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

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

BACKGROUND: This study evaluates the accuracy, biomechanical profile, and learning curve of the transverse process trajectory technique (TPT) compared to the straightforward (SF) and in-out-in (IOI) techniques. SF and IOI have been used for fixation in the thoracic spine. Although widely used, there are associated learning curves and symptomatic pedicular breaches. We have found the transverse process to be a reproducible pathway into the pedicle. METHODS: Three surgeons with varying experience (experienced [E] with 20 years in practice, surgeon [S] with less than 10 years in practice, and senior resident trainee [T] with no experience with TPT) operated on 8 cadavers. In phase 1, each surgeon instrumented 2 cadavers, alternating between TPT and SF from T1 to T12 (n = 48 total levels). In phase 2, the E and T surgeons instrumented 1 cadaver each, alternating between TPT and IOI. Computed tomography scans were analyzed for accuracy of screw placement, defined as the percentage of placements without critical breaches. Axial pullout and derotational force testing were performed. Statistical analyses include paired t test and analysis of variance with Tukey correction. RESULTS: Overall accuracy of screw placement was comparable between techniques (TPT: 92.7%; SF: 97.2%; IOI: 95.8%; P = .4151). Accuracy by technique did not differ for each individual surgeon (E: P = .7733; S: P = .3475; T: P = .4191) or by experience level by technique (TPT: P = .1127; FH: P = .5979; IOI: P = .5935). Pullout strength was comparable between TPT and SF (571 vs 442 N, P = .3164) but was greater for TPT versus IOI (454 vs 215 N, P = .0156). There was a trend toward improved derotational force for TPT versus SF (1.06 vs 0.93 Nm/degrees, P = .0728) but not for TPT versus IOI (1.36 vs 1.16 Nm/degrees, P = .74). Screw placement time was shortest for E and longest for T for TPT and SF and not different for IOI (TPT: P = .0349; SF: P < .0001; IOI: P = .1787) but did not vary by technique. CONCLUSIONS: We describe the TPT, which uses the transverse process as a corridor through the pedicle. TPT is an accurate method of thoracic pedicle screw placement with potential biomechanical advantages and with acceptable learning curve characteristics. CLINICAL RELEVANCE: This study provides the surgeon with a new trajectory for pedicle screw placement that can be used in clinical practice.

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

The anterior approach to spine surgery is considered safe and has the potential for improving value in patient care. The unique advantages of the procedure (compared with posterior surgical instrumentation and fusion), particularly when used for correction of scoliosis, include avoiding disruption of spinal musculature for surgical exposure and reducing the number of fused vertebrae (thereby preserving postoperative spinal flexibility). In addition, there is evidence to suggest that there is a reduction in the risk of infection or need for blood transfusion in the perioperative period. Conducting a safe and appropriate anesthetic for this type of surgical approach requires careful preoperative planning with both the surgical and neurophysiology teams. Each anesthetic plan should involve appropriate patient selection in the preoperative period, an arterial line placement (for hemodynamic monitoring and blood gases), as well as appropriate venous access, intraoperative one-lung ventilation (OLV) to optimize the surgical field, and postoperative multimodal analgesia to help maximize early physical therapy with the goal of maintaining spine mobility. Intraoperatively, communication amongst teams and an intimate knowledge of physiology and complications of intrathoracic surgery and OLV remains essential to ensuring patient safety and a satisfactory surgical result. Although relatively few surgeons in the United States perform an anterior approach to thoracic spine surgery, it is gaining widespread favor as maintaining patient safety and outcome data continue to demonstrate that the approach offers unique advantages to the posterior approach.

Background: Severe, rigid thoracolumbar scoliosis presents a surgical challenge to achieve 3-dimensional correction, maximize distal motion segments, and avoid operative morbidity conferred by combined anterior-posterior approaches or 3-column osteotomies. We present a new approach for releasing these curves, using multilevel posterolateral convex disc release (PCDR) and posterior instrumented fusion. Methods: There were 3 adults and 1 adolescent (mean age, 31.8 years; 2 females) with severe progressive thoracic and transforaminal lumbar (major) idiopathic scoliosis (IS) who were treated with 3-level PCDR, multiple posterior column osteotomies, and posterior instrumented thoracolumbar fusion with all–pedicle screw constructs. Results: Restoration of global coronal and sagittal alignment was achieved for all patients (minimum 2-year follow-up). Lowest instrumented vertebra (LIV) was L4 in 2 patients and L3 in the remaining 2. All except 1 were fused to the lower end vertebra. Postoperatively, mean thoracolumbar curve was reduced from 77.3° (range, 69°–91°) to 21.8° (72%Δ), LIV tilt decreased from 26.8° to 8.3°, and LIV translation improved (2.5–1.2 cm; 58%Δ), whereas lumbar lordosis remained unchanged. Average central sacral vertical line shift measured via C7 sagittal vertical axis changed from 1.4 to −0.7 cm. There were no complications except for dysesthesias in the lower extremity on the side of the PCDR in 1 patient, which resolved after 3 months. Conclusions: Severe thoracolumbar IS presents a surgical challenge to achieve 3-dimensional correction, minimize fusion levels, and avoid procedural morbidity. PCDR is a novel technique that may facilitate this correction with minimal procedure-related morbidity.

Traditionally, adolescent idiopathic scoliosis (AIS) has not been associated with back pain, but the increasing literature has linked varying factors between pain and AIS and suggested that it is likely underreported. Our objective was to investigate factors associated with post-op pain in AIS. A prospectively collected multicenter registry was retrospectively queried. Pediatric patients with AIS having undergone a fusion with at least 2 years of follow-up were divided into two groups: (1) patients with a postoperative SRS pain score ≤ 3 or patients having a reported complication specifically of pain, and (2) patients with no pain. Patients with other complications associated with pain were excluded. Of 1744 patients, 215 (12%) experienced back pain after postoperative recovery. A total of 1529 patients (88%) had no complaints of pain, and 171 patients (10%) had pain as a complication, with 44 (2%) having an SRS pain score ≤ 3. The mean time from date of surgery to the first complaint of back pain was 25.6 ± 21.6 months. In multivariate analysis, curve type (16% of Lenke 1 and 2 curves vs. 10% of Lenke 5 and 6, p = 0.002) and a low preoperative SRS pain score (no pain 4.15 ± 0.67 vs. pain 3.75 ± 0.79, p

Fusion is the current standard of care for AIS. Anterior vertebral body tethering (AVBT) is a motion-sparing alternative gaining interest. As a novel procedure, there is a paucity of literature on safety. Here, we report 90-day complication rates in 184 patients who underwent AVBT by a single surgeon. Patients were retrospectively reviewed. Approaches included 71 thoracic, 45 thoracolumbar, 68 double. Major complications were those requiring readmittance or reoperation, prolonged use of invasive materials such as chest tubes, or resulted in spinal cord or nerve root injury. Minor complications resolved without invasive intervention. Mean operative time and blood loss were 186.5 ± 60.3 min and 167.2 ± 105.0 ml, respectively. No patient required allogenic blood transfusion. 6 patients experienced major (3.3%), and 6 had minor complications (3.3%). Major complications included 3 chylothoracies, 2 hemothoracies, and 1 lumbar radiculopathy secondary to screw placement requiring re-operation. Minor complications included 1 patient with respiratory distress requiring supplementary oxygen, 1 superficial wound infection, 2 cases of prolonged nausea, and 1 Raynaud phenomenon. In 184 patients who underwent AVBT for AIS, major and minor complication rates were both 3.3%.

