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Background Context: Facet joint violation by pedicle screws may lead to adjacent-segment disease and postoperative pain. Previous studies have reported the incidence of rostral facet joint violation using various pedicle screw insertion techniques. However, the incidence of facet joint violations with robotic guidance has not been determined., Purpose: To investigate and compare the incidence of rostral facet joint violation by pedicle screws under robotic guidance and computerized tomography (CT) navigation guidance., Study Design/setting: Retrospective matched cohort., Patient Sample: All patients who underwent robotic-assisted lumbar fusion at a major spine center up until 2023 were retrospectively identified and matched 1:3 to patients undergoing CT navigation guidance based by on age, sex, rostral vertebral level, and length of construct. Inclusion criteria consisted of age greater than 18 years, bilateral pedicle screw fixation, and presence of a postoperative CT scan of the lumbar spine or abdomen/pelvis at any point in the postoperative period., Outcome Measures: Rostral facet joint violations., Methods: Descriptive statistics were used to compare cohorts: frequencies, chi-squared analysis for categorical variables, and t-test for continuous variables., Results: A total of 408 rostral pedicle screws were implanted in 204 patients (Robot: 102; Navigation: 306). Overall, 13 (12.3%) rostral facet joint violations were observed in the robot cohort and 75 (24.5%) in the navigation cohort (p=.01). Specifically, fewer robotic violations were observed at the L2 (3.5% vs 32.1%, p=.003) and L3 levels (3.9% vs 18.1%, p=.08) compared to navigation. No difference was observed at L4 and L5. Bilateral violations are significantly reduced with robotic approaches (5.3% vs 14.4%, p=.03). Lastly, more facet joint violations were observed during open approaches (robot: 18.8%, navigation: 27.3%) than percutaneous approaches (robot: 11.6%, navigation: 7.1%) in both groups (p<.001). The rate of L4 facet violations was 18.8% in the robotic cohort and 27.3% in the navigation cohort. The rate of L5 facet violations was 31.3% in the robotic cohort and 29.2% in the navigation cohort., Conclusions: Use of robotic assistance in lumbar pedicle screws significantly reduced the rate of rostral facet joint violations compared to navigation guidance at L2 and L3 levels, but not at L4 and L5, with facet violations approaching nearly one-third of the patients at L5 screws. Rostral facet violations can play a significant role in adjacent segment degeneration and disease. Technical factors and trajectory issues likely play a role and addressing these components should minimize unintended facet violation and proximal adding on., Competing Interests: Declaration of competing interest One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2024 Elsevier Inc. All rights reserved.)

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., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To characterize the frequency of incidental dural tears in pediatric spine surgery, their treatment, complications, and results of long-term follow-up., Methods: A retrospective review of all pediatric patients who underwent a posterior spinal fusion (PSF) between 2004-2019 at a tertiary children's hospital was conducted. Electronic medical records were reviewed for patient demographics, intra-operative data, presence of an incidental dural tear, repair method, and patient outcomes., Results: 3043 PSFs were reviewed, with 99 dural tears identified in 94 patients (3.3% overall incidence). Mean follow-up was 35.7 months (range 0.1-142.5). When the cause of the dural tear was specified, 69% occurred during exposure, 5% during pedicle screw placement, 4% during osteotomy, 2% during removal of implants, and 2% during intra-thecal injection of morphine. The rate of dural tears during primary PSF was significantly lower than during revision PSF procedures (2.6% vs. 6.2%, p < 0.05). 86.9% of dural tears were repaired and/or sealed intraoperatively, while 13.1% had spontaneous resolution. Postoperative headaches developed in 13.1% of patients and resolved at a mean of 7.6 days. There was no difference in the incidence of headaches in patients that were ordered bedrest vs. no bedrest (p > 0.99). Postoperative infections occurred in 9.5% of patients and 24.1% patients were identified to have undergone a revision surgery., Conclusions: Incidence of intra-operative dural tears in pediatric spine surgery is 3.3%. Although complications associated with the dural tear occur, most resolve over time and there were no long-term sequelae in patients with 2 years of follow up., Level of Evidence: Level IV., (© 2024. The Author(s).)

Study Design: Retrospective cohort study., Objective: This study compares reoperation rates and complications following single-level anterior lumbar interbody fusion (ALIF)/lateral lumbar interbody fusion (LLIF) and transforaminal lumbar interbody fusion (TLIF)/posterior lumbar interbody fusion (PLIF)., Summary of Background Data: ALIF, LLIF, TLIF, and PLIF are widely used for degenerative disc disease. Lumbar interbody fusions have high rates of reoperation, primarily related to adjacent segment pathology and pseudarthrosis., Materials and Methods: The PearlDiver database was queried for patients (2010-2021) who had single-level ALIF/LLIF or TLIF/PLIF with same-day, single-level posterior instrumentation. ALIF/LLIF were combined, and similarly, TLIF/PLIF were combined, given how these operations are indistinguishable from Current Procedural Terminology coding. All patients were followed for ≥2 years and excluded if they had spinal traumas, fractures, infections, or neoplasms before surgery. The two cohorts, ALIF/LLIF and TLIF/PLIF, were matched 1:1 based on age, sex, Elixhauser-comorbidity index, smoking status, and diabetes. The primary outcome was the incidence of all-cause subsequent lumbar operations. Secondary outcomes included 90-day surgical complications., Results: After 1:1 matching, each cohort contained 14,070 patients. All-cause subsequent lumbar operations were nearly identical at five-year follow-up (9.4% ALIF/LLIF vs. 9.5% TLIF/PLIF, P =0.91). Survival analysis using all-cause subsequent lumbar operations as the endpoint showed an equivalent 10-year survival rate of 86.0% (95%CI: 85.2-86.8). Within 90 days, TLIF/PLIF had more infections (1.3% vs. 1.7%, P =0.007) and dural injuries (0.2% vs. 0.4%, P =0.001). There was no difference in wound dehiscence, hardware complications, or medical complications., Conclusion: As utilized in real-world clinical practice, single-level anterolateral versus posterior approaches for interbody fusion have no effect on long-term reoperation rates., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The aim of this study was to characterize antibiotic prophylaxis practices in pediatric patients who have received posterior arthrodesis for spinal deformity and understand how these practices impact 30-day postoperative infection rates., Methods: This was a retrospective cohort study using the National Surgical Quality Improvement Program Pediatric database for year 2021. Patients 18 years of age or younger who received posterior arthrodesis for scoliosis or kyphosis correction were included. The outcome of interest was 30-day postoperative infection. Fisher's exact test and multivariable regression analysis were used to analyze the impact of intravenous antibiotic prophylaxis, intraoperative intravenous antibiotic redosing after 4 h, postoperative antibiotic prophylaxis, intraoperative topical antibiotics on 30-day postoperative infection, and various antibiotic prophylaxis regimens., Results: A total of 6974 patients were included in this study. The 30-day infection rate was 2.9%. Presurgical intravenous antibiotic (11.5% vs. 2.7%, p = 0.005), postoperative antibiotic (5.7% vs. 2.4%, p < 0.01), and intraoperative topical antibiotic (4.0% vs. 2.7%, p = 0.019) were associated with significantly reduced infection rates. There was no significant difference in infection rates between patients that received cefazolin versus vancomycin versus clindamycin. The addition of Gram-negative coverage did not result in significant differences in infection rates. Multivariable regression analysis found postoperative intravenous antibiotics and intraoperative topical antibiotics to reduce infection rates., Conclusions: We found the use of presurgical intravenous antibiotics, postoperative intravenous antibiotics, and intraoperative topical antibiotics to significantly reduce infection rates. Results from this study can be applied to future research on implementation of standardized infection prevention protocols., Level of Evidence: Level II., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Study Design: Retrospective review., Objective: Our goal was to investigate the incidence of cervical degenerative disk disease (DDD) in patients with adolescent idiopathic scoliosis (AIS), before surgical intervention., Summary of Background Data: AIS is often associated with thoracic hypokyphosis and compensatory cervical kyphosis. In adults, cervical kyphosis is associated with DDD. Although cervical kyphosis has been reported in up to 60% AIS patients, the association with cervical DDD has not been reported., Materials and Methods: A retrospective review was conducted from January 2014 to December 2019 of all consecutive AIS patients. Inclusion criteria were AIS patients over 10 years of age with cervical magnetic resonance imaging and anterior-posterior and lateral spine radiographs within 1 year of each other. Magnetic resonance imaging were reviewed for evidence of cervical DDD. Severity of cervical changes were graded using the Pfirrmann classification and by a quantitative measure of disk degeneration, the magnetic resonance signal intensity ratio., Results: Eighty consecutive patients were included (mean age: 14.1 years, SD=2.5 years). Increasing cervical kyphosis was significantly correlated to decreasing thoracic kyphosis ( r =0.49, P <0.01) and increasing major curve magnitude ( r =0.22, P =0.04). Forty-five patients (56%) had the presence of DDD (grades 2-4) with a mean cervical kyphosis of 11.1° (SD=9.5°, P <0.01). More cervical kyphosis was associated with more severe cervical DDD as graded by Pfirrmann classification level ( P <0.01). Increasing cervical kyphosis was also positively associated with increasing magnetic resonance signal intensity ratio ( P <0.01). Nine patients had ventral cord effacement secondary to DDD with a mean cervical kyphosis of 22.8° (SD=8.6°) compared with 2.6° (SD=11.2°) in those who did not ( P <0.01)., Conclusions: Cervical kyphosis was significantly associated with increasing severity of cervical DDD in patients with AIS. Patients with evidence of ventral cord effacement had the largest degree of cervical kyphosis with a mean of 22.8±8.6°. This is the first study to evaluate the association between cervical kyphosis in AIS with cervical DDD., Competing Interests: D.L.S. has received royalties from Wolters Kluwer Health, Zimmer Biomet, Globus Medical, and Medtronic; consulting fees from Zimmer Biomet, Globus Medical, Top Doctors, and Orthobullets; research funding from NuVasive; has ownership interest in Zipline Medical Inc., Green Sun Medical, and Orthobullets; and has held leadership or advisory positions in the Pediatric Spine Foundation and CHLA Foundation. V.T. holds a leadership or advisory position for the Journal of Bone and Joint Surgery . K.D.I. has received consulting fees from Orthopediatrics and has served on a safety or advisory board with Medtronic. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: The authors report no conflicts of interest.

