Search

Purpose: Brace treatment is the most common nonoperative treatment to prevent curve progression in adolescent idiopathic scoliosis (AIS). The goal of this review and analysis is to characterize curve behavior after completion of brace treatment and to identify factors that may facilitate the estimation of long-term curve progression., Method: A review of the English language literature was completed using the MEDLINE (PUBMED) database of publications after 1990 until September 2020. Studies were included if they detailed a minimum of 1 year post-brace removal follow-up of AIS patients. Data retrieved from the articles included Cobb angle measurements of the major curves at "in-brace," weaning, and follow-up visit(s) for all patients described and for subset populations., Results: From 75 articles, 18 relevant studies describing a follow-up period of 1-25 years following brace removal were included in the analyses. The reviewed literature demonstrates that curves continue to progress after brace treatment is completed with three main phases of progression: (i) immediate (upon brace removal) where a mean curve progression of 7° occurs; (ii) short term (within five years of brace removal) where a relatively high progression rate is evident (0.8°/year); and (iii) long term (more than five years after brace removal) where the progression rate slows (0.2°/year). The magnitude and rate of curve progression is mainly dependent on the degree of curve at weaning as curves weaned at < 25° progress substantially less than curves weaned at ≥ 25° at 25 years., Conclusion: Curves continue to progress after brace removal and the rate and magnitude of progression are associated with the curve size at weaning, with larger curves typically exhibiting more rapid and severe progression. This analysis provides physicians and patients the ability to estimate long-term curve size based on the curve size at the time of weaning., Level of Evidence: IV., (© 2023. The Author(s).)

Purpose: To evaluate the impact of patients lost to follow-up on outcomes of surgery for adolescent idiopathic scoliosis (AIS) at 10-year postoperative., Methods: Preoperative, 2-year, and 5-year postoperative demographic, radiographic, and SRS-22 data from a prospective multi-center registry were compared between patients with a 10-year follow-up visit versus those without. A second analysis utilized variables that were different between the groups, along with SRS scores, in a cohort of patients with preoperative, 2-, 5-, and 10-year postoperative SRS scores (complete cohort) to impute missing 10-year data (imputed cohort) utilizing Markov chain Monte Carlo simulation., Results: 250 patients had 10-year follow-up (21%). Those with 10-year follow-up had a greater percentage of patients who underwent anterior procedures (p < 0.05). Radiographically, the groups were similar at all three time points. SRS-22 scores demonstrated slightly worse pain and function preoperatively and at 2 year in those lost to follow-up (effect size eta = 0.11-0.12), with no differences at 5 year. Imputed data analysis demonstrated similar trends over time in SRS-22 scores compared to the complete cohort for total score and all domains except pain. There was no significant difference in imputed versus complete 10-year SRS-22 scores (p > 0.05)., Conclusion: This study identified early differences between patients with 10-year follow-up and those without, though effect sizes were small and non-existent at 5 years. SRS-22 scores at 10 year between the complete and imputed data sets did not differ. Clinically relevant outcomes of the subset who followed-up at 10 year are likely generalizable to the entire eligible AIS population., (© 2021. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background: Pediatric deformity surgery traditionally involves major blood loss. Patients refusing blood transfusion add extra clinical and medicolegal challenges; specifically the Jehovah's witnesses population. The objective of this study is to review the safety and effectiveness of blood conservation techniques in patients undergoing pediatric spine deformity surgery who refuse blood transfusion., Methods: After obtaining institutional review board approval, we retrospectively reviewed 20 consecutive patients who underwent spinal deformity surgery and refused blood transfusion at a single institution between 2014 and 2018. We collected pertinent preoperative, intraoperative and most recent clinical and radiological data with latest follow-up (minimum two-year follow-up)., Results: Twenty patients (13 females) with a mean age of 14.1 years were identified. The type of scoliotic deformities were adolescent idiopathic (14), juvenile idiopathic (1), neuromuscular (3) and congenital (2). The major coronal Cobb angle was corrected from 55.4° to 11.2° (80% correction, p <  0.001) at the latest follow-up. A mean of 11.4 levels were fused and 5.6 levels of Pontes osteotomies were performed. One patient underwent L1 hemivertebra resection and three patients had fusion to pelvis. Estimated blood loss, percent estimated blood volume loss, and cell saver returned averaged 307.9 mL, 8.5%, and 80 mL, respectively. Average operative time was 214 min. The average drop in hemoglobin after surgery was 2.9 g/dL. The length of hospital stay averaged 5.1 days. There were no intraoperative complications. Three postoperative complications were identified, none related to their refusal of transfusion. One patient had in-hospital respiratory complication, one patient developed a late infection, and one patient developed asymptomatic radiographic distal junctional kyphosis., Conclusions: Blood conservation techniques allow for safe and effective spine deformity surgery in pediatric patients refusing blood transfusion without major anesthetic or medical complications, when performed by an experienced multidisciplinary team., Level of Evidence: Level IV.

