927 AIS patients included in the ASC-NSQIP data and 721 in the SG database. Total complication rate was 9.4% NSQIP and 3.6% SG. At 90 days, there were fewer surgical site infections reported by SG than ASC-NSQIP (0.6% vs. 1.6%, p = 0.03). Similarly, there were less spinal cord injuries (0.8% vs 1.5%, p = 0.006), 30-day readmissions (0.8% vs. 2.6%, p = 0.002), and 30-day reoperations (0.6% vs. 1.7%, p = 0.02) in the SG cohort. Comparison of these two data sets suggests a range of complications and readmission rates, with the SG demonstrating lower values. These results are likely multi-factorial with the performance improvement initiative of the SG playing a role. Understanding the rate and ultimate risk factors for readmission and complications from big data sources has the potential to further drive quality improvement. III.

AIS patients and their parents will have distinct perspectives regarding the impact of AIS on patients’ lives. Current outcome assessment tools for AIS do not fully assess patient-specific disease impact and fail to distinguish between patient and parent perspectives. Patient Generated Index (PGI) has been used in other disease states to assess individual experiences. This study assesses PGI in operative AIS patients and their parents. Level 1, prospective multi-center study. 44 AIS patient and parent pairs completed the PGI questionnaire comprised of three stages (S1, S2, S3) and decision regret (DR). S1 asks for five areas of the patient’s life most affected by AIS and a 6th encompassing all other areas of their lives affected, S2 focuses on the magnitude of effect, S3 identifies desire to improve affected areas and DR if the surgery did not improve the specific area. S1 free responses were organized into 14 domains. Descriptive statistics were reported for stage scores; free-response format of PGI and DR limited ability for paired sample t test analysis. Mean age at surgery was 14.3 years, 84% female, and mean major curve magnitude was 61°. The three most common patient-reported concerns prior to surgery were (in descending order): sports, general function, and general fitness. However, the three most common parent-reported concerns were (in descending order): general function, sports, and appearance. Patients reported self-esteem and parents reported physical appearance as the most affected domain (S2). Patients reported pain and self-esteem and parents reported sleep and self-esteem as main operative aspirations (S3). Decision regret was the highest for uncertainty of future health in patients and sleep in parents. AIS patients and their parents reported different concerns and DR regarding surgical treatment. PGI provides insight into patient and parent views toward the disease as well as treatment aspirations.

Validation of classification system. To externally validate the Proximal Humerus Ossification System (PHOS) as a reliable skeletal maturity scoring system and to assess the learning curve associated with teaching the procedure to individuals of varying levels of experience. Assessment of skeletal maturity is essential for treatment decisions in Adolescent Idiopathic Scoliosis (AIS). PHOS is a five-stage system that uses the proximal humeral physis in assessing skeletal maturity and has been shown to reliably grade skeletal age leading up to and beyond peak growth age (PGA). This system is advantageous in the AIS patient, as it is often captured in standard scoliosis films. A medical student, an orthopedic surgery resident (PGY-2), spine fellow, and experienced scoliosis surgeon in his 25th year in practice were given a three-slide PHOS learning module. Each participant rated 100 X-rays on two separate occasions, separated by 1 week. Intra- and inter-observer reliability, as well as cross-institutional reliability, were calculated using intraclass correlation coefficients (ICC) with 95% confidence intervals [CI95]. Average intra-observer reliability ICC between scoring sessions was 0.94 [0.92, 0.96] and inter-observer reliability by level of training were 0.94 [0.91, 0.96], 0.93 [0.9, 0.95], 0.94 [0.91, 0.96], 0.96 [0.94, 0.97] for the medical student, PGY-2, fellow, and attending, respectively. Reliability across institutions was 0.99 [0.98, 0.99]. Combined rating observations (n = 400) showed 82% exact matches, as well as 17% and 1% mismatches by 1 and 2 stages, respectively. Similar to the PHOS developers, we found PHOS stage 3 to occur immediately after PGA. PHOS is easily learned and employed by raters with varying levels of training. It comprises a five-stage system to reliably measure bone age leading up to PGA and thereafter. This new system relies on visualization of the proximal humerus, which is readily available on standard scoliosis X-rays. Level III.