For diverse procedures, sizable geographic variation exists in rates and outcomes of surgery, including for degenerative lumbar spine conditions. Little is known about how surgeon training and experience are associated with surgeon-level variations in spine surgery practice and short-term outcomes. This retrospective observational analysis characterized variations in surgical operations for degenerative lumbar scoliosis or spondylolisthesis, two common age-related conditions. The study setting was two large spine surgery centers in one region during 2017-19. Using data (International Classification of Diseases-10th edition and current procedural terminology codes) extracted from electronic health record systems, we characterized surgeon-level variations in practice (use of instrumented fusion - a more extensive procedure that involves device-related risks) and short-term postoperative outcomes (major in-hospital complications and readmissions). Next, we tested for associations between surgeon training (specialty and spine fellowship) and experience (career stage and operative volume) and use of instrumented fusion as well as outcomes. Eighty-nine surgeons performed 2481 eligible operations. For the study diagnoses, spine surgeons exhibited substantial variation in operative volume, use of instrumented fusion, and postoperative outcomes. Among surgeons above the median operative volume, use of instrumented fusion ranged from 0% to >90% for scoliosis and 9% to 100% for spondylolisthesis, while rates of major in-hospital complications ranged from 0% to 25% for scoliosis and from 0% to 14% for spondylolisthesis. For scoliosis, orthopedic surgeons were more likely than neurosurgeons to perform instrumented fusion for scoliosis [49% vs. 33%, odds ratio (OR) = 2.3, 95% confidence interval (95% CI) 1.3-4.2, P-value = .006] as were fellowship-trained surgeons (49% vs. 25%, OR = 3.0, 95% CI 1.6-5.8; P = .001). Fellowship-trained surgeons had lower readmission rates. Surgeons with higher operative volumes used instrumented fusion more often (OR = 1.1, 95% CI 1.0-1.2, P < .05 for both diagnoses) and had lower rates of major in-hospital complications (OR = 0.91, 95% CI 0.85-0.97; P = .006). Surgical practice can vary greatly for degenerative spine conditions, even within the same region and among colleagues at the same institution. Surgical specialty and subspecialty, in addition to recent operative volume, can be linked to variations in spine surgeons' practice patterns and outcomes. These findings reinforce the notion that residency and fellowship training may contribute to variation and present important opportunities to optimize surgical practice over the course of surgeons' careers. Future efforts to reduce unexplained variation in surgical practice could test interventions focused on graduate medical education. Graphical Abstract., (© The Author(s) 2024. Published by Oxford University Press on behalf of International Society for Quality in Health Care.)

Case: A healthy 5-year-old boy presented with a gradual onset of headaches and acute global right-sided weakness over 10 days. The work-up revealed unstable os odontoideum leading to multiple posterior circulation infarcts with vertebral artery dissection. He underwent antiplatelet therapy, cervical collar immobilization, and delayed occiput to C2 posterior spinal fusion and instrumentation with iliac crest autograft. At 2-year follow-up, the patient had a solid fusion mass, appropriate cervical alignment, and was without neurologic sequelae., Conclusion: This case adds to a sparse body of literature in the management of vertebral artery dissection with vertebrobasilar insufficiency secondary to unstable os odontoideum., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C260)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: After discontinuation of growth-friendly (GF) surgery for early onset scoliosis, patients are termed graduates: they undergo a spinal fusion, are observed after final lengthening with GF implant maintenance, or are observed after GF implant removal. The purpose of this study was to compare the rates of and reasons for revision surgery in two cohorts of GF graduates: before or after 2 years of follow-up from graduation., Methods: A pediatric spine registry was queried for patients who underwent GF spine surgery with a minimum of 2 years of follow-ups after graduation by clinical and/or radiographic evidence. Scoliosis etiology, graduation strategy, number of, and reasons for revision surgery were queried., Results: There were 834 patients with a minimum of 2-year follow-up after graduation who were analyzed. There were 241 (29%) congenital, 271 (33%) neuromuscular, 168 (20%) syndromic, and 154 (18%) idiopathic. 803 (96%) had traditional growing rod/vertical expandable titanium rib as their GF construct and 31 (4%) had magnetically controlled growing rod. Five hundred ninety-six patients (71%) underwent spinal fusion at graduation, 208 (25%) had GF implants retained, and 30 (4%) had GF implants removed.In the entire cohort, there were 108/834 (13%) patients who underwent revision surgery. Of the revisions, 71/108 (66%) occurred as acute revisions (ARs) between 0 and 2 years from graduation (mean 0.6 y), and the most common AR indication was infection (26/71, 37%). The remaining 37/108 (34%) patients underwent delayed revision (DR) surgery >2 years (mean 3.8 y) from graduation, and the most common DR indication was implant issues (17/37, 46%).Graduation strategy affected revision rates. Of the 596 patients with spinal fusion as a graduation strategy, 98/596 (16%) underwent revision, compared with only 8/208 (4%) patients who had their GF implants retained, and 2/30 (7%) that had their GF implants removed ( P ≤ 0.001).A significantly higher percentage of the ARs had a spinal fusion as the graduation strategy (68/71, 96%) compared with 30/37 DRs, (81%, P = 0.015). In addition, the 71 patients who underwent AR undergo more revision surgeries (mean: 2, range: 1 to 7) than 37 patients who underwent DR (mean: 1, range: 1 to 2) ( P = 0.001)., Conclusion: In this largest reported series of GF graduates to date, the overall risk of revision was 13%. Patients who undergo a revision at any time, as well as ARs in particular, are more likely to have a spinal fusion as their graduation strategy. Patients who underwent AR, on average, undergo more revision surgeries than patients who underwent DR., Level of Evidence: Level III, comparative., Competing Interests: C.K.H.: Medtronic—Paid consultant; Orthopediatrics—Paid consultant. J.B.E.: Biomet—Paid consultant; DePuy, A Johnson & Johnson Company—IP royalties; Johnson & Johnson—Paid consultant; Journal of Children’s Orthopedics—Editorial or governing board. G.H.T.: Executive Committee Growing Spine Founding—Board or committee member; Journal of Pediatric Orthopedics—Editorial or governing board; Orthopediatrics —IP royalties, Paid consultant, Stock or stock options; Orthopediatrics—Travel expenses and per diem financial or material support; Scoliosis Research Society—Board or committee member; Shriner’s Hospital for Children—Executive Committee and Medical Advisory Board Member; Shriner’s Hospital for Children—Salary as Interim Chief Medical Officer; Societe Internationale de Chirurgie Orthopedique et de Traumatologie—Board or committee member; Wolters Kluwer Health, Lippincott Williams & Wilkins—Publishing royalties. P.D.S.: DePuy, A Johnson & Johnson Company – IP royalties, Paid consultant, Research support, Globus Medical – IP royalties, Journal of Bone and Joint Surgery—Editorial or governing board; Journal of Bone and Joint Surgery, American—Publishing royalties; Orthopediatrics—Financial or material support; Scoliosis Research Society—Board or committee member. J.T.S.: Biomet—Paid consultant; Children’s Spine Foundation—Board of Directors; DePuy, A Johnson & Johnson Company—Paid consultant; Globus Medical—IP royalties, Paid consultant; GS Medical—Paid consultant; Missonix—Paid presenter or speaker; Nuvasive—Paid consultant; Scoliosis Research Society—Board or committee member; Wishbone Medical—Paid consultant. D.L.S.: CHLA Foundation—Board or committee member; Grand Rounds—Paid consultant; Green Sun Medical—Stock or stock options; Growing Spine Foundation—Board or committee member; Growing Spine Study Group—Board or committee member; Journal of Children’s Orthopaedics—Editorial or governing board; Nuvasive – Research support (paid to Growing Spine Foundation); Orthobullets—Editorial or governing board, Paid consultant; Stock or stock options; Orthopedics Today—Editorial or governing board; Spine Deformity—Editorial or governing board; Wolters Kluwer Health—Publishing royalties; ZimmerBiomet—IP royalties, Financial or material support, Paid consultant, Paid presenter or speaker; Zipline Medical, Inc.—Stock or stock options. R.F.M.: Globus Medical—Paid consultant; Pediatric Orthopaedic Society of North America—Board or committee member; Scoliosis Research Society—Board or committee member. The remaining authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To assess the following hypotheses related to vertebral body tethering (VBT): 1. VBT is associated with asymmetric (concave > convex) increases in height over the instrumented vertebra. 2. The instrumented Cobb angle improves following VBT surgery with growth., Methods: This is a retrospective case series of pediatric patients from a multicenter scoliosis registry treated with VBT between 2013 to 2021., Inclusion Criteria: patients with standing radiographs at < 4 months and ≥ 2 years after surgery. Distances between the superior endplate of the UIV and the inferior endplate of the LIV were measured at the concave corner, mid-point, and convex corner of the endplates. The UIV-LIV angle was recorded. Subgroup analyses included comparing different Risser scores and tri-radiate cartilage (TRC) closed versus open using student t-tests., Results: 83 patients met inclusion criteria (92% female; age at time of surgery 12.5 ± 1.4 years) with mean follow-up time of 3.8 ± 1.4 years. Risser scores at surgery were: 0 (n = 33), 1 (n = 12), 2 (n = 10), 3 (n = 11), 4 (n = 12), and 5 (n = 5). Of the 33 Risser 0 patients, 17 had an open TRC, 16 had a closed TRC. The UIV-LIV distance at concave, middle, and convex points significantly increased from immediate post-op to final-follow-up for Risser 0 patients, but not for Risser 1-5 patients. Increases in UIV-LIV distance were not significantly different between concave, middle, and convex points for all groups. There was no significant improvement or worsening in UIV-LIV angle for any group., Conclusion: At a mean of 3.8 years following VBT, 33 Risser 0 patients demonstrated significant growth in the instrumented segment, though there was no difference between concave or convex growth, even for patients with open TRC., (© 2023. The Author(s).)