Selective fusions of the structural curve remain a common treatment strategy for adolescent idiopathic scoliosis, yet long-term outcomes are not well-understood. The purpose of this study was to report 10-year prospective radiographic and patient-rated outcomes of selective fusions of the main thoracic (MT) or thoracolumbar/lumbar (TL/L) curve, with particular attention to the behavior of the uninstrumented, compensatory curve.A prospectively collected multicenter database was used to identify patients who had been followed regularly for least 10 years after a selective MT or TL/L fusion for adolescent idiopathic scoliosis. Interval radiographs were evaluated for coronal and sagittal Cobb angles as well as overall coronal balance. Scores on the Scoliosis Research Society Questionnaire (SRS-24) were catalogued and evaluated. Radiographic outcomes and SRS-24 scores were compared between preoperative and postoperative time points using repeated-measures analysis of variance. Individual patient records were screened for recent curve progression of5°, and these cases were methodically evaluated.Fifty-one patients with selective fusions (21 MT and 30 TL/L) for adolescent idiopathic scoliosis who had been followed for at least 10 years were identified. The instrumented MT and TL/L curves were corrected by an average of 51% and 60%, respectively, at 10 years. The uninstrumented, compensatory curves had gradual spontaneous correction that approached the magnitude of the fused curve at 5 years postoperatively, with the correction maintained at 10 years. This led to excellent coronal balance. A subgroup of patients had recent progression of the primary curve adjacent to the prior fusion or within the instrumented segments, resulting in a compensatory progression of the uninstrumented curve. On the whole, SRS scores did not decrease during follow-up, and no patient had secondary operations.Selective fusion of a primary thoracic or lumbar curve in properly selected patients with adolescent idiopathic scoliosis will result in spontaneous correction of the uninstrumented curve and a durable result for at least 10 years.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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

Study design Longitudinal. Objectives To evaluate whether the rate of patients who report low health-related quality of life (HRQOL) scores at 2 years following surgical correction of adolescent idiopathic scoliosis (AIS) improves by 5 years postoperatively. Summary of background data HRQOL scores are dependent upon a number of factors and even in instances of good surgical correction of a spinal deformity, are not guaranteed to be high postoperatively. Understanding how a low HRQOL score varies over the postoperative period can help surgeons more effectively counsel patients and temper expectations. Methods A multicenter database was reviewed for patients with both 2 and 5-year follow-up after spinal fusion and instrumentation for AIS. From a cohort of 916 patients, 52 patients with low HRQOL scores at their 2-year follow-up were identified and reevaluated at 5-year follow-up. A low HRQOL outcome was defined as having SRS-22 domain or total scores less than 2 standard deviations below the mean score. Reoperations were also evaluated to determine if they were associated with HRQOL scores. Results Of those patients with low SRS-22 HRQOL scores at 2 years postoperatively, improvements were seen in all SRS-22 domains and total scores at the 5-year time point. The greatest change was seen in the satisfaction category where 41 patients showed improvement. The rate of reoperations during this period did not significantly impact patient-reported outcomes. Conclusions Having a low HRQOL score 2 years after surgery for AIS does not guarantee a low score 5 years after surgery. Promisingly, most patients demonstrate some improvement in all domains for patient-reported SRS-22 scores at 5-year compared to 2-year follow-up. Understanding the longer term postoperative evolution in patient-reported outcomes may help surgeons to effectively manage and counsel patients who are dissatisfied in the short term.Level of Evidence: 3.

Background: Experimental and clinical data suggest that reducing inflammation without affecting lipid levels may reduce the risk of cardiovascular disease. Yet, the inflammatory hypothesis of atherothrombosis has remained unproved. Methods: We conducted a randomized, double-blind trial of canakinumab, a therapeutic monoclonal antibody targeting interleukin-1β, involving 10,061 patients with previous myocardial infarction and a high-sensitivity C-reactive protein level of 2 mg or more per liter. The trial compared three doses of canakinumab (50 mg, 150 mg, and 300 mg, administered subcutaneously every 3 months) with placebo. The primary efficacy end point was nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. RESULTS: At 48 months, the median reduction from baseline in the high-sensitivity C-reactive protein level was 26 percentage points greater in the group that received the 50-mg dose of canakinumab, 37 percentage points greater in the 150-mg group, and 41 percentage points greater in the 300-mg group than in the placebo group. Canakinumab did not reduce lipid levels from baseline. At a median follow-up of 3.7 years, the incidence rate for the primary end point was 4.50 events per 100 person-years in the placebo group, 4.11 events per 100 person-years in the 50-mg group, 3.86 events per 100 person-years in the 150-mg group, and 3.90 events per 100 person-years in the 300-mg group. The hazard ratios as compared with placebo were as follows: in the 50-mg group, 0.93 (95% confidence interval [CI], 0.80 to 1.07; P = 0.30); in the 150-mg group, 0.85 (95% CI, 0.74 to 0.98; P = 0.021); and in the 300-mg group, 0.86 (95% CI, 0.75 to 0.99; P = 0.031). The 150-mg dose, but not the other doses, met the prespecified multiplicity-adjusted threshold for statistical significance for the primary end point and the secondary end point that additionally included hospitalization for unstable angina that led to urgent revascularization (hazard ratio vs. placebo, 0.83; 95% CI, 0.73 to 0.95; P = 0.005). Canakinumab was associated with a higher incidence of fatal infection than was placebo. There was no significant difference in all-cause mortality (hazard ratio for all canakinumab doses vs. placebo, 0.94; 95% CI, 0.83 to 1.06; P = 0.31). Conclusions: Antiinflammatory therapy targeting the interleukin-1β innate immunity pathway with canakinumab at a dose of 150 mg every 3 months led to a significantly lower rate of recurrent cardiovascular events than placebo, independent of lipid-level lowering. (Funded by Novartis; CANTOS ClinicalTrials.gov number, NCT01327846.)

STUDY DESIGN Retrospective review of a prospective adolescent idiopathic scoliosis (AIS) registry. OBJECTIVE To study the evolution of the operative approach, outcomes, and complication rates in AIS surgery over the past 20 years. SUMMARY OF BACKGROUND DATA Surgical techniques in AIS surgery have evolved considerably over the past 20 years. We study the trends in the operative management of AIS over this period and their impact on perioperative outcomes. METHODS A total of 1819 AIS patients (1995-2013) with 2-year F/U were studied. Operative approach, perioperative parameters, major complication rates, and SRS outcomes were assessed. Linear regression was used to assess the trend of changes over 5-year quartiles. RESULTS Mean age at surgery was 14.6 ± 2.1 years, 80.2% were females, and this remained consistent throughout. Operative time, EBL/level, and LOS decreased over the 20 years (P

Sagittal alignment abnormalities in Scheuermann kyphosis (SK) strongly correlate with quality of life measures. The changes in spinopelvic parameters after posterior spinal fusion have not been adequately studied. This study is to evaluate the reciprocal changes in spinopelvic parameters following surgical correction for SK.Ninety-six operative SK patients (65% male; age 16 years) with minimum 2-year follow-up were identified in the prospective multicenter study. Changes in spinopelvic parameters and the incidence of proximal (PJK) and distal (DJK) junctional kyphosis were assessed as were changes in Scoliosis Research Society-22 (SRS-22) questionnaire scores.Maximum kyphosis improved from 74.4° to 46.1° (p.0001), and lumbar lordosis was reduced by 10° (-63.3° to -53.3°; p .0001) at 2-year postoperation. Pelvic tilt, sacral slope, and sagittal vertical axis remained unchanged. PJK and DJK incidence were 24.2% and 0%, respectively. In patients with PI45°, patients who developed PJK had greater postoperative T2-T12 (54.8° vs. 44.2°, p = .0019), and postoperative maximum kyphosis (56.4° vs. 44.6°, p = .0005) than those without PJK. In patients with PI ≥45°, patients with PJK had less postoperative T5-T12 than those without (23.6° vs. 32.9°, p = .019). Thoracic and lumbar apices migrated closer to the gravity line after surgery (-10.06 to -4.87 mm, p.0001, and 2.28 to 2.10 mm, p = .001, respectively). Apex location was normalized to between T5-T8 in 68.5% of patients with a preoperative apex caudal to T8, whereas 90% of patients with a preoperative apex between T5 and T8 remained unchanged. Changes in thoracic apex location and lumbar apex translation were associated with improvements in the SRS function domain.PJK occurred in 1 in 4 patients, a lower incidence than previously reported perhaps because of improved techniques and planning. Both thoracic and lumbar apices migrated closer to the gravity line, and preoperative apices caudal to T8 normalized in more than two-thirds of patients, resulting in improved postoperative function. Individualizing kyphosis correction to prevent kyphosis and PI mismatch may be protective against PJK.