Body surface topography (ST) improvements are associated with surgical correction in adolescent idiopathic scoliosis (AIS) and correlate with radiographic imaging. Prospective observational study. Patients undergoing correction of AIS are most affected by body image. Radiographs have been the standard assessment tool but do not assess body shape features. ST, a validated, radiation-free assessment tool, directly represents the patient’s deformity. We set out to assess ST improvements associated with surgical correction in AIS. Twenty-three consecutive operative AIS patients were enrolled and had radiographs and posterior ST obtained pre- and postoperatively (PO). ST changes were compared using paired t test, and correlations of ST with radiograph measurements were evaluated by linear regression. Mean age at surgery was 15.0 ± 2 years, 82.6% female with mean follow-up of 1.0 year. Major Cobb angle improved from 56.91° ± 15.57° to 13.70° ± 4.89°. ST scoliosis angle corrected from 41.43° ± 11.52° to 11.78° ± 7.84° (p

Accurate reporting of long-term complications of surgical treatment of adolescent idiopathic scoliosis (AIS) is critical, but incomplete. This study aimed to report on the rate of complications following surgical treatment of AIS among patients with at least 10 years of follow-up.This was a retrospective review of prospectively collected data from a multicenter registry of patients who underwent surgical treatment for AIS with minimum 10-year follow-up. Previously published complications were defined as major if they resulted in reoperation, prolonged hospital stay/readmission, neurological deficits, or were considered life-threatening. Rates and causes of reoperations were also reviewed.Two hundred and eighty-two patients were identified with mean age at surgery of 14.6 ± 2.1 years. Mean follow-up was 10.6 (range 9.5-14) years. Eighty-seven patients had anterior spinal fusion (ASF); 195 had posterior spinal fusion (PSF). The overall major complication rate was 9.9% (n = 28) in 27 patients. Among PSF patients, the complication rate was 9.7% (n = 19) in 18 patients. The complications were surgical site infection (37%), adding-on (26%), pulmonary (16%), neurologic (11%), instrumentation (5%), and gastrointestinal (5%). In ASF patients, the complication rate was 10.3% (n = 9) among nine patients. The complications were pulmonary (44%), pseudoarthrosis (22%), neurologic (11%), adding-on (11%), and gastrointestinal (11%). The reoperation rate was 6.0% (n = 17) among 17 patients. Although most of the complications presented within the first 2 years (60.7%), surgical site infection and adding-on were also seen late into the 10-year period.This is the largest prospective study with at least a 10-year follow-up of complications following spinal fusion for AIS, the overall major complication rate was 9.9% with a reoperation rate of 6.0%. Complications presented throughout the 10-year period, making long-term follow-up very important for surveillance.Therapeutic II.

This study aimed to determine (1) does vertebral body tethering (VBT) produce differential growth modulation in individual vertebrae in patients with idiopathic scoliosis, (2) does VBT change disc shape, and (3) does VBT affect total spine length?Patients with idiopathic scoliosis treated with VBT of the main thoracic curve and minimum 2-year follow-up were included. Vertebrae and discs were categorized as uninstrumented proximal thoracic, instrumented main thoracic, or uninstrumented thoracolumbar-lumbar. The left- and right-sided heights of each vertebra and disc were measured on subsequent radiographs to assess for differential growth. T1-T12 thoracic and T1-S1 thoracolumbar growth velocities were compared with standardized reference data.Fifty-one patients (764 vertebrae and 807 discs) were analyzed. The average major curve magnitude improved from 46° ± 11° to 17° ± 11° at 2-year follow-up. Differential growth was observed in MT vertebrae, in which the left/concave side grew 2.0 ± 2.2 mm compared with 1.5 ± 2.3 mm on the right/convex (tethered) side (p 0.001). Differential height changes were observed for all discs, but were most pronounced in instrumented MT discs, in which the right/convex sides decreased by an average of 1.2 mm each, compared with no significant height change on the left/concave side. Total spinal growth velocities were not significantly different from standard reference data.Vertebral body tethering limits convex spinal growth as designed while permitting concave growth. Curve correction results from differential vertebral growth and decreased convex disc height. Overall spinal growth continues at the expected rate.Level IV case series.