Purpose: Although the pediatric population typically has a high union rate, the cervical spine has a reputation for frequent pseduarthrosis, as high as 38% in some prior series. Our purpose was to examine the rate and risk factors for pseudarthrosis in pediatric cervical spine fusions., Methods: Retrospective review of all patients with ≥ 2 years follow-up undergoing cervical spinal fusion between January 2004 and December 2019 at a tertiary pediatric hospital. Pseudarthrosis was defined as an absence of radiographic union as assessed by the attending surgeon for which revision surgery was performed., Results: 64 patients (mean age: 8.4 ± 4.7 years) met inclusion criteria. Mean follow-up was 63.3 ± 41.4 months (range: 24-187 months). 28 fusions (44%) included the occiput. 41 patients (64%) had instrumentation, while 23 patients (36%) had uninstrumented fusions. 48 (75%) patients had a halo for a mean of 97.6 ± 49.5 days. The incidence of pseudarthrosis was as follows: overall = 8/64 (12.5%); posterior fusion = 14.8% (8/54); anterior fusions = 0% (0/4); and anteroposterior fusions = 0% (0/6). The rate of pseudarthrosis was over 8 times higher in fusions involving the occiput (occipitocervical fusion: 25.0%; 7/28 vs. cervical alone: 2.8%; 1/36; p = 0.02). Although not statistically significant, the rate of pseudarthrosis was 3 times higher in uninstrumented fusions (21.7%; 5/23) than instrumented fusions (7.3%; 3/41) (p = 0.12). In patients with uninstrumented fusion to the occiput, pseudarthrosis rate was 35.7% (5/14), which was higher compared to those who did not (6.0%; 3/50) (p = 0.01). Incidence of pseudarthrosis was similar in patients who received autograft (13.0%; 7/54) compared to allograft alone (10.0%; 1/10) (p > 0.999)., Conclusions: The pseudarthrosis rate in pediatric cervical spine fusions remained high despite frequent use of halo immobilization and autograft. Patients with uninstrumented occipitocervical fusions are at particularly high risk with more than 1 in 3 developing a pseudarthrosis., Study Design: Retrospective, Comparative., Level of Evidence: III., (© 2023. The Author(s).)

Growing rod (GR) instrumentation and the elongation, derotation, and flexion (EDF) casting technique are 2 alternatives for the treatment of early-onset scoliosis. Our purpose was to investigate the cost of these treatment options. This was a retrospective cohort study of patients with early-onset scoliosis treated at 2 institutions from 2007 to 2014 with either GR instrumentation or EDF casting. Patients with <2 years of follow-up were excluded. Physician and hospital charges and collections, total procedures, and procedure times until final follow-up or time of fusion were compared. Nineteen patients met the inclusion criteria; 8 in the GR group and 11 in the EDF casting group. There were no significant differences between the groups in age (P = .23), public versus private insurance (P = 1.0), or major curve (P = .21) at the initiation of treatment. Excluding final fusion, the EDF casting patients had an average of 2.1 (range: 0.7-6.6) procedures/year while the GR patients had an average of 1.5 (range: 0.8-2.7) procedures/year. The average procedure time for the EDF group was 104.2 minutes; the average procedure time for the GR group, excluding the index procedure, was 62.40 minutes (P = .001). Physician charges were 85% less for the EDF group (EDF= $1892.75, GR= $12,354.53, P < .001). Physician collections were 71% less for the EDF group (EDF= $731.10, GR= $2554.88, P = .001). Hospital charges and collections were similar between the groups (P = .82, P = .42). Physician charges for casting were approximately 18% of that of GRs. Compared to GRs, physician collections were 71% less for EDF casting patients per year., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Identifying beneficial preventive strategies for surgical-site infection (SSI) in individual patients with different clinical and surgical characteristics is challenging. The purpose of this study was to investigate the association between preventive strategies and patient risk of SSI taking into consideration baseline risks and estimating the reduction of SSI probability in individual patients attributed to these strategies., Methods: Pediatric patients who underwent primary, revision, or final fusion for their spinal deformity at 7 institutions between 2004 and 2018 were included. Preventive strategies included the use of topical vancomycin, bone graft, povidone-iodine (PI) irrigations, multilayered closure, impermeable dressing, enrollment in quality improvement (QI) programs, and adherence to antibiotic prophylaxis. The CDC definition of SSI as occurring within 90 days postoperatively was used. Multiple regression modeling was performed following multiple imputation and multicollinearity testing to investigate the effect of preventive strategies on SSI in individual patients adjusted for patient and surgical characteristics., Results: Univariable regressions demonstrated that enrollment in QI programs and PI irrigation were significantly associated, and topical vancomycin, multilayered closure, and correct intraoperative dosing of antibiotics trended toward association with reduction of SSI. In the final prediction model using multiple regression, enrollment in QI programs remained significant and PI irrigation had an effect in decreasing risks of SSI by average of 49% and 18%, respectively, at the individual patient level., Conclusion: Considering baseline patient characteristics and predetermined surgical and hospital factors, enrollment in QI programs and PI irrigation reduce the risk of SSI in individual patients. Multidisciplinary efforts should be made to implement these practices to increase patient safety., Level of Evidence: Prognostic level III study., (© 2022. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background: Trisomy 21 or Down syndrome is associated with multiple orthopaedic manifestations. Although cervical instability is the most common spinal condition associated with Down syndrome, the prevalence of scoliosis has been estimated at 4.8% to 8.7%. Very few prior studies have documented the role of spinal fusion in this population, and all have included ≤10 patients., Methods: An institutional review board-approved multicenter retrospective analysis of patients with Down syndrome treated with spinal fusion between January 2009 and December 2019 was performed by cross-referencing Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth and Tenth Revisions (ICD-9 and ICD-10) codes. Patients were followed for ≥2 years, with a mean follow-up of 3.77 years. Clinical and radiographic outcomes were collected, and complications were documented using the Clavien-Dindo-Sink (CDS) classification., Results: A total of 23 patients were included: 96% had ≥1 medical comorbidities, including 16 (70%) with congenital heart disease, of whom 88% had previous cardiac surgery, and 10 (44%) with thyroid disorders. All 23 patients underwent posterior spinal fusion. The mean estimated blood loss was 617 ± 459 mL, the mean length of the surgical procedure was 290 ± 92.7 minutes, and the mean length of hospital stay was 6.03 ± 2.91 days. The major Cobb angle measured 61.7° ± 17.6°, which corrected to 19.4° ± 14.8° (68.6% correction; p < 0.001), with well-maintained correction at 2 years of 22.0° ± 10.3° (64.3% correction; p = 0.158). Thirteen (57%) of 23 patients had a change in curve of >5°. There were no intraoperative complications; however, 12 patients (52%) sustained postoperative complications (e.g., need for reoperation, implant failure, and pulmonary complications), including 6 patients with CDS type 3 or 4 (e.g., wound dehiscence, late superficial abscess, pleural effusion, pseudarthrosis, and readmission for hypoxia). Four patients (17%) required a revision surgical procedure. One patient (4%) required an unplanned intensive care unit admission., Conclusions: Although instrumented spinal fusion can effectively correct spinal deformity in these patients, complications are more frequent than in children with adolescent idiopathic scoliosis, with over half of patients sustaining a complication., Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H249 )., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Case: We present 3 cases in which spinal rods extending beyond the intended level of fusion caused injury to adjacent structures, which we term "adjacent segment impingement." All cases presented as back pain with no neurological symptoms, with a minimum 6 years of follow-up from the initial procedure. Treatment consisted of extending the fusion to include the affected adjacent segment., Conclusion: We recommend surgeons check to ensure spinal rods are not abutting adjacent level structures at the time of the initial implant while considering that adjacent levels may move closer to the rod during spine extension or twisting., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B979)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Aim: To develop and validate a risk calculator based on preoperative factors to predict the probability of surgical site infection (SSI) in patients with cerebral palsy (CP) undergoing spinal surgery., Method: This was a multicenter retrospective cohort study of pediatric patients with CP who underwent spinal fusion. In the development stage, preoperative known factors were collected, and a risk calculator was developed by comparing multiple models and choosing the model with the highest discrimination and calibration abilities. This model was then tested with a separate population in the validation stage., Results: Among the 255 patients in the development stage, risk of SSI was 11%. A final prediction model included non-ambulatory status (odds ratio [OR] 4.0), diaper dependence (OR 2.5), age younger than 12 years (OR 2.5), major coronal curve magnitude greater than 90° (OR 1.3), behavioral disorder/delay (OR 1.3), and revision surgery (OR 1.3) as risk factors. This model had a predictive ability of 73.4% for SSI, along with excellent calibration ability (p = 0.878). Among the 390 patients in the validation stage, risk of SSI was 8.2%. The discrimination of the model in the validation phase was 0.743 and calibration was p = 0.435, indicating 74.3% predictive ability and no difference between predicted and observed values., Interpretation: This study provides a risk calculator to identify the risk of SSI after spine surgery for patients with CP. This will allow us to enhance decision-making and patient care while providing valid hospital comparisons, public reporting mechanisms, and reimbursement determinations., (© 2022 Mac Keith Press.)