Background: The prevalence of adolescent idiopathic scoliosis (AIS) in diverse regions of the world has been studied. Access to care varies widely, and differences in disease severity and operative treatment outcomes are not well understood. This study aimed to determine variation in disease presentation and operative complications for AIS patients from an international cohort., Methods: This is a retrospective study carried out at seven surgical centers in the United States (Manhattan and Miami), Ghana, Pakistan, Spain, Egypt, and China. A total of 541 consecutive patients with AIS were evaluated. Preoperative major curve magnitude, operative parameters, and complications were compared among sites using analysis of variance with post hoc tests and Pearson correlation coefficients. Univariate and multivariate forward stepwise binary logistic regressions determined the variables most predictive of complications., Results: Countries with lowest-access to care (Ghana, Egypt, and Pakistan) displayed larger curves, more levels fused, longer operative time (OT), and greater estimated blood loss (EBL) than the other countries (p ≤ .001). Increasing curve magnitude was correlated with greater levels fused, longer OT, and greater EBL in all groups (p = .01). In the univariate regression analysis, Cobb magnitude, levels fused, EBL, and OT were associated with complication occurrence. Only OT remained significantly associated with complication occurrence after adjusting for Cobb magnitude, levels fused, and site (odds ratio [OR] = 1.005, 95% confidence interval 1.001-1.007, p = .003). Complications were greatest in Pakistan and Ghana (21.7% and 13.5%, respectively) and lowest in Miami (6.5%)., Conclusions: Larger curve magnitudes in the least-access countries correlated with more levels fused, longer OT, and greater EBL, indicating that increased curve magnitude at surgery could explain the difference in operative morbidity between low- and high-access countries. With OT as the prevailing predictive factor of complications, we suggest that increased curve magnitude leads to longer OTs and more complications. A lack of access to orthopedic care may be the largest contributor to the postponement of treatment., Level of Evidence: Level II., (Copyright © 2019 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: Single-center retrospective study., Objective: To analyze two-year postoperative outcomes following spinopelvic fixation in pediatric patients using the anatomic trajectory (AT) portal for iliac screws., Summary: Iliac fixation is crucial in situations requiring fusion to sacrum. Challenges include complex anatomy, pelvic deformation, severe deformity, and previous surgery. The PSIS portal requires significant dissection, rod connectors, and complex bends. The SAI portal requires navigating the screw across the SI joint to the ilium. The anatomic trajectory (AT), first reported in 2009, is between the PSIS and SAI portal, without prominence, connectors, or complex bends., Methods: Fifty-four patients aged ≤18 years requiring instrumentation to the Ilium with minimum follow-up of two years (mean 44 months) were clinically and radiographically evaluated. Changes in coronal curve magnitude and pelvic obliquity were assessed using paired t test for patients with cerebral palsy. Spondylolisthesis reduction was assessed in patients with moderate- to high-grade spondylolisthesis (Meyerding grade 3 and 4)., Results: A total of 108 iliac screws were inserted using AT portal in 54 patients. Twenty-eight neuromuscular and syndromic patients had an initial mean coronal curve of 85° corrected to 23° at two years (p < .001) and a pelvic obliquity of 22° corrected to 4° (p < .001). Twenty patients with moderate- to high-grade spondylolisthesis treated with reduction and interbody fixation improved significantly with respect to their slip angles (7° ± 14.7° to -7.9° ± 6.1°, p = .003). In the neuromuscular group, two surgical site infections occurred, two had implant fractures, and 12 had asymptomatic iliac screw loosening, none requiring revision. In the spondylolisthesis group, there were no neurologic complications and one had prominent screw requiring removal. Of 108 iliac screws, 2 rod connectors were employed., Conclusion: Iliac screw insertion using the AT portal is a safe and effective method of pelvic fixation in pediatric patients with satisfactory radiographic correction and minimal complications., Level of