Body Image Disturbance Questionnaire-Scoliosis version (BIDQ-S) is a sensitive outcomes instrument to evaluate improvements in body image-related psychosocial effects with surgical correction.Prospective observational study.The BIDQ-S was previously validated (convergent validity, internal consistency) as a tool to assess body image-related distress and psychosocial impairment in adolescent idiopathic scoliosis (AIS). This study was conducted to evaluate responsiveness to change in the BIDQ-S associated with surgical treatment of AIS two years postoperatively to complete the validation of this questionnaire.Seventy-five consecutive operative AIS patients were enrolled and completed BIDQ-S and Scoliosis Research Society-22 (SRS-22) at preoperative and two-year postoperative visits. Demographic and radiographic data were collected. Preoperative and two-year postoperative BIDQ-S (1 = best, 5 = worst) and SRS-22 scores (1 = worst, 5 = best) were compared using paired t test. Correlations between BIDQ-S and SRS-22 scores were evaluated by linear regression.Eighty-four percent of the subjects were females, with average age at surgery of 14.4 ± 1.6 years. The mean follow-up was 2.26 years (range 2.0-4.5). The major Cobb was corrected from 50.0° ± 7.2° to 14.2° ± 5.8° (Δ = 71.3% ± 12.1%; p.0001). There was a significant improvement in BIDQ-S scores after surgery (1.64 ± 0.51 to 1.21 ± 0.38, p.0001). BIDQ-S improvements were correlated with change in SRS self-image (p = .0055), activity (p = .0057), mental (p = .0018), and overall mean (p = .0007) domains. Preoperative, two-year postoperative, and Δ BIDQ-S score were not associated with major Cobb magnitude, truncal rotation, or Lenke curve type. Patients who reached SRS-22r minimal clinically important difference (MCID) in activity and self-image domains had worse preoperative BIDQ scores than those who did not reach MCID (activity 1.91 vs. 1.54 [1 = best, 5 = worst], p = .0099; self-image 2.08 vs. 1.51, p.0001). Greater improvement in BIDQ-S was noted in patients who reached MCID in SRS-22 self-image than those who did not (Δ = 0.77 vs. 0.38, p = .0052).BIDQ-S is responsive to surgical correction of AIS. The BIDQ-S is a valuable clinical outcome tool to assess the psychosocial effects of scoliosis in adolescents augmenting existing outcome instruments.