Background: The outcomes of congenital scoliosis (CS) patients undergoing hemivertebra (HV) resection surgery with a 2-level fusion versus a >2-level fusion are unclear. We hypothesized that CS patients undergoing HV resection and a >2-level fusion have decreased curve progression and reoperation rates compared with 2-level fusions., Methods: Retrospective review of prospectively collected data from a multicenter scoliosis database. Fifty-three CS patients (average age 4.5, range 1.2 to 10.9 y) at index surgery were included. Radiographic and surgical parameters, complications, as well as revision surgery rates were tracked at a minimum of 2-year follow-up., Results: Twenty-six patients had a 2-level fusion while 27 patients had a >2-level fusion with similar age and body mass index between groups. The HV was located in the lumbar spine for 69% (18/26) 2-level fusions and 30% (8/27) >2-level fusions ( P =0.006). Segmental HV scoliosis curve was smaller in 2-level fusions compared to >2-level fusions preoperatively (38 vs. 50 degrees, P =0.016) and at follow-up (25 vs. 34 degrees, P =0.038). Preoperative T2-T12 (28 vs. 41 degrees, P =0.013) and segmental kyphosis (11 vs. 23 degrees, P =0.046) were smaller in 2-level fusions, but did not differ significantly at postoperative follow-up (32 vs. 39 degrees, P =0.22; 13 vs. 11 degrees, P =0.64, respectively). Furthermore, the 2 groups did not significantly differ in terms of surgical complications (27% vs. 22%, P =0.69; 2-level fusion vs. >2-level fusion, respectively), unplanned revision surgery rate (23% vs. 22%, 0.94), growing rod placement or extension of spinal fusion (15% vs. 15%, P =0.95), or health-related quality of life per the EOS-Questionnaire 24 (EOSQ-24). Comparison of patients with or without the need for growing rod placement or posterior spinal fusion revealed no significant differences in all parameters analyzed., Conclusions: Two-level and >2-level fusions can control congenital curves successfully. No differences existed in curve correction, proximal junctional kyphosis or complications between short and long-level fusion after HV resection. Both short and long level fusions are viable options and generate similar risk of revision. The decision should be individualized by patient and surgeon., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Despite tremendous efforts, the incidence of surgical site infection (SSI) following the surgical treatment of pediatric spinal deformity remains a concern. Although previous studies have reported some risk factors for SSI, these studies have been limited by not being able to investigate multiple risk factors at the same time. The aim of the present study was to evaluate a wide range of preoperative and intraoperative factors in predicting SSI and to develop and validate a prediction model that quantifies the risk of SSI for individual pediatric spinal deformity patients., Methods: Pediatric patients with spinal deformity who underwent primary, revision, or definitive spinal fusion at 1 of 7 institutions were included. Candidate predictors were known preoperatively and were not modifiable in most cases; these included 31 patient, 12 surgical, and 4 hospital factors. The Centers for Disease Control and Prevention definition of SSI within 90 days of surgery was utilized. Following multiple imputation and multicollinearity testing, predictor selection was conducted with use of logistic regression to develop multiple models. The data set was randomly split into training and testing sets, and fivefold cross-validation was performed to compare discrimination, calibration, and overfitting of each model and to determine the final model. A risk probability calculator and a mobile device application were developed from the model in order to calculate the probability of SSI in individual patients., Results: A total of 3,092 spinal deformity surgeries were included, in which there were 132 cases of SSI (4.3%). The final model achieved adequate discrimination (area under the receiver operating characteristic curve: 0.76), as well as calibration and no overfitting. Predictors included in the model were nonambulatory status, neuromuscular etiology, pelvic instrumentation, procedure time ≥7 hours, American Society of Anesthesiologists grade >2, revision procedure, hospital spine surgical cases <100/year, abnormal hemoglobin level, and overweight or obese body mass index., Conclusions: The risk probability calculator encompassing patient, surgical, and hospital factors developed in the present study predicts the probability of 90-day SSI in pediatric spinal deformity surgery. This validated calculator can be utilized to improve informed consent and shared decision-making and may allow the deployment of additional resources and strategies selectively in high-risk patients., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G814)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: It is unclear whether traditional growing rod (TGR) treatment outcomes vary by early-onset scoliosis (EOS) subtype. The goal of this study was to compare radiographic outcomes and complications of TGR treatment by EOS subtype., Methods: We queried an international database of EOS patients from 20 centers to identify "graduates" who had (1) undergone primary TGR treatment from 1993 to 2014; (2) completed TGR treatment; and (3) had an uneventful clinical examination within 6 months after completion of TGR treatment with no anticipated further intervention. We included 202 patients in 4 etiologic subgroups: neuromuscular (n=65), syndromic (n=57), idiopathic (n=52), and congenital (n=28). Mean age at surgery was 7.1 years (range, 1.6 to 14.9 y); mean duration of follow-up was 8 years (range, 2 to 18.6 y). The groups did not differ by mean age, body mass index, sex, number of lengthenings, or duration of follow-up. The following preoperative differences were significant: (1) greater mean major curve in the neuromuscular versus idiopathic subgroup; (2) shorter spinal height (T1-S1) in the congenital versus idiopathic subgroup; and (3) smaller proportion of ambulatory patients in the neuromuscular subgroup versus all other subgroups., Results: We found no significant differences among subgroups in mean major curve correction or changes in thoracic height (T1-T12), spinal height, or global kyphosis at any point. Rates of deep surgical site infection, implant-related complications, and neurological complications were not different among subgroups. The medical complication rate was significantly lower in the idiopathic group compared with the other groups., Conclusions: Major curve correction and spinal and thoracic height increases did not differ significantly at any point by EOS subtype. Rates of deep surgical site infection, implant-related complications, and neurological complications did not differ by subtype. Except for the lower rate of medical complications in the idiopathic group, our findings suggest that, after TGR treatment, patients can expect similar outcomes regardless of their EOS subtype., Level of Evidence: Level III, therapeutic., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To investigate the risk and predictive factors of junctional issues after conversion from Traditional growing rod (TGR) to definitive spinal fusion in Early-onset scoliosis (EOS)., Methods: Retrospective review of a multicenter EOS database. TGR patients who received final fusion with at least two-year follow-up were included. Proximal (PJA) and Distal junctional angles (DJA) on pre-final fusion, post-final fusion (within one year of surgery), and at latest follow-up were measured on lateral upright spinal radiographs. Differences in values among designated time points and predictive factors of junctional issues were evaluated statistically., Results: Forty-six of 251 patients (28 females, 18 males and mean age at final fusion: 12 ± 2 [9-17] years) met the inclusion criteria. Mean follow-up between first postoperative measurement and latest follow-up was 49 ± 22 (24-112) months. No statistical differences in PJA and DJA values were available at pre-fusion, first post-fusion, or latest follow-up (p = 0.827, p = 0.076). Fifty percent of patients had extension of TGR instrumentation at fusion, either proximal or distal. No factor including sex and etiology, lumbar lordosis, thoracic kyphosis, major curve magnitude, PJA, and DJA at pre-fusion was found to be a predictive issue for extension of index TGR instrumentation, except the history of at least one implant-related complication during the period from index surgery to the definitive fusion., Conclusion: PJA and DJA remained stable when transitioning from TGR to final posterior spinal fusion. But 50% of patients had extension of construction at fusion, either proximal or distal., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To identify curve/correction characteristics associated with adding-on at 2 years after posterior spinal fusion (PSF) in Lenke 1/2 AR curves., Methods: A prospective multicenter registry was queried to identify patients with adolescent idiopathic scoliosis (AIS), Lenke 1/2 AR curves, who underwent PSF with a minimum of 2-year follow-up. Patient characteristics as well as pre- and post- operative radiographic variables were evaluated using Classification and Regression Tree (CART) analysis to determine which factors contribute to adding-on., Results: 253 patients treated with PSF were assessed for adding-on, of which 50 met our adding-on criteria. Univariate analysis revealed adding-on was associated several factors including: post-operative thoracic and lumbar curve magnitude (p > 0.001), first erect (FE) end instrumented vertebra (EIV) angulation (p = 0.009) and EIV translation (p = 0.001), younger age (p = 0.027), Risser stage (p = 0.024), and a more proximal lowest instrumented vertebra (LIV) (p < 0.001). Multivariate CART analysis showed the chance of adding-on was more than 2 times greater (42 vs 16%) when the chosen LIV was translated more than 2.7 cm from the CSVL. When the LIV was within 2.7 cm, the post-op risk of adding-on was increased when the LIV was not perfectly leveled (> 0.5°)., Conclusion: In Lenke 1 and 2 AR curves, pre-operative LIV translation appears to be an independent risk factor for adding-on; and in those with < 2.7 cm of LIV translation, FE LIV angulation also seems to increase the risk of adding-on. These factors are relevant in determining appropriate LIV selection and aid in identifying patients at risk for developing adding-on., (© 2021. Scoliosis Research Society.)

Study Design: Retrospective cohort, multicenter. A single surgeon study demonstrated that pedicle tract preparation with power tools was associated with lower fluoroscopy times and revision rates compared to manual tools, while maintaining patient safety., Objective: Our purpose was to determine the safety of power-assisted pedicle tract preparation by early adopters of this technology., Methods: Retrospective review comparing patients that underwent posterior spinal fusion by seven pediatric spine surgeons at six institutions between January 1, 2008 and August 31, 2019. The manual pedicle tract preparation used a pedicle awl. Power tract preparation used a flexible 2.0-2.4 mm drill bit, followed by a larger drill bit or a reamer. All screws were inserted with power technique., Results: In the manual tract preparation group, 9424 screws were placed in 585 cases. In the power tract preparation group, 22,209 screws were placed in 1367 cases. Seven patients (7/1952; 0.36%; 95% CI: 0.14-0.74%) had 11 mal-positioned screws (11/31,633; 0.03%; 95% CI: 0.017-0.062%). Seven screws (7/9424; 0.07%; 95% CI: 0.030-0.15%) were in the manual cohort and four (4/22,209; 0.02%; 95% CI: 0.0049-0.046%) were in the power cohort. There were significantly more revisions per screw in the manual cohort (p = 0.02). However, there were not significantly more revisions per patient in the manual cohort (manual: 0.5%, 3/585 vs. power: 0.3%, 4/1,367; p = 0.43). Of these seven, three patients (3/585; 0.5%; 95% CI: 0.1-1.5%) experienced neurologic injury or neuro-monitoring changes requiring screw removal in the manual cohort, and 1 patient (1/1,367, 0.07%; 95% CI: 0.002-0.4%) in the power cohort (p = 0.08). Three additional patients underwent revision in the power cohort: 1 for an asymptomatic lateral breech, 1 for a spinal headache/medial breech that developed after an MVA, and 1 for an iliac vein injury during pedicle tract preparation., Conclusion: This is the first multi-center study examining power pedicle preparation. Overall, 99.9% of pedicle screws placed with power pedicle preparation did not have complications or revision. Equivalent patient safety was demonstrated compared to manual technique., Level of Evidence: III., (© 2021. Scoliosis Research Society.)