Background Reporting accurate surgical complication rates to patients and their families is important in the management of adolescent idiopathic scoliosis (AIS). In this study, we report the rate of major complications following the surgical treatment of AIS both in the perioperative period and among patients with a minimum of 2 years of follow-up. Methods We reviewed the prospectively collected data of a multicenter registry of patients who underwent surgical treatment of AIS during the period of 1995 to 2014 in order to identify all complications. A complication was defined as "major" if it resulted in reoperation or in spinal cord or nerve root injury, or was life-threatening. A total of 3,582 patients with preoperative and early postoperative data (4 to 6 weeks of follow-up) were included. A subset of 2,220 patients with a minimum of 2 years of follow-up comprised the cohort for delayed complications. Overall complication rates were calculated, as was the percentage of complications according to the year of the index surgery and type of surgical approach. Results The mean age of the 3,582 patients at the time of surgery was 14.8 ± 2.2 years. The average major curve magnitude was 56° ± 13° for thoracic curves and 51° ± 11° for lumbar. In 365 patients, anterior spinal fusion (ASF) with instrumentation was performed, and in 3,217 patients, posterior spinal fusion (PSF) with instrumentation was performed; 142 patients in the PSF group underwent concomitant anterior release. There were 192 major complications, with 93 (2.6%) occurring perioperatively. Perioperative complications included wound-related (1.0% of the patients), neurologic (0.5%), pulmonary (0.4%), instrumentation-related (0.4%), and gastrointestinal (0.2%) complications. One patient died. The mean annual perioperative major complication rate based on the year of surgery ranged from 0% to 10.5%. The complication rate by surgical approach was 3.0% for ASF and 2.6% for PSF (2.4% for PSF only and 5.6% for PSF with anterior release). The major complication rate for the 2,220 patients with at least 2 years of follow-up was 4.1%; all but 1 had a reoperation (4.1%). The majority of these major complications were wound and instrumentation-related (1.9% and 0.8%, respectively). Conclusions After surgery for AIS, a 2.6% rate of perioperative major complications and a 4.1% rate of major complications at 2 or more years after surgery can be anticipated. The complication rate decreased over the period of study. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

STUDY DESIGN A retrospective analysis of a prospectively collected database was performed. OBJECTIVE The purpose of this study is to compare 3-dimensional correction associated with the anterior release (AR) and contemporary posterior instrumentation versus posterior-only surgery. SUMMARY OF BACKGROUND DATA The role of AR as a tool in the treatment of adolescent idiopathic scoliosis (AIS) has seen a decline with the popularization of thoracic pedicle screw instrumentation. METHODS Five surgeons were queried for all surgical thoracic AIS cases from 2003 to 2010 treated with thoracoscopic AR/fusion and contemporary posterior instrumentation and fusion and thoracic pedicle screw instrumentation (>80% screws) with 2-year follow-up. These cases were then matched with posterior spinal fusion only cases from a multicenter prospective database. The 2 groups were matched on the basis of major curve magnitude within 5 degrees, T5-T12 kyphosis within 9 degrees, and angle of trunk rotation within 9 degrees. Radiographic and clinical parameters were compared for the 2 groups. Continuous variables were analyzed with analysis of variance and categorical dependent variables with the χ test. RESULTS A total of 47 cases of AR were matched to 47 (1:1 match) posterior spinal fusion cases. Preoperative parameters were similar between groups (P>0.05). Postoperatively, AR cases had a lower major curve (20 vs. 25 degrees, P=0.034; 72% vs. 66% correction, P=0.037). T5-T12 kyphosis was greater in the AR cases (26 vs. 20 degrees; P=0.005). The angle of trunk rotation was similar for the groups. Anchor density was lower in the AR group (1.6 vs. 1.9; P

BACKGROUND At academic medical centers, residents and fellows play an integral role as surgical first assistants in spinal deformity surgery. However, limited data exist on whether the experience level of the surgical assistant affects outcomes. METHODS We conducted a multicenter, multisurgeon study comparing perioperative and postoperative outcomes after adolescent idiopathic scoliosis (AIS) surgery for the same 11 surgeons who performed cases that were assisted by residents compared with cases that were assisted by fellows. Blood loss, operative time, duration of hospitalization, complication rates, Scoliosis Research Society (SRS)-22 questionnaire scores, and radiographic outcomes were compared between the 2 groups. RESULTS We evaluated outcomes for 347 surgical procedures; 118 cases were assisted by residents and 229 were assisted by fellows. Preoperative radiographic and demographic parameters were not different between the groups. The resident group had significantly more estimated blood loss than the fellow group (939 compared with 762 mL, p = 0.02). Otherwise, the perioperative characteristics were similar between the groups, including the volume of the autologous blood recovery system product that was transfused, the operative time, and the occurrence of intraoperative neuromonitoring changes. Postoperatively, the percentage correction of the Cobb angle, the number of levels that had been fused, the number of days until the discharge criteria had been met, and the rate of major complications were similar between the groups. At the 2-year follow-up, the overall and subdomain SRS-22 questionnaire scores were not different between the groups, except that patients in the resident-assisted group had slightly worse pain scores than those in the fellow-assisted group (4.3 compared with 4.5, p = 0.01). CONCLUSIONS The first assistant's level of training did not affect clinical or radiographic outcomes following AIS surgery. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Brace treatment is the most common nonoperative treatment for the prevention of curve progression in adolescent idiopathic scoliosis. The success reported in level 1 and 2 clinical trials is approximately 75%. The aim of this review was to identify the main risk factors that significantly reduce success rate of brace treatment. A literature search using the MEDLINE and Embase databases was conducted. Studies were included if they identified specific risk factor(s) for curve progression. Studies that looked at nighttime braces, superiority of one type of brace over another, the effect of physical therapy on brace performance, cadaver or nonhuman studies were excluded. A total of 1,022 articles were identified of which 25 met all of the inclusion criteria. Seven risk factors were identified: Poor brace compliance (eight studies), lack of skeletal maturity (six studies), Cobb angle over a certain threshold (six studies), poor in-brace correction (three studies), vertebral rotation (four studies), osteopenia (two studies), and thoracic curve type (two studies). Three risk factors were highly repeated in the literature which identified specific subgroups of patients who have a much higher risk to fail brace treatment and to progress to fusion. This data demonstrates that 60% to 70% of the patients referred to bracing are Risser 0 and 30% to 70% of this group will not wear the brace enough to ensure treatment efficacy. Furthermore, Risser 0 patients who reach the accelerated growth phase with a curve ≥40° are at 70% to 100% risk of curve progression to the fusion surgical threshold despite proper brace wear. Skeletally immature patients with relatively large magnitude scoliosis who are noncompliant are at a higher risk of failing brace treatment.

BACKGROUND CONTEXT The minimal clinically important difference (MCID) is the smallest change in an outcomes instrument deemed relevant to a patient. MCID values proposed in spine research are limited by poor discriminative abilities to accurately classify patients as “improved” or “not improved.” Furthermore, the MCID should not compare relative effectiveness between two groups of patients, though it is frequently used for this. The minimum detectable measurement difference (MDMD) is an alternative to the MCID in outcomes research. The MDMD must be greater than the MCID for the latter to be of value and the MDMD can compare change between groups. PURPOSE The purpose of this study was to determine the MDMD for the Scoliosis Research Society-22r (SRS-22r) in adolescent idiopathic scoliosis (AIS) patients treated with surgery. STUDY DESIGN Retrospective cohort study from multi-center registry. PATIENT SAMPLE Patients treated surgically for AIS. OUTCOME MEASURES Self-reported SRS-22r. METHODS An observational cohort of surgically treated AIS patients was queried for patients with complete baseline, 1-year, and 2-year SRS-22r data. The MDMD was calculated for SRS-22r domain and subscores. Effect size (ES) and standardized response mean were calculated to measure responsiveness of the SRS-22r to change. MDMD values were compared with MCID values. Research grants were received from DePuy Synthes Spine, EOS imaging, K2M, Medtronic, NuVasive, and Zimmer Biomet to Setting Scoliosis Straight Foundation. RESULTS One thousand two hundred and eighty-one AIS patients (1,034 female, 247 male, mean age 14.6 years) were analyzed. MDMD values were between 0.23 and 0.31. SRS-Pain MDMD was 0.3, greater than the MCID of 0.2. SRS-Activity MDMD was 0.24, greater than the MCID of 0.08. SRS-self-image MDMD was 0.3, less than the MCID of 0.98. Sixty-four percent of those with baseline SRS-self-image>4.0 improved MDMD or more, whereas only 14% improved beyond the MCID. ES and standardized response mean were highest for subscore and self-image. CONCLUSIONS The MDMD can compare the relevance of change in SRS-22r scores between groups of AIS patients. SRS-pain and SRS-activity MDMD values are greater than the MCID and should serve as the threshold for clinically relevant improvement. MDMD may help evaluate change in patients with baseline self-image>4.0.