Evidence: Level 4., (Copyright © 2018 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: Preoperative and two-year follow-up health-related quality of life (HRQOL) data were prospectively collected in 82 Scheuermann kyphosis (SK) and 995 adolescent idiopathic scoliosis (AIS) patients using the Scoliosis Research Society-22 patient questionnaire (SRS-22) outcomes instrument in a multicenter study. Visual analog scale (VAS) scores were also collected for the SK population., Objectives: This study assessed changes in HRQOL prospectively and compared them to those occurring in AIS., Summary of Background Data: There has been limited evaluation of patient-reported HRQOL changes with operative management of SK., Methods: Median SRS values for the SK and AIS cohorts were compared using a repeated measure of analysis of variance with age as a covariate and using a Mann-Whitney U nonparametric comparison., Results: Kyphosis was corrected from 73.9° to 45.8° (p < .001); the major curve in AIS was corrected from 55.5 to 20.2 (p < .001). Preoperative and magnitude of radiographic correction, kyphosis apex and body mass index in SK were not correlated with baseline or change in HRQOL. SK SRS scores improved after surgery in all domains with the greatest change (2.8-4.4) in self-image (p < .001). Changes in SRS Pain, Activity, and Self-Image domains met the minimal clinically important difference. Baseline SK and AIS scores differed significantly in the Self-Image, Mental Health and Total Score domains, with SK having worse scores (p < .001). At two years postoperatively, the greatest improvements were made in Self-Image, along with Mental Health and Total Score, and the SK group achieved greater gains (p < .001). At two years postoperatively, the SK scores improved to reach equivalent values to the AIS scores. VAS scores improved from 3.69 to 1.51, and these changes were correlated with change in the Pain, Mental Health, and Total Score SRS domains (p < .001)., Conclusions: Surgery for SK in the adolescent population results in significant improvements in HRQOL, which outpace those of the AIS population., Level of Evidence: Level II., (Copyright © 2018 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Background: Anterior-posterior spinal fusion (APSF) is the traditional treatment for patients with idiopathic scoliosis and open triradiate cartilage (OTRC). Our goals were to assess whether posterior-only spinal fusion (PSF) with pedicle screws can halt deformity progression as effectively as APSF in patients with OTRC, and whether selection of the distal fusion level influences curve progression., Methods: We studied a prospective multicenter database to identify all children with 2-year radiographic and clinical follow-up who were 11 years or younger with Risser grade 0 and OTRC who were treated with (1) PSF (OTRC-PSF group, N=20); or (2) APSF (OTRC-APSF group, N=9). A reference group was constructed of 20 children who were 18 years or younger with Risser grade 4 or 5 and closed triradiate cartilage (CTRC) and who were treated with PSF (CTRC-PSF group) and matched in preoperative curve magnitude and type to the OTRC-PSF group. The 3 groups were compared with respect to operative time, blood loss, length of hospital stay, and radiographic and functional outcomes (significance, P<0.05)., Results: OTRC-APSF patients had significantly longer operative time (P<0.01), greater blood loss (P=0.02), and longer hospital stays (P<0.01) than OTRC-PSF patients. At 2 years, 7 (35%) OTRC-PSF patients had >10 degrees of curve progression compared with no patients in the OTRC-APSF group (P=0.042) and 1 patient in the CTRC-PSF group (P=0.018). The OTRC-PSF group had the highest number of patients fused to the stable vertebra. Of the 11 OTRC-PSF patients fused to 1 vertebra short of stable, 6 (55%) had >10 degrees of curve progression. Of the 9 OTRC-PSF patients fused to at least the stable vertebra or lower, only 1 (11%) had curve progression. There were no significant differences in Scoliosis Research Society outcome scores between OTRC-PSF patients who did and those who did not have >10 degrees of curve progression., Conclusions: PSF with pedicle screws was associated with curve progression in a significantly greater proportion of patients with OTRC compared with APSF. Not fusing to stable was also associated with curve progression in patients treated with PSF but not APSF., Level of Evidence: Level III-therapeutic.