Study Design: Retrospective, multicenter comparative., Objectives: Our purpose was to compare early onset scoliosis (EOS) patients treated with ultra-low, low, and high implant density constructs when undergoing conversion to definitive fusion. Larson et al. demonstrated that implant density (ID) at fusion does not correlate with outcomes in the treatment of adolescent idiopathic scoliosis, but did not address growth-friendly graduates., Methods: EOS patients treated with growth-friendly constructs converted to fusion between 2000 and 2017 were reviewed from a multicenter database. ID was defined as number of pedicle screws, hooks, and sublaminar/bands per level fused. Patients were divided into ultra-low ID (< 1.3), low (≥ 1.3 and < 1.6), and high ID (≥ 1.6)., Exclusion Criteria: < 2 years follow-up from fusion or inadequate radiographs., Results: A total of 152 patients met inclusion criteria with 39 (26%) patients in the high ID group, 33 (22%) patients in the low ID group, and 80 (52%) in the ultra-low ID group. Groups were similar in operative time (p = 0.61), pre-fusion major curve (p = 0.71), mean number of levels fused (p = 0.58), clinical follow-up (p = 0.30), and radiographic follow-up (p = 0.90). Patients in the low ID group (11.6 ± 1.5 years) were slightly younger at the time of definitive fusion than patients in the ultra-low ID group (12.9 ± 2.2 years) and high ID group (12.5 ± 1.7 years) (p = 0.009). There was significantly more blood loss in the high ID group than the other two groups (high ID: 946.8 ± 606.0 mL vs. low ID: 733.9 ± 434.5 mL and ultra-low ID: 617.4 ± 517.2 mL; p = 0.01), but there was no significant difference with regard to percent of total blood volume lost (high ID: 59.3 ± 48.7% vs. low ID: 54.5 ± 37.5% vs. ultra-low ID: 51.7 ± 54.9%; p = 0.78). There was a difference in initial improvement in major curve between the groups (high ID: 21.6° vs. low ID: 18.0° vs. ultra-low ID: 12.6°; p = 0.01). However, during post-fusion follow-up, correction decreased 7.1° in the high ID group, 2.6 in the low ID group, and 2.8 in the ultra-low ID group (p = 0.19). At final follow-up, major curve correction from pre-fusion was similar between groups (high ID: 14.5° vs. low ID: 15.5° vs. ultra-low ID: 9.7°, p = 0.14). At final follow-up, there was no difference in T1-T12 length gain (p = 0.85), T1-S1 length gain (p = 0.68), coronal balance (p = 0.56), or sagittal balance (p = 0.71). The revision rate was significantly higher in the ultra-low ID group (13.8%; 11/80) versus the high ID group (2/39; 5.1%) and low ID group (0/33; 0%) (p = 0.04)., Conclusions: Although an ID < 1.3 in growth-friendly graduates produces similar outcomes with regard to curve correction and spinal length gain as low and high ID, this study suggests that an ID < 1.3 is associated with an increased revision rate., Level of Evidence: III., (© 2021. Scoliosis Research Society.)

Study Design: Retrospective cohort study., Objective: The purpose of this study is to investigate the incidence of surgical site infection in neuromuscular scoliosis (NMS) patients at a tertiary children's hospital before and after the implementation of strategies mentioned in the 2013 Best Practice Guideline., Summary of Background Data: Patients with NMS are at high risk for surgical site infection following spine surgery. In 2013, a Best Practice Guideline for surgical site infection prevention in high-risk pediatric spine surgery patients reported strategies to decrease incidence. To date, no studies have looked at the efficacy of these strategies., Methods: A retrospective review of surgical site infection in NMS patients was performed. NMS patients undergoing primary posterior spinal fusion from January 2008 to December 2012 (Group 1) and January 2014 to December 2018 (Group 2) were included, with 2013 excluded as a transition year. The primary outcome was incidence of surgical site infection within 1 year of surgery, as defined by the Centers for Disease Control and National Healthcare Safety Network. All patients had at least 1 year of documented follow-up., Results: One hundred ninety eight patients were included, 62 in Group 1 and 136 in Group 2. Age, BMI, sex, fusion to pelvis, preoperative Cobb angle, incontinence, drain use, blood loss, surgical time, and other perioperative values were similar (P > 0.05). Deep surgical site infection occurred in 10 (16.1%) patients in Group 1 and six (4.4%) patients in Group 2 (P = 0.005). Thirteen (59.1%) identified organisms were gram-negative, with 11 (84.6%) isolated from Group 1 (P = 0.047). Polymicrobial infections accounted for six (37.5%) infections overall., Conclusion: The incidence of surgical site infection in NMS patients decreased significantly (16.1% vs. 4.4%) after the implementation of the strategies mentioned in the 2013 Best Practice Guideline. Further studies are required to continue to decrease the incidence in this high-risk population.Level of Evidence: 3., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Surgical planning for Adolescent Idiopathic Scoliosis (AIS) relies on the coronal and sagittal plane to determine the lowest instrumented vertebra (LIV). Failure to include the stable sagittal vertebra (SSV) within the construct can increase the incidence of postoperative distal junctional kyphosis (DJK). The purpose of this study is to assess the variability of SSV within patients and to identify positional parameters that may lead to its change., Methods: This is a case-control study of AIS patients with changes in SSV throughout serial radiographs. Radiographic sagittal parameters and hand positioning for the patients with changes in SSV were compared to patients with stable SSV. Additionally, a subgroup analysis was conducted to compare the positional parameters of only the patients with changes in SSV., Results: 46 patients with a mean age of 15 ± 1.8 years old at the time of surgery were included in this study. 33/76 (43.4%) image pairs were found to have a change in SSV. Positional parameters associated with the more distally measured SSV were found to have a more negative sagittal vertebral axis (p = 0.001), more positive pelvic shift (p = 0.023), and more negative Global Sagittal Axis (p = 0.001) when compared to the more proximally measured SSV., Conclusion: Significant variability exists in the determination of SSV in AIS patients undergoing serial radiographs. Positional parameters associated with the proximal and distally measured SSV also have variability which indicates that posture has a significant impact on this measure. Surgeons need to be aware of SSV variability during preoperative planning and must consider multiple parameters for the determination of LIV., Level of Evidence: 3.

Study Design: Multicenter retrospective., Objective: To determine the long-term complication rate associated with surgical treatment of spondylolisthesis in adolescents. There is limited information on the complication rate associated with posterior spinal fusion (PSF) of spondylolisthesis in the pediatric and adolescent population., Methods: Patients who underwent PSF for spondylolisthesis between 2004 and 2015 at four spine centers, < 21 years of age, were included. Exclusion criteria were < 2 years of follow-up or anterior approach. Charts and radiographs were reviewed., Results: 50 patients had PSF for spondylolisthesis, 26 had PSF alone, while 24 had PSF with trans-foraminal lumbar interbody fusion (TLIF). Mean age was 13.9 years (range 9.6-18.4). Mean follow-up was 5.5 years (range 2-15). Mean preoperative slip was 61.2%. 20/50 patients (40%) experienced 23 complications requiring reoperation at a mean of 2.1 years (range 0-9.3) for the following: implant failure (12), persistent radiculopathy (3), infection (3), persistent back pain (2), extension of fusion (2), and hematoma (1). In addition, there were 22 cases of radiculopathy (44%) that were transient. Rate of implant failure was related to preoperative slip angle (p = 0.02). Reoperation rate and rates of implant failure were not associated with preoperative % slip (reoperation: p = 0.42, implant failure: p = 0.15), postoperative % slip (reoperation: p = 0.42, implant failure: p = 0.99), postoperative kyphosis of the lumbosacral angle (reoperation: p = 0.81, implant failure: p = 0.48), change in % slip (reoperation: p = 0.30, implant failure: p = 0.12), change in slip angle (reoperation: p = 0.42, implant failure: p = 0.40), graft used (reoperation: p = 0.22, implant failure: p = 0.81), or addition of a TLIF (reoperation: p = 0.55, implant failure: p = 0.76)., Conclusion: PSF of spondylolisthesis in the adolescent population was associated with a 40% reoperation rate and high rate of post-operative radiculopathy. Addition of a TLIF did not impact reoperation rate or rate of radiculopathy.

Background: Parental mental status and behavior may influence postoperative recovery and the use of pain medication. The purpose of this study is to identify if parents with high anxiety are associated with prolonged narcotic use in adolescent patients following posterior spinal fusion surgery. Prolonged narcotic use in this study was defined as opioid use at their first postoperative visit., Methods: AIS patients age 11 to 20 years undergoing posterior spinal fusion and a parent were prospectively enrolled. At the preoperative appointment, patients completed the Spence Children's Anxiety Scale and parents completed the State-Trait Anxiety Inventory. High parental anxiety was defined as 1 SD above the normative mean. At the first postoperative visit, patients were asked about medication use., Results: A total of 58 patients (49 females and 9 males) were enrolled. Overall, 29% (17/58) of parents had a high general anxiety trait on the State-Trait Anxiety Inventory and 71% (41/58) had normal general anxiety. Of the patients whose parents had high general anxiety, 47% (8/17) were still taking narcotics at their first postoperative visit compared with 20% (8/41) of patients with normal anxiety parents (P=0.03)., Conclusions: Patients with high general anxiety parents were more than twice as likely to still be on narcotics at their first postoperative visit. This information can be used to counsel families on the impact of anxiety on narcotic usage., Level of Evidence: Level II-prognostic studies-investigating the effect of a patient characteristic on the outcome of the disease.