Bone morphogenetic protein (BMP) can increase the likelihood of solid arthrodesis in spinal surgery. This would imply fewer reoperations for pseudarthrosis, but small cohort sizes are inadequate to monitor these events. We sought to examine adolescent idiopathic (AIS) and non-idiopathic scoliosis (NIS) for reoperation events with and without the use of BMP using a large statewide database.The 2008-2011 New York State Inpatient Database was queried using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Patients age 10 and older with a diagnosis of scoliosis and an index fusion of greater than 2 spinal motion segments were included. Patient identifiers and linkage variables were used to identify revisits. The relative risk of reoperation was calculated. The use of BMP at the initial inpatient stay was used to define the two cohorts for relative risk assessment.A total of 2,658 and 2,431 cases were identified of AIS and NIS, respectively. The use of BMP at the initial visit was performed at a rate of 4.5% for AIS and 21.0% for NIS fusion surgery. For posterior fusion cases longer than eight levels, the reoperation rate for pseudarthrosis was 1.0% in AIS and 18.4% in NIS (p.001). For NIS fusions greater than eight levels, the rate of reoperation for pseudarthrosis after using BMP at the index surgery was 5% and 22% when BMP was not used, a relative risk of 4.0 (p.001). For AIS, there was no substantial increase in risk when not using BMP for fusion greater than eight levels (p.001).We found a significant decrease in the risk of reoperation for pseudarthrosis after long fusions when using BMP in the case of NIS. In contrast, use of BMP does not benefit the AIS population.

In pediatric spinal deformity the gold standard for curve surveillance remains standing full-column radiographs, but repeated exposure to ionizing radiation motivates us to look for nonradiographic solutions. This study tests a modern system of surface topography (ST) to determine whether it is reliable and reproducible.Patients from 6 pediatric spinal deformity clinics were recruited for enrollment. Inclusion criteria were age 8-18; diagnosis of scoliosis measuring ≥10 and50 degrees or increased kyphosis of ≥45 degrees. Standing radiographs and ST scans (DIERS Formetric, Diers Medical Systems, Chicago, IL) were obtained on all patients and then measured and compared. A single investigator using a validated electronic measurement tool performed all radiographic measurements. Analysis of reproducibility and comparison of ST and radiographs were done.A total of 193 patients were enrolled (148 F [77%]). The mean age was 13.25 years (range 8-18). The scoliosis magnitude was as follows: thoracic average 22.7 ± 10 degrees; lumbar average 19.6 ± 9 degrees. The kyphosis magnitude was 54.0 ± 11 degrees. The reproducibility for each ST parameter for 3 repeated scans was strong (interclass correlation = 0.855-0.944). Comparison to radiographic measurements was strong in the thoracic (r = 0.7) and moderate in the lumbar curve (r = 0.5). There was an average difference of 5.8 degrees in the thoracic spine and 8.8 degrees in the lumbar spine between ST Cobb angle estimates and radiographs. Thoracic kyphosis also had a strong correlation (r = 0.8) with radiographs.Although the results are intended to measure similar aspects of deformity as the traditional Cobb angle, the measurement is not intended to be an exact estimation. The utility of ST is in the reproducible quantification of deformity after the initial radiograph has been taken. This has the potential to make longitudinal assessment of change in deformity without serial radiographs.

A cross-sectional survey of surgeon members of the Scoliosis Research Society (SRS).This study sought to characterize the incidence, clinical presentation, diagnostic workup, treatment, and neurologic prognosis following delayed postoperative neurologic deficit (DPND) in patients undergoing spinal deformity surgery.DPND is a potentially devastating condition following spinal surgery, characterized by the development of a neurological deficit within hours or days of the surgical procedure. To date, only case reports and small case series have been published on the topic.We developed a survey to characterize DPND following spinal deformity surgery. This survey was distributed to surgeon members of the SRS through email and standard mail. The overall response rate was 38% (352/929).Our results suggest an estimated DPND incidence of 1 of 9910 cases (0.01%). Eighty-one surgeons (23%) experienced at least 1 DPND in the past 10 years (92 total cases). Most common diagnoses were scoliosis (69%), kyphosis (23%), and spondylolisthesis (14%); 20% were revision surgeries. The number of hours to deficit onset was as follows: 1 to 12 (36%), 13 to 24 (27%), 25 to 48 (27%), more than 48 (10%). The most commonly cited sources of injury included ischemic injury (38%) and cord compression (15%). Forty-one percent experienced complete neurologic recovery, 26% partial, and 33% no recovery. Twenty-one percent of patients achieved final neurologic status within 1 week, 38% by 1 month, and 73% by 6 months. Patients with compression-related DPND had a significantly greater likelihood of experiencing some neurologic recovery (≥1 ASIA Grade) than ischemia-related DPND (86% versus 51%, P = 0.049).DPND occurs at an estimated incidence of 0.01%. Sixty-three percent of DPND cases occurred within the first 24 hours and 90% within 48 hours. Complete (41%) or partial (26%) neurologic recovery may be expected, especially in compression-related DPND, emphasizing the need for perioperative vigilance, prompt recognition, and early intervention.4.

Objective The purpose of this study was to assess L4–S1 inter-vertebral coronal motion of the unfused distal segments of the spine in patients with adolescent idiopathic scoliosis (AIS) after instrumented fusion with regards to postoperative time and fusion length, independently. Methods Coronal motion was assessed by standardized radiographs acquired in maximum right and left bending positions. The intervertebral angles were measured via digital radiographic measuring software and the motion from the levels of L4–S1 was summed. The entire cohort was included to evaluate the effect of follow-up time on residual motion. Patients were grouped into early ( 10 years) follow-up groups. A subset of patients (n = 35) with a primary thoracic curve and a nonstructural modifier type “C” lumbar curve were grouped as either selective fusion (lowest instrumented vertebra [LIV] of L1 and above) or longer fusion (LIV of L2 and below) and effect on motion was evaluated. Results The data for 259 patients are included. The distal residual unfused motion (from L4 to S1) remained unchanged across early, midterm, to long-term follow-up. In the selective fusion subset of patients, a significant increase in motion from L4 to S1 was seen in the patients who were fused long versus the selectively fused patients, irrespective of length of follow-up time. Conclusion Motion in the unfused distal lumbar segments did not vary within the >10-year follow-up period. However, in patients with a primary thoracic curve and a nonstructural lumbar curve, the choice to fuse longer versus shorter may have significant consequences. The summed motion from L4 to S1 is 50% greater in patients fused longer compared with those patients with a selective fusion, in which postoperative motion is shared by more unfused segments. The implications of this focal increased motion are unknown, and further research is warranted but can be surmised.

STUDY DESIGN Observational cohort study of prospective database registry. OBJECTIVE To determine the incidence of neurological complications in AIS patients undergoing surgical treatment with PO. SUMMARY OF BACKGROUND DATA Despite the widespread use of Ponte Osteotomies (PO) in adolescent idiopathic scoliosis (AIS) correction, outcomes and complications in patients treated with this technique have not been well characterized. METHODS A multicenter prospective registry of patients undergoing surgical correction of AIS was queried at 2-year follow-up for patient demographics, surgical data, deformity characteristics, and peri-operative complications. A neurological complication was defined as perioperative nerve root or spinal cord injury as identified by the surgeon. Patients were divided into those who underwent peri-apical PO and those without, and further stratified by Lenke curve classification into 3 groups (I-types 1 and 2, II-types 3, 4, 6, and III-type 5). Patients with- and without neurological complications were compared with respect to baseline demographics, surgical variables, curve types, fusion construct types (screws vs. hybrid), curve magnitude (coronal and sagittal Cobb), apical vertebral translation, and coronal-deformity angular ratios (C-DAR). RESULTS Of 2210 patients included in the study, 1611 underwent PO. Peri-operative neurological complications occurred in 7 patients, with 6 in the PO group (0.37%) and 1 in non-PO group (0.17%) though this was not a statistically significant risk factor for peri-operative neurological injury (P = 0.45). Neuromonitoring alerts were recorded in 168 patients (7.6%: 9.3% PO group; 4.2% no-PO group (P

Determining whether to fuse a Lenke 5 curve to L3 or to L4 is often a difficult decision. The purpose of this study was to determine preoperative variables predictive of an "ideal" or "less than ideal" outcome for Lenke 5 curves instrumented to L3.A multicentre registry of adolescent idiopathic scoliosis patients was queried for surgically treated Lenke 5 curves with a lowest instrumented vertebra (LIV) of L3 and minimum 2 years of follow-up. Five seasoned surgeons qualitatively rated the 2-year postoperative images as "ideal" or "less than ideal" with respect to correction and alignment. Preoperative and postoperative radiographic variables were compared between the two groups. Multivariate regression analysis was performed to determine variables most predictive of a "less than ideal" outcome.One hundred and thirty-nine patients met criteria. Twenty-three were considered "less than ideal" by ≥ 3 surgeons; 81 were unanimously "ideal". Preoperatively, the "less than ideal" group had significantly stiffer curves, greater apical translation, and greater LIV angulation and translation. Multivariate regression found that preoperative L3 translation (p = 0.009) was the single most important predictor of a "less than ideal" outcome: 3.5 cm consistently resulted in an "ideal" outcome, while 3.5 cm risked a "less than ideal" result.While multiple variables are important in achieving an "ideal" outcome in Lenke 5 curves, this study found preoperative L3 translation was the most important predictor of success with an L3 translation 3.5 cm being a potential threshold for selecting L3 as the LIV. These slides can be retrieved under Electronic Supplementary Material.