Informed decision making for operative treatment of the skeletally mature adolescent idiopathic scoliosis (AIS) patient meeting surgical indications requires a discussion of differences in operative morbidity in adult scoliosis versus AIS. This study evaluated differences in operative data and outcomes between AIS and adult scoliosis patients based on an estimated natural history of curve progression.Twenty-eight adult scoliosis patients (43.7 ± 15.8 years; 93% F) were 1:2 matched with 56 (Risser 4/5) AIS patients (15.7 ± 2.1 years) based on gender and curve type as vetted by 5 surgeons' consensus in committee. Curve progression of 0.3°/year for the first 10 years following skeletal maturity and a 0.5°/year thereafter was assumed to estimate curve progression from AIS to adulthood for the adult counterpart. Operative data, complications, and quality of life (Scoliosis Research Society [SRS-22r] questionnaire) measures were evaluated, with a minimum 2-year follow-up.Postoperative major Cobb and percentage correction were similar between adult versus AIS, whereas operative time, percentage estimated blood loss (EBL; % total blood volume), length of hospital stay (LOS), and total spine levels fused were greater for adult patients (p.05). No difference was found in EBL, operative time, or LOS when normalized by levels fused. Ten (36%) adult scoliosis patients were fused to the pelvis compared with none in AIS (p.0001). Major complication rate was higher for adult versus AIS (25% vs. 5.4%; p .05). Preoperative SRS-22r scores were worse for adult patients; however, they demonstrated greater improvement in SRS-22r than the AIS cohort at final follow-up. A higher percentage of adult patients reached the MCID in self-image domain than the AIS patients (92.3% vs. 61.8%; p = .0040).Treatment of the adult scoliosis patient who has undergone an estimated natural history of progression is characterized by greater levels fused, operative time, and higher complication rates than the AIS counterpart. Longer-term follow-up of AIS is needed to define the benefits of early intervention of relatively asymptomatic adolescent patients versus late treatment of symptomatic disease in the adult.

Retrospective review of prospectively collected data.To determine whether adolescent idiopathic scoliosis (AIS) patients with active complications at two-year follow-up demonstrate lower Scoliosis Research Society (SRS-22) questionnaire scores.There is limited evidence as to whether the SRS-22 is sensitive to complications in postoperative AIS patients.Surgical patients with SRS-22 scores completed at two-year follow-up were included. Five groups were created: no complication, minor complication resolved by 2 years, major complication resolved by 2 years, minor complication active, and major complication active at 2 years. Likelihood of reaching a minimal clinically important difference (MCID) for pain (0.20) and self-image (0.98) was evaluated.1,481 patients were identified. Major complications active at two years existed in 2.2% of patients. These patients had the lowest score in all domains and total scores (p.05). If a minor complication was active, scores were impacted for pain, self-image, satisfaction, and total (p.05). No differences were found between no complication and resolved complications. Patients with active major complications were more likely to have a pain score that worsened from pre- to two years reaching MCID (52%) compared to the other four groups (range 18%-29%, odds ratio [OR] 3.6, p.001). They also had a nonsignificant decreased rate of improvement of self-image score at an MCID level (42% vs. range 51%-66%, OR 0.56, p = .10).When timing is considered, the SRS-22 demonstrates the ability to discriminate between patients with and without a complication. Active experience of a major complication impacted SRS-22 scores, in particular, the rate of worsening scores for pain, self-image, function, and total score.Level III.

To identify the prevalence and predictors of nonspecific back pain in primary thoracic adolescent idiopathic scoliosis (AIS) patients at 10 years after surgery.This was a case-control multi-center study. A query of patients who underwent surgical correction of major thoracic AIS between 1997 and 2007 with 10-year follow-up was reviewed. SRS-22 pain scores at 10 years were classified as below normal (≤ 2 standard deviations below average for controls of similar age/sex from published literature) or within/above the control range.One hundred and seventy-one patients with an average of 10.5 ± 0.8-years follow-up were included. Average age at surgery was 14 ± 2 years. The rate of pain was 23% for males and 11% for females (p = 0.08). Differences in age, 10-year SRS mental health score, and radiographic measures were noted. Of 12 patients who underwent revision surgery, 42% reported below normal pain scores versus 11% in cases without revision (p = 0.012). Classification and regression tree (CART) analysis identified 10-year thoracic curve magnitude and 10-year mental health scores as significant predictors. Thoracic Cobb of ≤ 26° at 10 years was associated with a 7% rate of below normal pain scores compared to 27.5% when the curve was 26° (OR = 4.8, p 0.05). Of those with a curve ≤ 26°, no patients had abnormal pain if the SRS mental health score was 4.2 and 15% had more pain than normal if mental health score was ≤ 4.2 (OR 23, p 0.05).Increased primary thoracic curve magnitude ( 26°) at 10 years was the primary predictor of increased pain. For patients with less coronal deformity ( 26°), a poor mental health score was associated with an increased rate of pain. Male gender and revision surgery may also play a role in increased pain, however, the overall frequency of these variables were low.Level 3.