Study Design: Retrospective., Objectives: To assess final outcomes in patients with early-onset scoliosis (EOS) who underwent growth-preserving instrumentation (GPI). Various types of growth-preserving instrumentation (GPI) are frequently employed, but until recently had not been utilized long enough to assess final outcomes., Methods: GPI "graduates" with multi-level congenital curves were identified. Graduation was defined as a final fusion or 5 years of follow-up without planned future surgeries. Outcomes included radiographic parameters and complications., Results: 26 patients were included. 11 had associated diagnoses; eight had fused ribs. 17 were treated with traditional growing rods, seven with vertically expandable prosthetic ribs, and two with Shilla procedures. The mean GPI spanned 12.3 levels including 10.7 motion segments, age at index surgery was 5.5 years, treatment spanned 7.5 years, and follow-up was 9.2 years. 24 patients underwent final fusion. Mean major curve decreased from 73° to 49° with index surgery (p < 0.01) and remained unchanged through a final follow-up. Final major curve was < 40° in 9 patients (35%), 40°-60° in 11 patients (42%), and > 60° in 6 patients (23%). None worsened throughout treatment. Mean T1-T12 height increased 2.4 cm with index surgery (p = 0.02) and 5.4 cm total (p < 0.01). T1-T12 height increased in all patients and was ultimately < 18 cm in 10 patients (38%), 18-22 cm in 10 patients (38%), and > 22 cm in 6 patients (23%). On average, there were 2.6 complications per patient, including 1.7 implant failures. 12 patients (46%) experienced ≥ 3 complications; four patients (15%) experienced none., Conclusion: We observed successful prevention of deformity progression but substantial residual deformity among GPI graduates with multi-level congenital EOS. Most coronal curve correction was attained during GPI implantation; thoracic height improved throughout treatment. While some favorable results were found, treatment strategies allowing improved deformity correction would be valuable for this challenging population., Level of Evidence: Therapeutic-III.

Background: Growth-friendly treatment of early-onset scoliosis (EOS) has changed with the development and evolution of multiple devices. This study was designed to characterize changes in the use of growth-friendly implants for EOS from 2007 to 2017., Methods: We queried the Pediatric Spine Study Group database for patients who underwent index surgery with growth-friendly implants from July 2007 to June 2017. In 1298 patients, we assessed causes of EOS; preoperative curve magnitude; age at first surgery; patient sex; construct type; lengthening interval; incidence of "final" fusion for definitive treatment; and age at definitive treatment. α=0.05., Results: From 2007 to 2017, the annual proportion of patients with idiopathic EOS increased from 12% to 33% (R=0.58, P=0.006). Neuromuscular EOS was the most common type at all time points (range, 33% to 44%). By year, mean preoperative curve magnitude ranged from 67 to 77 degrees, with no significant temporal changes. Mean (±SD) age at first surgery increased from 6.1±2.9 years in 2007 to 7.8±2.5 years in 2017 (R=0.78, P<0.001). As a proportion of new implants, magnetically controlled growing rods increased from <5% during the first 2 years to 83% in the last 2 years of the study. Vertically expandable prosthetic titanium ribs decreased from a peak of 48% to 6%; growth-guidance devices decreased from 10% to 3%. No change was seen in mean surgical lengthening intervals (range, 6 to 9 mo) for the 614 patients with recorded lengthenings. Final fusion was performed in 88% of patients who had undergone definitive treatment, occurring at a mean age of 13.4±2.4 years., Conclusions: From 2007 to 2017, neuromuscular EOS was the most common diagnosis for patients treated with growth-friendly implants. Patient age at first surgery and the use of magnetically controlled growing rods increased during this time. Preoperative curve magnitude, traditional growing rod lengthening intervals, and rates of final fusion did not change., Level of Evidence: Level II.

Study Design: Retrospective multi-center enrollment., Objective: To examine the impact of patient and surgical factors on proximal complication and revision rates of early onset scoliosis patients using a multicenter database. Proximal anchor pullout and junctional kyphosis are common causes necessitating revision surgery during growth friendly treatment of early onset scoliosis (EOS). Many options exist for proximal fixation and may impact the rate of these complications., Methods: Retrospective review of multicenter database of patients with growth friendly constructs for EOS. Inclusion criteria were patients with index instrumentation < 10 years of age and minimum of 2 year follow-up., Results: 353 patients met the inclusion criteria and had the following constructs: growing rods with spine anchors = 303; growing rods with rib anchors = 15 and VEPTR = 35. Mean age at index instrumentation was 6.0 years. Mean preoperative Cobb angle was 76° and mean kyphosis was 54°. Mean follow-up was 6.0 years. 21.8% of patients (77/353) experienced anchor pullout. Lower anchor pullout rates were associated with a higher numbers of proximal anchors (p = 0.003, r = - 0.157), and 5 or more anchors were associated with lower rates of anchor pullout (p = 0.014). Anchor type (rib hooks vs spine anchors vs rib cradle) did not impact rate of anchor pullout (p = 0.853). Kyphosis data was available for 198 patients. 23.2% (46/198) of these patients required proximal extension of their construct after index surgery. Initial instrumentation below the upper end vertebrae (UEV) of kyphosis was associated with higher rates of subsequent proximal revision; 28.9% (20/69) compared to 20.1% (26/129) for those instrumented at or above the UEV (p = 0.035). Preoperative kyphosis and change in thoracic kyphosis were not associated with anchor pullout (p = 0.436, p = 0.115) or proximal revision rates (p = 0.486, p = 0.401)., Conclusion: Five or more anchors are associated with lower rates of anchor pullout. Proximal anchor placement at or above the UEV resulted in a significant decrease in rates of proximal extension of the construct.

Study Design: Retrospective, multicenter., Objective: To investigate clinical outcomes in particular T1-S1 growth in patients with SHILLA instrumentation independent of inventor's reports. Guided growth with apical fusion and sliding pedicle screws (GGC/SHILLA) is an alternative to distraction-based growing rods for the treatment of EOS. A recent report of patients treated with GGC primarily at the center where the procedure was invented reported surprisingly good spinal growth similar to normal growth., Methods: Retrospective review of EOS patients treated with GGC between 2007 and 2013 was performed from a multicenter database prior to final fusion. Inclusion criteria were < 10 years at index surgery and minimum 2-year follow-up. Patients with GGC performed at the inventor's institution or prior spinal instrumentation were excluded. Predicted normal T1-S1 change during the growth period was calculated for each patient based on Dimeglio's growth rates., Results: 20 patients (mean age at surgery: 5.7 years) with the following diagnoses met inclusion criteria: syndromic (N = 9), neuromuscular (N = 5), idiopathic (N = 3) and congenital (N = 3). Preoperative mean Cobb was 77° (range 33°-111°). Mean increase in T1-S1 length from preoperative to postoperative was 51.5 mm, and change from postoperative to final follow-up was 21.8 mm (4.2 mm/year) which was 36% of predicted growth. 15/20 (75%) patients underwent 21 revision surgeries most commonly for implant complications (N = 26) and 8/20 (40%) underwent definitive fusion at a mean of 5.1 ± 1.2 years after guided growth surgery., Conclusion: This study constitutes the largest case series of patients with EOS treated with GGC outside of the inventor's institution. The change in T1-S1 observed through the follow-up period in EOS patients treated with GGC was approximately 1/3rd of predicted normal growth, and less than 1/3rd of growth reported in previous reports. Similar curve correction and complication rates but less T1-S1 growth during the growth period were found compared to prior GGC (SHILLA) series.

Study Design: Retrospective comparative study., Objective: To determine how the use of dedicated spine surgical nurses and scrub technicians impacted surgical outcomes of posterior spinal fusions for adolescent idiopathic scoliosis (AIS). Dedicated team approaches to surgery have been shown to improve surgical outcomes. However, their study on orthopaedics and spine surgery is limited., Methods: A retrospective review of all patients who underwent a primary posterior spinal fusion of seven or more levels for AIS at a tertiary care pediatric hospital with a minimum of 2 years of follow-up from 2006 to 2013 was conducted. Our institution had dedicated spine surgeons and anesthesiologists throughout the study period, but use of dedicated spine nurses and scrub technicians was variable. The relationship between the proportion of nurses and scrub technicians that were dedicated spine and surgical outcome variables was examined. A multiple regression was performed to control for the surgeon performing the case and the start time., Results: A total of 146 patients met criteria. When teams were composed of < 60% dedicated spine nurses and scrub technicians, there was 34 min more total OR time (p = .008), 27 min more surgical time (p = .037), 7 min more nonsurgical OR time (p = .030), 30% more estimated blood loss (EBL) (p = .013), 27% more EBL per level instrumented (p = .020), 113% more allogeneic transfusion (p = .006), and 104% more allogeneic transfusion per level instrumented (p = .009). There was no significant difference in length of stay, unplanned staged procedures, surgical site infection, reoperation, or major medical complications., Conclusions: Performing posterior spinal fusions for AIS patients with dedicated spine nurses and scrub technicians is associated with a significant decrease in total OR time, blood loss, and transfusion rates., Level of Evidence: III.

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.

Study Design: A multicenter retrospective study., Objective: The aim of this study was to compare pelvic obliquity correction and reoperation rate in neuromuscular scoliosis patients who had their pelvis included in a posterior spinal fusion (pelvic fusion, PF) at their index procedure versus revision procedures., Summary of Background Data: There is limited information on outcomes specific to fusing to the pelvis for neuromuscular scoliosis in a revision operation versus index surgery., Methods: Charts and radiographs were reviewed of patients with PF for neuromuscular scoliosis from January 2003 to August 2015 at four high-volume pediatric spine centers with >2 year follow-up., Results: Two hundred eighty-five patients met inclusion criteria; 271 had PF done at index surgery and 14 had PF done during revision surgery. Before index procedure, there were no significant differences in Cobb angle (P = 0.13). Before PF, there was no difference in pelvic obliquity (P = 0.26). At the time of fusion to the pelvis, estimated blood loss (P = 0.23) and operative time (P = 0.43) did not differ between index and revision groups. Percent correction in pelvic obliquity was similar for both groups (P = 0.72). Overall, 69 patients had complications requiring return to the operating room. Excluding the revision surgery for inclusion of the pelvis for the revision group, there was still a lower reoperation rate with index PF (22.9%, n = 62/271) than revision PF (50.0%, n = 7/14) (P = 0.02). Implant failures were significantly higher in the revision group (index = 7.4%, 20/271; revision = 42.9%, 6/14; P < 0.001)., Conclusion: PF at the index spinal fusion led to similar correction of pelvic obliquity with approximately half the reoperation rate compared with PF at a revision surgery. Operative time and blood loss were similar between index and revision spinal fusion., Level of Evidence: 4.