A 15-year-old boy with X-linked myotubular myopathy associated with severe hypotonia and pectus excavatum presented for posterior spinal fusion of T2-sacrum because of rest pain and severe progressive neuromuscular scoliosis. Previously, he experienced 2 separate instances of cardiac arrest after prone positioning under general anesthesia. A preoperative computed topography angiogram in the supine and prone positions revealed inferior vena cava and right ventricular outflow tract obstruction on prone positioning. Successful positioning and posterior spinal fusion occurred by staging the procedure, correction of volume status, early use of vasoactive and inotropic agents, and oblique prone positioning.

To evaluate changes in pulmonary function tests (PFT) at 5 years post-operatively in patients with adolescent idiopathic scoliosis (AIS) and to determine whether these changes are progressive or static after 2 years.AIS surgical patients with pre-operative and 5 year post-operative forced expiratory volume (FEV) and forced vital capacity (FVC) were included. The percentage of patients with pulmonary impairment at 5 years was calculated. Repeated measures ANOVA was used to evaluate changes between pre-operative PFT and 5 years post-operative PFT and to determine whether the changes differed between curve types and approach. A sub-analysis of patients with 2 year data was performed to determine whether PFT changes were static or progressive.Two hundred and sixty-two patients had undergone pre-operative and 5 year post-operative PFTs. At 5 years, 42% were normal, 41% had mild impairment, and 17% had moderate-severe impairment. Overall, there was a decline in % predicted FVC (p 0.05); FEV remained stable. There was no difference based on major curve type (p 0.05). Anterior instrumentation cases declined significantly between pre-operative PFT and 5 years post-operative PFT (FEV: - 10% open, - 6% thoracoscopic; FVC: - 13% open, - 8% thoracoscopic) (p ≤ 0.02). The posterior cases remained stable (2% FEV, p = 0.7; - 0.6% FVC, p = 0.06). A subgroup of 90 patients with 2 year post-operative PFTs demonstrated that changes were progressive between 2 and 5 years post-operatively. The average change in FVC from 2 to 5 years was significantly different between the anterior open (- 9%) and posterior-only (0.7%) groups (p = 0.015).In patients who underwent anterior instrumentation, PFTs declined from the pre-operative to the 5 years post-operative time point. There was a progressive decline of 4-10% beyond 2 years post-operatively. Patients who underwent posterior instrumentation remained stable. These slides can be retrieved under Electronic Supplementary Material.

BACKGROUND: The true benefits of scoliosis surgery in cerebral palsy (CP) remain uncertain. Our aims were to determine the benefits of spinal fusion according to health-related quality of life (HRQoL) improvement at long-term follow-up and to explore the effect of surgery-related complications on clinical outcomes. METHODS: The cases of consecutive patients who had Gross Motor Function Classification System (GMFCS) level-IV or V cerebral palsy with 5-year follow-up from a prospective, longitudinal, multicenter database were analyzed. Caregivers completed the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaire and 4 Likert-type anchor questions preoperatively and at 1, 2, and 5 years of follow-up. Data on complications were collected prospectively. Preoperative CPCHILD scores were compared with postoperative scores at the 1, 2, and 5-year follow-up evaluations. Preoperative CPCHILD scores were compared with postoperative scores at the 1, 2, and 5-year follow-up evaluations using repeated-measures analysis of variance (ANOVA). Spearman correlation coefficient was used to explore the association between changes in the CPCHILD at 1, 2, and 5-year follow-up and the reported complications within the follow-up period. Similarly, a comparative analysis between the percentage distribution of the answers to the 4 anchor questions and the reported complications was also performed. RESULTS: Sixty-nine patients with a mean age (and standard deviation) of 13.4 ± 2.6 years at enrollment were analyzed. The major Cobb angle was a mean of 81.9° ± 26.7° preoperatively and improved to a mean of 28.7° ± 14.4° at 2 years and 30.7° ± 15.3° at 5 years postoperatively. Significant improvements in CPCHILD personal care, positioning, and comfort domains were noted at all time points. The mean increase in the total score was 7.19 (p < 0.001) at 1 year, and the score gain was maintained at 2 and 5 years postoperatively. The overall complication rate was 46.4% at 1 year, 1.4% between 1 and 2 years, and 4.3% at 2 to 5 years postoperatively, with surgical intervention required in 6 patients within 1 year and in 2 additional patients within 5 years following scoliosis surgery. There was no correlation between complications and CPCHILD scores postoperatively at all time points, with the only exception of a weak correlation (ρ = -0.450, p = 0.002) with CPCHILD comfort score at 1 year after surgery. CONCLUSIONS: Scoliosis surgery in patients with CP leads to a significant improvement in HRQoL, which is maintained 5 years following surgery. The substantial complication rate does not correlate with HRQoL changes postoperatively, suggesting that the benefits of surgery outweigh the risks in this fragile population. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Preoperative and two-year follow-up health-related quality of life (HRQOL) data were prospectively collected in 82 Scheuermann kyphosis (SK) and 995 adolescent idiopathic scoliosis (AIS) patients using the Scoliosis Research Society–22 patient questionnaire (SRS-22) outcomes instrument in a multicenter study. Visual analog scale (VAS) scores were also collected for the SK population. This study assessed changes in HRQOL prospectively and compared them to those occurring in AIS. There has been limited evaluation of patient-reported HRQOL changes with operative management of SK. Median SRS values for the SK and AIS cohorts were compared using a repeated measure of analysis of variance with age as a covariate and using a Mann-Whitney U nonparametric comparison. Kyphosis was corrected from 73.9° to 45.8° (p < .001); the major curve in AIS was corrected from 55.5 to 20.2 (p < .001). Preoperative and magnitude of radiographic correction, kyphosis apex and body mass index in SK were not correlated with baseline or change in HRQOL. SK SRS scores improved after surgery in all domains with the greatest change (2.8–4.4) in self-image (p