Study design Retrospective, comparative, multicenter. Introduction Growth modulating spinal implants are used in the management of scoliosis such as anterior vertebral body tethering. A motion-sparing posterior device (PDDC) was recently approved for the treatment of moderate AIS. The purpose of this study was to determine if the PDDC can modulate growth in skeletally immature patients with AIS. Methods From a database of patients treated with the PDDC over 4 years, we identified those who had a minimum of 2 years follow-up. Pre-operative and post-operative Cobb angles and coronal plane wedging of the apical vertebra were evaluated on standing full length radiographs. Independent sample t test and one-way ANOVA with post-hoc Tukey HSD analysis was used to compare three groups in varying skeletal maturity: Risser 0–1, Risser 2–3, and Risser 4–5. Results 45 patients (14.2-years old, 11–17) were evaluated with a mean pre-op curve of 46° (35°-66°). The average preoperative major curve magnitude, of either Lenke 1 or 5 curve type, was similar among the three groups 47.6°, 46° and 41.5°. Deformity correction was similar in the three groups, with reduction to 26.4°, 20.4° and 26.2°, respectively, at final follow-up [p ]. Pre-op wedging 7.4° (3.8°–15°) was reduced after surgery to 5.7° (1°–15°) (p n = 16) had preoperative wedging of 9.5° (6°–14.5°) that was reduced to 5.4° (1°–8°) postoperatively (p n = 15) had pre-op 7.7° (4°–15°) vs. post-op 7.0° (3°–15°); Risser 4–5 (n = 14) had pre-op 4.8° (3.8°–6.5°) vs. post-op 4.7° (3.7°–6.5°). Delta Wedging in Risser 0–1 stage was significantly different than for Risser 2–3 and for Risser 4–5. Conclusion The posterior dynamic deformity correction device was able to modulate vertebral body wedging in skeletally immature patients with AIS. This was most evident in patients who were Risser 0–1. In contrast, curve correction was similar among the three groups. This finding lends support to the device’s ability to modulate growth.

Study Design Survey-based cross-sectional study. Objectives To describe interobserver agreement among experienced spine surgeons in choosing neutral vertebra (NV) based on manual measurements from radiographs. Secondarily, to use axial vertebral rotation (AVR) values obtained from low-dose stereoradiography (SR) post-processing software (SterEOS 2D/3D) to separately designate the NV in subject cases and to compare manually derived and software-derived NV designations. Summary of Background Data Investigators have previously suggested that parameters such as Lenke classification, stable vertebra level, end vertebra level, and NV level be used to decide on fusion levels in adolescent idiopathic scoliosis (AIS). Studies have revealed suboptimal interobserver reliability in these vertebral designations. SR post-processing software may represent a useful tool for standardizing NV designation. Methods Thirty-two subjects with idiopathic scoliosis and Lenke 1–4 curves were assessed. Experienced surgeons (range of 7–35 years in practice) assigned NV based on preoperative radiographs. Interobserver reliability was quantified using the Fleiss Kappa statistic. Surgeon responses were compared with NV designations made using AVR values provided by SR postprocessing software. Agreement between these values was quantified using percentage agreement. Results Surgeons exhibited moderate agreement in choosing NV based on radiographs (Kappa 0.444). Surgeon responses agreed with the SR-derived NV in 26.9% of cases, lay within 1 level in 82.1% of cases, and lay within 2 levels in 97.5% of cases. Surgeons were more likely to choose distal to the SR NV rather than proximal. Conclusions Variability in instrumented level selection and outcomes in idiopathic scoliosis may be partially related to inconsistency in selection of the NV. The use of SR post-processing software may provide a more reliable method for choosing NV. Level of Evidence Level II.