Study Design: Retrospective review of prospectively collected data., Objective: To compare the use of spine-based versus rib-based implants for the treatment of early-onset scoliosis (EOS) in the setting of rib fusions., Summary of Background Data: Treatment for severe early-onset spinal deformity with rib fusions includes growing spine devices with proximal rib or spine anchors. The results of treatment, however, have not been compared between spine-based versus rib-based proximal anchors., Methods: 169 patients with rib fusions treated with rib-based or spine-based constructs and minimum two-year follow-up were included. Sixteen patients were treated with proximal spine-based anchors and 153 with proximal rib-based devices (VEPTRs). Overall, 104 of the patients with rib-based fixation underwent thoracoplasty at the index surgery. We evaluated change in T1-T12 and T1-S1 height, coronal Cobb angle, kyphosis, and number of lengthening/revision surgeries., Results: Kyphosis increased a mean of 7° in the rib-based group and decreased a mean of 20 degrees in the spine-based group (p = .002). Major Cobb angle decreased in both groups (p < .0001); however, the spine-based group had greater Cobb angle improvement (24 vs. 11 degrees, p = .04). From implant and lengthening of distraction devices, there was a mean 3.3-cm (22%) increase in T1-T12 height and a mean of 8.0 lengthenings in the rib-based group compared with a 5.7-cm increase and 6.3 lengthening surgeries in the spine-based group. Patients with rib-based constructs had a mean of 11 total procedures, whereas spine-based patients had a mean of 8., Conclusions: Patients underwent a mean of eight lengthening surgeries before final fusion or cessation of lengthening with a modest 2.3-cm increase in T1-T12 height. Compared with proximal rib anchors, proximal spine anchors controlled kyphosis and improved Cobb angle correction for early-onset scoliosis with rib fusions., (Copyright © 2018 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Background: Intraoperative hypothermia may be associated with increased blood loss due to the effects of temperature on clotting but this has not been evaluated in the setting of pediatric posterior spinal fusion (PSF). The purpose of this study was to determine if a correlation exists between intraoperative hypothermia and estimated blood loss (EBL) or transfusion requirements in pediatric patients undergoing PSF., Methods: A retrospective review of consecutive patients undergoing PSF for scoliosis at a single institution between 6/2004 and 3/2012 was performed. Exclusion criteria were fewer than 10 levels fused, anterior spinal fusion, and patients below 9 years old at time of surgery. Temperature was measured every 15 seconds using esophageal temperature probe. Input variable of hypothermia was analyzed as a binary variable Tmin ≤35°C at any point during anesthesia and as integrated temperature area under the curve (TAUC)., Results: A total of 510 with an average age of 14.6 years (range, 9.0 to 24.3 y) met inclusion criteria. Totally, 56% (287/510) had idiopathic scoliosis (IS) and 44% (223/510) were non-IS. Hypothermia (Tmin≤35°C) was experienced by 45% (230/510) of all patients [48% (137/287) of IS; 42% (93/223) of non-IS]. A total of 63% (323/510) of patients were transfused with packed red blood cells (PRBC) [49% (141/287) of IS patients; 82% (182/223) of non-IS patients]. There was no correlation between Tmin≤35°C and transfusion of PRBC in all included patients (P=0.49); (IS patients P=0.45, non-IS patients P=0.61). There was no significant difference in EBL between patients who experienced hypothermia and those who did not (P=0.33; IS patients P=0.21, non-IS patients P=0.87). There was no significant correlation between TAUC and transfusion of PRBC for all patients (P=0.35), IS patients (P=0.26) and non-IS patients (P=0.54) or between TAUC and EBL (P=0.80); (IS patients P=0.57. non-IS patients P=0.62)., Conclusions: There was no significant correlation between intraoperative hypothermia and EBL or transfusion of PRBC in pediatric patients undergoing PSF., Level of Evidence: Level III.

Introduction: The aim of this study was to investigate whether preoperative methicillin-resistant Staphylococcus aureus (MRSA) swab results were predictive of surgical site infections (SSIs) in pediatric patients who have undergone spinal fusion., Methods: We conducted a retrospective chart review of patients who underwent posterior spinal fusion between 2004 and 2014 to determine preoperative MRSA colonization status and SSI rates and organisms. Before October 1, 2012, we administered vancomycin to the patients for infection prophylaxis; beginning October 1, 2012, patients received ceftazidime and Ancef (cefazolin for injection; GlaxoSmithKline). We added powdered vancomycin to all bone grafts., Results: A total of 1,200 patients met inclusion criteria. Of the patients, 2.3% (n = 28 of 1,200) were positive for MRSA, and an SSI developed in 3.1% (n = 37 of 1,200). No significant difference in infection rates was found between patients whose MRSA swab was positive and negative (positive swab = 1 SSI, negative swab = 36 SSIs; P = 0.88). Three SSIs were caused by MRSA., Conclusion: The results of a preoperative MRSA nasal swab had no correlation with SSI rates., Level of Evidence: Level III.

Study Design: Multicenter retrospective review., Objective: To assess the effectiveness of using the stable sagittal vertebra (SSV) for selecting the lowest instrumented vertebrae (LIV) to prevent distal junctional kyphosis (DJK) in selective thoracic fusions., Summary of Background Data: Cho et al. reported that including the SSV in a fusion decreased the rate of DJK in thoracic hyperkyphosis., Methods: A retrospective review was performed of patients from two pediatric hospitals with adolescent idiopathic scoliosis who underwent selective posterior thoracic fusion with the LIV at L2 or above from 2000 to 2012. Patients with less than 2 years' follow-up were excluded. The primary outcome measure was DJK, defined radiographically as ≥10° between the superior end plate of the LIV and the inferior end plate of the vertebra below on a standing lateral radiograph. We investigated the SSV, which was defined as the vertebral level at which 50% of the vertebral body was in front of the posterior sacral vertical line (PSVL) on a standing lateral radiograph. This particular definition was referred to as SSV., Results: A total of 113 patients met the inclusion criteria. Mean age was 14.4 years. Mean Cobb angle was 58°. The overall rate of DJK was 7% (8/113). When the LIV was superior to SSV, the rate of DJK was 17% (8/46) versus 0% (0/67) when the LIV was at or inferior to SSV (p=.01). The rates of DJK for patients with the LIV one, two, and three levels above SSV were 17% (4/24), 7% (1/14), and 43% (3/7), respectively. There was no significant association between preoperative or postoperative maximum kyphosis, thoracic kyphosis, thoracolumbar kyphosis, pelvic incidence, sagittal balance or coronal balance, and development of DJK., Conclusion: Although LIV selection is complex, choosing the LIV at or below the SSV is a simple rule that minimizes the risk of DJK., Level of Evidence: Level IV., (Copyright © 2017 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Background: Despite recent popularity of sacral alar iliac (SAI) screws for fusion to the pelvis for neuromuscular scoliosis, there are little data regarding the failure rate of this technique compared with traditional modes of iliac fixation. Theoretical advantages of the SAI screws are obviating the need for a rod to iliac screw connector and a lower implant profile. The purpose of this study is to determine whether SAI screws have fewer failures than iliac screws in neuromuscular scoliosis., Methods: Review of neuromuscular patients treated with posterior spinal fusion with pelvic fixation from 2004 to 2012 with minimum 2-year follow-up was conducted. Medical records and imaging studies were reviewed. Patients were divided into 2 groups based on the type of pelvic fixation (SAI or iliac screws), and implant failures were compared between the groups., Results: A total of 101 patients were reviewed, including 55 patients with iliac screws and 46 patients with SAI screws. Implant failures included: disengagement of the rod to iliac screw connector (10%, 10/101), separation of screw head from screw shaft (4%, 4/101), and set screw disengagement (2%, 2/101). The SAI group had a lower implant failure rate (7%, 3/46) compared with the iliac screw group (24%, 13/55) (P=0.031). Rod to iliac screw connectors failed in 18% (10/55) of patients. There were significantly less surgical revisions in the SAI group (2%, 1/46) for pelvic screw prominence compared with the iliac screw group (11%, 6/55) (P=0.027)., Conclusions: SAI screws had a lower rate of implant failure and revision surgery compared with iliac screws. If rod to screw connector failures are excluded, the failure rate of SAI screws of 6.5% (3/46) is similar to that of iliac screws 5.5% (3/55); therefore, the most important advantage of the SAI technique may be obviating the need for a screw to rod connector., Level of Evidence: Level III.

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.

Purpose: Recently, several authors have proposed techniques for improving the fusion rate in pediatric posterior occipitocervical fusion including a variety of implants and the use of bone morphogenetic protein. A technique by Koop et al. using a periosteal flap for occipitocervical arthrodesis was described in 1984., Methods: A straight incision is made about the posterior neck to expose the occipitocervical region from the inion superiorly to the lowest cervical vertebrae to be fused inferiorly. The occiput is exposed superficial to the periosteum, which is then reflected and elevated from the occiput. The attachment is preserved at the caudal base of the flap and reflected over the intended area of fusion. When possible, fixation is then performed with cables, wires, screws, hooks, or plates., Case Example: A 6-year-old male with an occiput to C2 distraction injury underwent posterior spinal fusion from occiput to C3 using sublaminar wires, periosteal turndown flap, and autologous iliac crest bone graft., Conclusion: In small children with traumatic upper cervical spine instability, the periosteal turndown technique may be used as a safe adjunct for occipitocervical fusions.