BACKGROUND CONTEXT Surgical correction of adolescent idiopathic scoliosis is advocated for severe curves to preserve or improve pulmonary function, prevent progressive deformity and pain, and improve self-appearance. Restoration of sagittal and 3D alignment, in particular thoracic kyphosis (TK), has become increasingly emphasized in efforts to improve pulmonary function, thoracic volumes, provide improved sagittal balance, and prevent adjacent segment degeneration and deformity. PURPOSE To study the effects of thoracic kyphosis restoration in AIS type 1 and 2 curves on postoperative thoracic volume and pulmonary function. STUDY DESIGN/SETTING Retrospective review of prospective multicenter database. PATIENT SAMPLE Thirty-nine AIS patients with Type 1 and 2 curves with 5Y postoperative stereo-radiographic data and pulmonary function tests (PFTs). OUTCOME MEASURES Five-year spinal and rib cage measures and PFTs. METHODS A multicenter prospective registry of patients undergoing surgical correction of Type 1- and 2- AIS curves was queried for patients with 5-year postoperative visits including stereoradiographic assessment and PFTs. 3-dimensional (3D) radiographic analysis was performed to assess spinal alignment and chest wall dimensions at preoperative, first erect and 5 year postoperative time points. Variables were analyzed between time points with a one-way ANOVA and post-hoc Tukey analysis, and between variables with linear regression analysis. RESULTS A total of 39 patients met the inclusion criteria (37F, age 14.4±2.2). 3D spine alignment analyses demonstrated significant reduction in pre-op to 1st erect upper thoracic (41.3° to 11.6°), mid-thoracic (48.6° to 9.55°) and lumbar Cobb angles (19.7° to 8.9°), an increase in TK:T2-12 (20.0° to 39.8°) and TK:T5-12 (9.8 to 28.2°), and reduction in proximal and mid-thoracic apical vertebral rotation (9.5° to 2.1°) from preoperative to 1st erect postoperative (p 0.05 for all). 3D rib cage analysis demonstrated there was a small reduction in maximal depth (144 mm to 138 mm), maximum width (235 mm to 232 mm), and increase in thoracic height (220 mm to 230 mm, p CONCLUSIONS While thoracic kyphosis increases, coronal Cobb and apical vertebral rotation decrease postoperatively, these do not directly influence chest wall volume. Chest wall volume continues to increase between from first erect to 5 years due to presumed growth, which corresponds with an improvement in FEV1 and FVC at 5 year follow-up. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Prior adolescent idiopathic scoliosis (AIS) literature has demonstrated that patient satisfaction correlated weakly with individual SRS-22r domains and did not correlate with specific radiographic parameters. PURPOSE The purpose of this study is to demonstrate the effect of residual deformity on patient satisfaction. We hypothesize that in patients with AIS, residual deformity maybe associated with worse satisfaction. STUDY DESIGN/SETTING Retrospective analysis of a prospective AIS registry. PATIENT SAMPLE A total of 1,229 Lenke 1 and 2 AIS patients with available radiographic data and SRS scores at the 2-year follow-up were included. OUTCOME MEASURES Patient satisfaction using the SRS-22r satisfaction domain, categorized into 2 groups: Complete satisfaction (5/5) and incomplete satisfaction/dissatisfaction ( METHODS A total of 1,229 Lenke 1 and 2 AIS patients with available radiographic data and SRS scores at the 2-year follow-up were included. A score of 5 on the SRS-22r satisfaction domain at 2 years was considered “complete satisfaction,” and anything below a score of 5 was considered “incomplete satisfaction/dissatisfaction.” Radiographic parameters that were 2 standard deviations below the mean were deemed to have a “residual deformity.” Univariate and binary logistic analyses were performed to assess the association of residual deformity with patient satisfaction. RESULTS At the 2-year follow-up, 689 (60%) patients reported complete satisfaction, while 455 (40%) reported incomplete satisfaction/dissatisfaction. Radiographic factors associated with incomplete satisfaction/dissatisfaction were: residual trunk shift (OR 3.32, p=0.001) and residual major curve (OR 1.7, p=0.036). Patients with residual trunk shift and major curve also had worse SRS-22r self-image domain scores at the 2-year follow-up. Residual differences in shoulder height (p=0.534), T1 tilt angle (p=0.062), Apex to CSVL distance (p=0.969), and percent correction of the major curve (p=0.102) did not reach statistical significance for predicting incomplete satisfaction/dissatisfaction. CONCLUSIONS Residual curve (>34) and truncal shift (>2.2cm) impact patient satisfaction after surgery for AIS. These factors ought to be taken into account during surgical planning. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Scheuermann’s kyphosis (SK) presents as increased thoracic kyphosis or loss of lumbar lordosis with pathognomonic irregularities of the vertebral end plates. The majority of patients can be managed nonoperatively with bracing, short-term courses of NSAIDs, and physical therapy to address muscular discomfort. Surgical intervention should be considered for symptomatic patients with kyphosis exceeding 75°; however, smaller magnitude curves are also considered surgical if located in the thoracolumbar spine, if they are progressive, or if associated with significant pain or neurologic symptoms. A posterior approach with multilevel posterior column osteotomies at the apex of the deformity, segmental instrumentation, and fusion is the workhorse procedure. Junctional kyphosis is a complication that can often be avoided through careful selection of the upper (UIV) and lower instrumented vertebrae (LIV). In SK, the UIV should be the end vertebra; however, this is often difficult to visualize on lateral films, and therefore a line of best-fit technique may be used to aid selection. LIV is identified as the sagittal stable vertebra. Surgical correction of thoracic kyphosis and lumbar lordosis to values that are harmonious with the pelvic incidence (PI) is also important in preventing junctional kyphosis. In general terms, patients with high PI should be left with a larger thoracic kyphosis, while patients with relatively low PI should have a straighter sagittal profile. Asymptomatic, nonprogressive proximal junctional kyphosis (PJK) may be managed expectantly. The presence of progressive kyphosis, instability, or neurologic symptoms would mandate revision surgery with extension of the fusion proximally to a neutral or lordotic level.

Study design Multicenter review of prospectively collected data. Objective The purpose of this study was to evaluate whether a UIV of T2 reliably results in level shoulders postoperatively. Summary of background data Adolescent idiopathic scoliosis (AIS) patients with a risk of a high left shoulder postoperatively are generally recommended to have instrumentation to T2, those with neutral shoulders a T3 UIV, and those with an elevated right shoulder are recommended a UIV of T4 or below in order to achieve postoperative shoulder balance. Methods A prospective, multicenter AIS database was queried for subjects with minimum two-year follow-up who underwent posterior spinal fusion to correct their main thoracic deformity. Subjects were grouped based on their proximal fusion level. A high shoulder was defined as >1 cm difference on radiographs. Results A total of 626 subjects met inclusion criteria and were divided by UIVs of T2 189, T3 205, and T4 232. Preoperatively, the groups had similar rates of balanced shoulders (T2 47%, T3 49%, T4 45%) and high left shoulders (T2 8.5%, T3 8.8%, and T4 7.3%). Postoperatively, there was a greater percentage of postoperative shoulder imbalance for T2 (45%) and T3 (48%) UIV groups as compared to T4 (34%, p = .008). As expected, the T2 (46%) and T3 (49%) groups had significantly better upper thoracic curve correction as compared to the T4 group (42%, p Conclusions The selection of a T4 UIV results in more shoulder balance postoperatively than T2 or T3, regardless of which shoulder was elevated preoperatively. The selection of a T2 UIV does not guarantee postoperative shoulder balance following posterior treatment of main thoracic curves; however, when compared to the more caudal UIV of T4, an improved upper thoracic curve correction can be anticipated. Level of evidence Level 3.

Study Design Retrospective review of a prospectively collected multicenter database of patients with adolescent idiopathic scoliosis (AIS). Objective To determine if Ponte osteotomies improve correction in Lenke 1A and 1B AIS curves treated with pedicle screws. Summary of Background Data There is little data studying the risks and benefits of Ponte osteotomies in AIS. Methods We identified patients with Lenke 1A and 1B curve types treated with pedicle screw constructs and a 2-year follow-up. They were grouped based on whether they did (PO) or did not (NoPO) have Ponte osteotomies. Demographic, surgical, and radiographic data collected preoperatively and at 2 years were statistically analyzed using unpaired Student t test and Fisher exact test. Results One hundred ninety-one patients met the inclusion criteria (mean age of 14.7 ± 2.2 years), and among those, 125 patients (65.4%) had Ponte osteotomies (average of 4.3 ± 1.5 Pontes per patient). The patients treated with Ponte osteotomies had similar clinical and radiographic parameters (major Cobb: PO=51.5°, NoPO=50.8°, p=.6) to the patients who did not have Ponte osteotomies except that they had stiffer and more lordotic curves (Flexibility Index: PO=47.3%, NoPO=54.5%, p=.04; T5–T12 kyphosis: PO=18.7°, NoPO=23.2°, p=.02). At 2 years, the patients treated with Ponte osteotomies had significantly better thoracic Cobb angle correction (Correction Index: PO=67.1%, NoPO=61.8%, p=.01) and an increase in T5–T12 kyphosis (PO = +3.0°, NoPO=−0.4°, p=.045). The Ponte group demonstrated greater rib prominence correction (PO = 53.2%, NoPO=38.4%, p=.02). There were no neurologic events in this cohort. Conclusions Although the use of Ponte osteotomies was not randomized, these data suggest that greater deformity correction in all 3 planes may be possible when Ponte osteotomies are performed for the stiffer and more lordotic Lenke 1A and 1B curves. The clinical significance of these overall small statistical differences remains to be determined. Level of Evidence III.