Study Design: Prospective, multicenter study of Scheuermann's kyphosis (SK) and adolescent idiopathic scoliosis (AIS) compared to a control group., Objectives: Compare body mass index (BMI) and Scoliosis Research Society Questionnaire-22 (SRS-22) scores among two diagnosis and one control group., Summary of Background Data: BMI has been reported as increased in SK patients; however, there are few recent data on this subject or comparing SK to AIS., Methods: Ninety-two SK patients (37 female, 55 male, average age 16 years), 1,051 AIS patients (814 female, 237 male, average age 15 years), and 380 adolescents without scoliosis (controls) were compared based on age, gender, race, height (m), weight (kg), BMI, and SRS-22 scores. An analysis of variance was used to test differences in BMI and SRS-22 scores between the groups and between males and females. Pearson correlations determined the relationship between AIS T5-T12 kyphosis and BMI, SK max kyphosis and BMI, and to determine the relationship between BMI and SRS-22 scores in each group., Results: More SK patients were "obese" and "overweight" (28% and 22%) compared to the AIS (6% and 9%) and Control groups (5.8% and 17.9%) (p < .001). More AIS patients were "underweight" (27%, SK: 13%, Control: 12.1%; p < .03). T5-T12 kyphosis was weakly correlated with BMI (r = 0.17), whereas max kyphosis correlated well with BMI (r = 0.39, p < .00). The SK group had significantly lower (worse) SRS-22 scores than AIS patients in the Pain (3.97 vs. 4.10), Self-Image (2.86 vs. 3.35), Mental Health (3.72 vs. 4.02), and Total Score domains (3.62 vs. 3.92, p < .001). Increased pain scores were weakly correlated with decreasing BMI in all three groups., Conclusions: SK patients are at increased risk for elevated BMI and worse SRS-22 scores, indicating that they may suffer from delayed diagnosis and increased surgical complications. AIS patients are at increased risk for issues related to low BMI and should also be monitored., (Copyright © 2015 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: A prospective multicenter database of operative patients with Scheuermann kyphosis (SK) with minimum 1-year follow-up was studied for major complications compared with contemporaneous operative patients with adolescent idiopathic scoliosis (AIS) from the database., Objective: To evaluate complications associated with current surgical techniques in SK and AIS., Summary of Background Data: There is a paucity of literature regarding complications associated with SK surgical treatment, but prior data suggest an elevated neurological risk., Methods: Complication rates were compared using analysis of variance and Fisher exact test analyses. Major complications were those that were life-threatening, caused spinal cord, nerve root, or ocular injury or required reoperation including surgical site infections. A binary logistic regression determined the likelihood of complications based on diagnosis, levels fused, blood loss, operative time, and length of stay., Results: Ninety-seven patients with SK (57 males; mean age, 16.5 yr; 75.3° mean kyphosis) and 800 patients with AIS (622 females; mean age, 14.9 yr; 55.6° mean curvature) met inclusion criteria. Patients with SK had significantly more major complications than those with AIS (16.3% vs. 2.3%; P < 0.001). The SK group had more infections (10.3% vs. 0.75%) and reoperations (14.4% vs. 1.4%) (P < 0.001). Operative time was longer and more levels were fused in the SK group (P < 0.001). Surgical site infection was the most common complication. There were no significant differences in length of stay or blood loss. Patients with SK were 3.9× more likely to have a major complication than those with AIS (odds ratio: 0.26, P = 0.003). The number of levels fused was an independent predictor of major complications: each additional level fused increased the odds of a complication by 36% in both groups (odds ratio: 1.36, P = 0.034)., Conclusion: Major complications are 3.9× more likely to occur in operative SK than in AIS. The number of levels fused is an independent risk factor for major complications. Patients with SK are at higher risk for infections and reoperation than those with AIS., Level of Evidence: 2.

Study Design: Retrospective review of prospective data., Objective: To define optimal postoperative coronal parameters after selective thoracic fusions (STFs) and to test these parameters against recommended criteria for when to perform an STF., Summary of Background Data: Previous studies have provided recommendations for when STF should be performed; however, clear parameters for target outcomes are lacking., Methods: Patients with Lenke 1C to 4C curves with adolescent idiopathic scoliosis from a multicenter database who underwent STF with minimum 2 years of follow-up were included. Postoperative parameters included lumbar Cobb angle, trunk shift, coronal balance, percent lumbar correction, and deformity-flexibility quotient. First, the upper 95% confidence interval for each parameter was calculated (queried data threshold) and set as the limit of "optimal" outcomes. Second, an independent surgeon survey was performed, and in patients with unanimous surgeon agreement of "success," the upper 95% confidence interval was determined (surgeon-derived threshold). Scoliosis Research Society-22 scores were compared between those above and below these 2 thresholds. Then, these outcomes were used to determine whether adherence to, or disregard for, previously published guidelines for STF were predictive of final outcome., Results: A total of 106 patients were analyzed. Target postoperative parameters as determined by the queried data and surgeon-derived thresholds were similar and rounded to: deformity-flexibility quotient less than 4, lumbar Cobb angle less than 26°, lumbar correction more than 37%, coronal balance 2 cm or less, and trunk shift less than 1.5 cm. Patients within target parameters had significantly better Scoliosis Research Society-22 satisfaction scores. Neither preoperative apical vertebral translation ratio more than 1.2 nor Cobb angle ratio more than 1.2 predicted 2-year success. Preoperative lumbar curve less than 45° and lumbar bend less than 25° were associated with increased likelihood of optimal outcomes., Conclusion: Optimal postoperative outcomes for STF should include a lumbar Cobb angle less than 26°, coronal balance 2 cm or less, deformity-flexibility quotient less than 4, lumbar correction more than 37%, and trunk shift less than 1.5 cm. These findings suggest that performing an STF in patients with a preoperative lumbar Cobb angle less than 45° or a preoperative lumbar bend less than 25° will increase one's chances of success., Level of Evidence: 4.