Introduction: Hospital stay after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) has decreased only modestly over time despite a healthy patient population. The purpose of this study was to evaluate the impact of a novel postoperative pathway on length of stay (LOS) and complications., Methods: A retrospective review of patients undergoing PSF for AIS in 2011 to 2012 was performed at 2 institutions evaluating demographics, preoperative Cobb angles, surgical duration, blood loss, LOS, and postoperative complications. Patients at one center were managed using an accelerated discharge (AD) pathway emphasizing early transition to oral pain medications mobilization with physical therapy 2 to 3 times/d, and discharge regardless of return of bowel function. Expectations were set with the family before surgery for early discharge. Patients at the other center were managed without a standardized pathway., Results: One hundred five patients underwent PSF and were treated by an AD pathway, whereas 45 patients were managed using a traditional discharge (TD) pathway. There was no difference in proximal thoracic and main thoracic Cobb magnitudes and a small difference in thoracolumbar curve magnitudes (35.2±13.0 degrees AD vs. 40.6±11.4 degrees TD, P=0.004) between groups. Surgical time was slightly shorter in AD patients (median 3.1 vs. 3.9 h, P=0.0003) with no difference in estimated blood loss. LOS was 48% shorter in the AD group (2.2 vs. 4.2 d, P<0.0001). There was no difference in readmissions or wound complications between groups., Conclusions: Hospital stay was nearly 50% shorter in patients managed by the AD pathway without any increase in readmissions or early complications., Significance: Discharge after PSF for AIS may be expedited using a coordinated postoperative pathway. No increase in complications was seen using the AD pathway. Earlier discharge may reduce health care costs and allow an earlier return to normalcy for families., Level of Evidence: Level III-case control study.

Study Design: A retrospective study of consecutive patients., Objective: The purpose of this study was to determine implementing an accelerated protocol could decrease our average hospital stay and what impact this had on postoperative pain management., Summary of Background Data: To our knowledge, no prior studies have reviewed the effect of an accelerated discharge protocol on postoperative pain control for adolescent idiopathic scoliosis (AIS) following posterior spinal fusion., Methods: This is a retrospective review of all consecutive patients undergoing posterior spinal fusion (PSF) for AIS before (June 1, 2008-May 31, 2013 = traditional protocol) and after (June 1, 2013-October 22, 2014 = accelerated protocol) protocol implementation. Subjective response to the FACES Pain Intensity scale was collected for each postoperative day while in the hospital by the nursing staff., Results: There were 194 patients in the traditional pathway and 90 patients in the accelerated pathway. No significant differences in age at surgery, sex, or number of levels fused were present between the groups. Patients managed under the accelerated discharge had an average hospital stay of 3.7 days compared with 5.0 days for the traditional discharge (P < 0.001). There was no increased incidence of wound complications between the two groups [3.6% (7/194) vs. 3.3% (3/90), P = 0.91] or readmission [1.5% (3/194) vs. 4.4% (4/90), P = 0.213]. Hospital charges for postoperative care were significantly less in the accelerated discharge group than in the traditional group ($18,360 vs. $23,640, P < 0.0001). This corresponded to a 22% ($5280/$23,640) decrease in postoperative hospital charges. Patients had a small (<1 point change on FACES pain scale) but statistically significant increase in pain on postoperative days 2, 3, and 4 (P = 0.0001, P = 0.0079, P = 0.0076)., Conclusion: Accelerated discharge following PSF for AIS was associated with a 22% decrease in hospital charges in the postoperative period., Level of Evidence: 4.

Study Design: Prospective study of consecutive patients., Objective: The purpose of the study was to evaluate the incidence, risk factors, and time to resolution of lateral femoral cutaneous nerve palsy (LFCNP) after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS)., Summary of Background Data: No prior studies have prospectively evaluated the prevalence of LFCNP exclusively in the treatment of AIS., Methods: Between June 2014 and May 2015, patients undergoing PSF for AIS were examined preoperatively, postoperatively, and at follow-up clinic visits until the resolution of the LFCNP. All neurologic examinations were performed by attending pediatric orthopedic surgeons. Patients who underwent staged, revision or anterior procedures, had preoperative neurologic deficits or neuropathy, were excluded., Results: A total of 55 patients with an average age of 14 years (10-21) were enrolled. Twenty-five percent (14/55) of patients had a postoperative LFCNP. There were no other postoperative neurologic deficits. Of the 14 patients with an LFCNP, 57% of these were bilateral. Fourteen percent (2/14) of these patients had absent sensation to light touch, whereas 85% (12/14) had decreased sensation. No patients reported experiencing pain associated with the LFCNP or tenderness when the anterolateral thigh was palpated. The LFCNP did not limit postoperative mobilization or prolong hospital stay. The LFCNP was noted to resolve in an average of 3.6 days (1-18); 6/14 (43%) resolved after 1 day. No correlation was observed between occurrence of LFCNP and sex, age, height, body mass index, length of fusion, Cobb angle, or blood loss. The occurrence of LFCNP was associated with heavier weight (P = 0.032) and longer operative times (P = 0.016). Resolution of the LFCNP was associated with longer operative time (P = 0.010)., Conclusion: LFCNP occurred in 25% of AIS patients undergoing PSF. Risk of LFCNP increased with longer operative times and heavier patient weight. On average, LFCNP resolved in less than 4 days and did not cause any pain or limitations., Level of Evidence: 2.

Study Design: A retrospective review of patients who underwent posterior spinal fusion (PSF) and returned within 90 days with an acute infection., Objectives: The study motive is to identify and understand the risk factors associated with failure of retaining spinal implants and failure to treat acute infection., Background: The natural history of early surgical site infection (SSI) (less than 3 months) after PSF is not known and removing the implants early after PSF risks pseudarthrosis and deformity progression., Methods: Patients ranging from 1999 to 2011 with surgical site infections (SSIs) who required irrigation and debridement within 3 months of PSF were identified from 4 institutions. Univariable and multivariable regression analysis were used to identify risk factors associated with failure of acute infection treatment., Results: Eighty-two patients (59 female, 23 male) with a mean age of 13.6 years were identified. Median follow-up after initial surgery was 33 months (range: 12-112 months). Sixty-two (76%) were treated successfully with acute treatment and did not return with recurrent infection (cleared infection, group C); 20 (24%) returned later with chronic infection (recurrent infection, group R). Multivariable analysis indicated that patients with stainless steel implants (OR = 6.4, 95% CI = 1.7-32.1; p = .009) and older subjects (OR = 1.3, 95% CI = 1.0-1.6; p = .03) were more likely to present with recurrent infection. There was no difference between the groups with regard to the initial time of presentation post fusion, proportion of non-idiopathic diagnosis, rate of positive cultures, culture species, presence of fusion to pelvis, and time on antibiotic treatment., Conclusions: Seventy-six percent of patients presenting with an SSI less than 3 months after PSF did not require implant removal to clear their infection. Early postoperative SSIs can be treated with retention or implant exchange. Older patients and patients with stainless steel instrumentation are more likely to present with a late recurrent infection compared to other metals., Level of Evidence: Level III., (Copyright © 2016 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: Single-center retrospective review of spinal deformity patients undergoing removal of infected posterior spinal fusion implants over a 10-year period., Objective: To evaluate the intraoperative blood loss and perioperative complications of implant removal in posterior spinal fusions., Summary of Background Data: To our knowledge, no studies examine blood loss or complications associated with removal of infected spinal implants in spinal deformity., Methods: A retrospective review of 28 consecutive cases of infected posterior spinal fusion implant removal from 2003 to 2012 was performed. Exclusion criteria were patients with ≤6 levels of instrumentation, a partial removal of implants or a bleeding disorder., Results: The average estimated blood loss was 465 mL (range 100-1,505 mL). Average estimated blood volume was 3,814 mL (range 1,840-9,264 mL). The average percentage of estimated blood loss was 14.2% (range 1.9%-43.5%). On postoperative labs obtained at the conclusion of the procedure, there was an average loss in hematocrit of 6.6 from preoperative values. Seventy-one percent of patients (20/28) received a blood transfusion; 39% (11/28) of these received a transfusion intraoperatively and 54% (15/28) received a transfusion postoperatively. Forty-six percent of patients (13/28) experienced an associated medical complication in the postoperative period. Among these 13, there were 16 total complications, with the most common being seizures (4/16), pneumonia (2/16), and sepsis (2/16). Average hospital stay was 14 days (range 4-52)., Conclusion: Seventy-one percent of patients undergoing removal of infected spinal implants received a blood transfusion. We recommend having blood products available when removing posterior spinal instrumentation >6 levels. Patients and families should be counseled on the high risk of complications and expected hospital stay in these cases., Level of Evidence: Level III., (Copyright © 2016 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Study Design: Retrospective cohort study., Objectives: To determine the association of implant metal composition with the risk of surgical site infection (SSI) following pediatric spine surgery., Summary of Background Data: SSI is a well-described complication following pediatric spine surgery. Many risk factors have been identified in the literature, but controversy remains regarding metal composition as a risk factor., Methods: This was a retrospective study of patients who underwent posterior spinal instrumentation procedures between January 1, 2006, and December 31, 2008, at three large children's hospitals for any etiology of scoliosis and had at least 1 year of postoperative follow-up. Procedures included posterior spinal fusion, growth-friendly instrumentation, and revision of spinal instrumentation. The Centers for Disease Control and Prevention definition of SSI was used. A chi-squared test was performed to determine the relationship between type of metal instrumentation and development of an SSI., Results: The study included 874 patients who underwent 1,156 total procedures. Overall, 752 (65%) procedures used stainless steel instrumentation, 238 (21%) procedures used titanium instrumentation, and the remaining 166 (14%) procedures used cobalt chrome and titanium hybrid instrumentation. The overall risk of infection was 6.1% (70/1,156) per procedure, with 5.9% (44/752) for stainless steel, 6.7% (12/238) for titanium, and 6.0% (10/166) for cobalt chrome. The multiple regression analysis found no significant differences in the metal type used between patients with and without infection (p = .886) adjusting for etiology, instrumentation to pelvis, and type of procedures. When stratified based on etiology, the multiple regression analyses also found no significant difference in SSI between two metal type groups., Conclusions: This study found no difference in risk of infection with stainless steel, titanium, or cobalt chrome/titanium instrumentation and is adequately powered to detect a true difference in risk of SSI., Level of Evidence: Level II, prognostic., (Copyright © 2016 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)