Study Design Retrospective analysis of relevant in-hospital patient records from the New York State Inpatient Database. Objective We aimed to assess reoperation risk in adolescent idiopathic scoliosis (AIS) by surgeon and hospital operative volume. Summary of Background Data The need for early reoperation can be devastating for patient and family, is a burden to the physician and adds significant cost. Previous studies have shown improved outcomes associated with higher volume surgeons and hospitals, but reoperation events have not yet been explored. Methods The 2008-2011 New York State Inpatient Database was queried using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for adolescent idiopathic scoliosis patients aged 10-21 undergoing spine arthrodesis. Patient identifiers and revisit linkage variables were used to identify reoperation events. Annual surgeon and hospital volumes were stratified into tertiles (low, medium, high) via identifier codes. The relative risk of reoperation after spine arthrodesis was computed based on relevant patient inpatient stays. Results Over 2008 to 2011, a total of 3,928 primary fusion operations for AIS were identified. The overall rate of reoperation after spine fusion for idiopathic scoliosis was 7.1%. Low volume surgeons performed less than 6 AIS fusions per year, medium volume surgeons performed less than 43, and high volume surgeons performed from 43 to 228. Reoperation after a primary fusion for adolescent idiopathic scoliosis showed reduced frequency among higher volume surgeons (14.1% for low vs. 5.1% for high, p Conclusions Early reoperation after spine fusion for idiopathic scoliosis is seen more frequently in lower volume institutions and surgeons. Appreciating the resources and limitations at a clinician's institution is important to developing practices to prevent these devastating events. This work also has implications for strategies that aim to direct limited healthcare resources to centers with low complication rates.

Background: Wound drains that are left in place for a prolonged period of time have a higher rate of bacterial contamination. Following spinal surgery, a drain is often left in place for a longer period of time if it maintains a high output. Given the major consequences of an infection following spinal surgery and the lack of data with regard to the use of antibiotics and drains, we performed a study of patients with a drain following spinal surgery to compare infection rates between those who were treated with antibiotics for twenty-four hours and those who received antibiotics for the duration for which the drain was in place. Methods: We performed a prospective randomized trial of 314 patients who underwent multilevel thoracolumbar spinal surgery followed by use of a postoperative drain. The patients were randomized into two groups, one of which received perioperative antibiotics for twenty-four hours (twenty-four-hour group) and the other of which received antibiotics for the duration that the drain was in place (drain-duration group). Data collected included demographic characteristics, medical comorbidities, type of spinal surgery, and surgical site infection. Results: Twenty-one (12.4%) of the 170 patients in the twenty-four-hour group and nineteen (13.2%) of the 144 in the drain-duration group developed a surgical site infection (p = 0.48). There were no significant differences between the twenty-four-hour and drain-duration groups with respect to demographic characteristics (except for the American Society of Anesthesiologists [ASA] classification), operative time, type of surgery, drain output, or length of hospital stay. Conclusions: Continuing perioperative administration of antibiotics for the entire duration that a drain is in place after spinal surgery did not decrease the rate of surgical site infections. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

To assess the changes in gait pattern and clinical symptoms of patients with chronic non-specific low back pain (CNSLBP) following a home-based biomechanical treatment (HBBT). This was a retrospective analysis of 60 CNSLBP patients. All patients underwent a gait evaluation and completed self-assessment questionnaires at pre-treatment and after 3 and 6 months of a HBBT (AposTherapy). Twenty-four healthy, aged-matched individuals served as a reference group. Significant differences were found in all gait parameters and clinical symptoms between patients with CNSLBP and healthy people before treatment. Significant improvements were found in all gait parameters and clinical measures following 6 months of therapy including an increase in gait velocity (10.6 %), step length (5.6 %), cadence (5 %), and quality of life and a decrease in pain (13.3 %). There were no significant differences between groups in the gait parameters following 6 months of treatment. Significant differences exist between patients with CNSLBP and healthy controls in terms of gait pattern and self-assessed health status. The examined HBBT led to significant improvements in gait pattern, reduction in pain, improved function and increased quality of life. However, future studies should validate these results while comparing this treatment to other treatment modalities.

Background context Hyperkyphosis confers a significant risk for neurologic deterioration as well as compromised cardiopulmonary function. Posterior vertebral column resection (PVCR) is a challenging but effective technique for spinal cord decompression and deformity correction that even under the setting of limited resources can be performed to reduce the technical difficulties, the operating time, and possibly the complications of the traditional two-staged vertebral column resection (VCR). Purpose To report on the results of VCR performed through a single posterior approach (PVCR) in the treatment of severe rigid kyphosis in a series of patients treated and followed at a Scoliosis Research Society Global Outreach Program site in West Africa. Study design Retrospective case series. Patient sample Forty-five consecutive patients treated with PVCR for correction of severe rigid kyphosis. Outcome measures Clinical and radiographic outcomes and complications; Scoliosis Research Society outcome instrument (SRS-22). Methods From 2002 to 2009, 45 patients (20 male and 25 female) underwent PVCR for kyphosis from congenital deformity (nine) or secondary to tuberculosis of the spine (36). Preoperative demographics, preop and postop neurologic status, SRS-22 scores and complications were recorded; upright full spine X-rays were available in all patients. Mean age was 14 years (6–47 years); mean follow-up 27 months (2–79 months). Mean preoperative kyphosis measured 108°. The deformity apex was resected via a costotransverse (thoracic) or posterolateral (lumbar) approach; neurosurveillance with sensory (somatosensory-evoked potentials) and motor (motor-evoked potentials) potential was used in all cases. Posterior instrumentation was used in all patients, and anterior structural cage was used in 32 patients. Results Intraoperative monitoring changes occurred in 10 patients (22%), and one patient progressed to complete spinal cord injury. Average preoperative local kyphosis was 108° and corrected to 600 postoperatively. Postoperatively, no additional patient showed neurologic deterioration; of the 11 patients with preoperative gait disturbances, 4 improved to normal gait, 5 remained the same, and 2 showed deterioration of their walking ability to nonambulating level. Total SRS-22 scores improved from 3.18 to 3.54 (p=.01), primarily self-image domain. Conclusions Posterior vertebral column resection was successfully undertaken for the management of thoracic and thoracolumbar hyperkyphosis, demonstrating improvements in overall kyphosis and clinical outcome. Neuromonitoring provided the required safety to perform these challenging complex spine deformity procedures.

Ethnic disparities have been documented in the incidence and treatment of many diseases. Additionally, race and socioeconomic status (SES) have been shown to affect disease severity and access to care in the recent orthopedic literature.To assess the role, if any, that race, SES, and health insurance type play in disease severity and treatment decisions in patients with adolescent idiopathic scoliosis.Retrospective chart review.Pediatric patients seen in a single surgeon's practice over 6 years (2004-2009).Treatment modality (observation, bracing, or surgery).Data were obtained from 403 patients seen over 6 years (2004-2009). A patient-reported questionnaire was used to collect race, age, family income, and parent marital status data. Race was self-reported as "Asian," "black or African American," "Hispanic or Latino," "white or Caucasian," or "Other." Socioeconomic status was determined using family income and type of health insurance as indicators. Major curve magnitude and prescribed initial treatment (observation, brace, or surgery) were assessed from physician records. An independent sample t test was used to detect differences in curve magnitude of the different racial groups. A Pearson chi-square analysis was used to detect group differences for curves in surgical patients, defined as curves greater than 40°, and their initial treatment.Patients self-identified with one of the following racial groups: white (N=219), black (N=86), Hispanic (N=44), Asian (N=37), or Other (N=17). Mean curve magnitude was greater in black than in white patients (33° vs. 28°, p.05). Black patients were more likely to present with curves in the surgical range (34% vs. 24%, p.05) and were more likely to have surgery as their initial treatment than white patients (34% vs. 19%, p.05). Black patients had more limited health care plans and lower incomes compared with whites (p.001). Patients with higher access insurance plans presented at a younger age than patients with more limited access plans, irrespective of race (13.6 vs. 14.1, p.05). There was no difference in Cobb angle at presentation by income or type of insurance.Curve magnitude and percentage of patients with curves in the surgical range were greater in black than in white patients. There was no difference in age on presentation or treatment offered across all racial groups. Black patients were more likely to have surgery as their initial treatment than white patients. While race did have an impact on disease severity in this single surgeon's practice, SES did not.

Spine surgery is usually associated with large amount of blood loss, necessitating blood transfusions. Blood loss-associated morbidity can be because of direct risks, such as hypotension and organ damage, or as a result of blood transfusions. The antifibrinolytic, tranexamic acid (TXA), is a lysine analog that inhibits activation of plasminogen and has shown to be beneficial in reducing surgical blood loss.To consolidate the findings of randomized controlled trials (RCTs) investigating the use of TXA on surgical bleeding in spine surgery.A metaanalysis.Randomized controlled trials investigating the effectiveness of intravenous TXA in reducing blood loss in spine surgery, compared with a placebo/no treatment group.MEDLINE, Embase, Cochrane controlled trials register, and Google Scholar were used to identify RCTs published before January 2014 that examined the effectiveness of intravenous TXA on reduction of blood loss and blood transfusions, compared with a placebo/no treatment group in spine surgery. Metaanalysis was performed using RevMan 5. Weighted mean difference with 95% confidence intervals was used to summarize the findings across the trials for continuous outcomes. Dichotomous data were expressed as risk ratios with 95% confidence intervals. A p.05 was considered statistically significant.Eleven RCTs were included for TXA (644 total patients). Tranexamic acid reduced intraoperative, postoperative, and total blood loss by an average of 219 mL ([-322, -116], p.05), 119 mL ([-141, -98], p.05), and 202 mL ([-299, -105], p.05), respectively. Tranexamic acid led to a reduction in proportion of patients who received a blood transfusion (risk ratio 0.67 [0.54, 0.83], p.05) relative to placebo. There was one myocardial infarction (MI) in the TXA group and one deep vein thrombosis (DVT) in placebo.Tranexamic acid reduces surgical bleeding and transfusion requirements in patients undergoing spine surgery. Tranexamic acid does not appear to be associated with an increased incidence of pulmonary embolism, DVT, or MI.

This is a prospective, randomized, double-blinded comparison of tranexamic acid (TXA), epsilon aminocaproic acid (EACA), and placebo used intraoperatively in patients with adult spinal deformity.The purpose of this study was to provide high-quality evidence regarding the comparative efficacies of TXA, EACA, and placebo in reducing blood loss and transfusion requirements in patients undergoing posterior spinal fusion surgery.Spine deformity surgery usually involves substantial blood loss. The antifibrinolytics TXA and EACA have been shown to improve hemostasis in large blood loss surgical procedures.Fifty-one patients undergoing posterior spinal fusion of at least 5 levels for correction of adult spinal deformity were randomized to 1 of 3 treatment groups. Primary outcome measures included intraoperative estimated blood loss, total loss, (estimated blood loss + postoperative blood loss), and transfusion rates.Patients received TXA (n = 19), EACA (n = 19), or placebo (n = 13) in the operating room (mean ages: 60, 47, and 43 yr, respectively); TXA patients were significantly older and had larger estimated blood volumes than both other groups. Total losses were significantly reduced for EACA versus control, and there was a demonstrable but nonsignificant trend toward reduced intraoperative blood loss in both antifibrinolytic arms versus control. EACA had significant reductions in postoperative blood transfusions versus TXA.The findings in this study support the use of antifibrinolytics to reduce blood loss in posterior adult spinal deformity surgery.1.

Comparative effectiveness research provides information on the benefits and complications of specific treatments and can guide spine surgeons to best-quality practices. Although orthopedic implants comprise more than 25% of the perioperative costs for adolescent idiopathic scoliosis (AIS), there are few high-level studies comparing the various implant types, patterns, and number. Numerous studies have shown the superiority of all pedicle–screw constructs over hook-and-hybrid constructs. A wide variety of pedicle screw numbers, densities, and configurations are used in clinical practice. Many small studies indicate no significant difference in clinical outcomes between low-implant density and high-implant density constructs for the surgical treatment of moderate AIS, but these are likely underpowered. More work is needed to determine the appropriate number and distribution of implants for specific curve patterns to optimize the surgical care of AIS patients.

STUDY DESIGN Retrospective analysis of prospectively collected data from the 2001 to 2010 Nationwide Inpatient Sample database. OBJECTIVE To assess complication rates in adolescent spinal deformity by surgeon operative volume for procedures with a range of complexity. SUMMARY OF BACKGROUND DATA Surgeons performing higher volumes of lumbar spinal fusion have been associated with improved surgical outcomes, according to studies using the Nationwide Inpatient Sample. This relationship has not been shown in adolescent spinal deformity surgery. METHODS The Nationwide Inpatient Sample was queried for patients aged 10 to 18 years with in-hospital stays including spinal arthrodesis for scoliosis (adolescent idiopathic, neuromuscular, and congenital scoliosis). The primary end point was hospital stay morbidity: database-defined surgical, mechanical, major medical, and neurological complications. Length of stay and hospital charges were also analyzed. Annual surgeon volumes were stratified into quartiles based on number of cases (Q1: 1, Q2: 2-7, Q3: 8-19, and Q4: 20-97). To account for variation in surgical invasiveness, an operative complexity index was used. One-way analysis of variance was used to assess differences between quartiles for continuous measures and χ for categorical measures. RESULTS A total of 6100 spine fusion cases met inclusion criteria for adolescent scoliosis. All complications categories were less frequent for higher volume surgeons after a primary fusion for all diagnoses. This pattern held for increasing surgical invasiveness, such as fusing 9 or more levels and became more distinct for neurological complications when comparing surgeons performing combined anterior-posterior procedures. Including all adolescent scoliosis fusions, higher surgical volume was associated with decreased length of stay and hospital charges. CONCLUSION Perioperative complications after adolescent scoliosis fusion surgery are more frequent in lower volume settings. This may reflect a learning curve required for more complex cases as the trends are magnified in neuromuscular/congenital scoliosis cases or simply that higher volume surgeons are more adept at these fusions. The impact of volume on reduced length of stay and hospital charges has implications for future health care economics measures. LEVEL OF EVIDENCE 2.

Study Design Retrospective analysis of a prospectively collected single-center database. Objectives To report the incidence of and identify risk factors for perioperative complications in surgically treated pediatric and adult patients with complex spine deformities in an underserved region and Scoliosis Research Society Global Outreach Program site. Summary of Background Data Surgical treatment for complex spinal deformity is challenging and requires a multidisciplinary approach for optimal management. The incidence and risk factors for major perioperative complications in outreach sites with limited resources are unknown. Methods A total of 427 consecutive patients who underwent instrumented spinal fusion for complex spinal deformities were reviewed. Clinical, radiographic, and demographic data were reviewed at preoperative and postoperative time points, and potential risk factors for perioperative complications were assessed. The authors performed multivariate logistic regression analysis (LRA) to determine independent risk factors for postoperative complications and neurological deficits. Results Major complications were seen in 85 cases, which consisted of neurologic deficits (n = 27; 17 transient and 10 permanent), wound infections (n = 17), implant-related problems (n = 35), progressive deformity (n = 13), and death (n = 6). Among the possible risk factors, univariate LRA indicated 3-column osteotomies as a risk factor for postoperative major complications and multivariate LRA indicated 3-column osteotomies as an independent risk factor for neurological deficit. Curves 100° and above were at higher risk for complications. Conclusions Postoperative complications were seen in 20% of surgically treated patients with complex spine deformities at a Scoliosis Research Society SRS Global Outreach Program site. Three-column osteotomies were identified as an independent risk factor of both postoperative complications and neurological deficits. The significant observed correlation of 3-column osteotomies and postoperative neurological deficits should serve as a guide for surgeons in the preoperative planning and management of severe spinal deformities, especially in locations with limited resources. Patients undergoing correction of large curves may also have a higher complication rate.

The frequency of disc degeneration (DD) in the distal mobile segments will increase over time following surgery for adolescent idiopathic scoliosis (AIS). Retrospective review of a prospective AIS registry. Durability of surgical outcomes is essential for maintenance of quality of life as well as for family decision making and for assessment of the value of a healthcare intervention. We assessed DD, its risk factors, and association with health-related quality of life 10 years after AIS surgery. Five radiographic indicators of DD, previously validated, were evaluated preoperatively and 1 month, 2, 5, and 10 years postoperatively by a radiologist in operative AIS patients. A composite radiographic score (CRS; range 0-10) was calculated using the sum of each of the DD indicators. The severity of CRS in relation to the time point after surgery and various risk factors were assessed using linear regression or Pearson χ2 test. CRS ≥3 was chosen to indicate significant DD. Association of CRS with SRS-22 outcome was evaluated by linear regression. 193 consecutive patients (mean age at surgery 14.4 years; 86% female) were assessed. Surgical approach included 102 posterior and 91 anterior fusions. Contributors to maximum CRS at 10 years were Schmorl’s nodes (7.3% of patients), osteophytes (40.4%), sclerosis (29%), and irregular endplate (8.3%). CRS ≥3 occurred in 1.6%, 0.54%, 3.7%, 6.8%, and 7.3% of patients at the various time points (r 2=0.83, p=.0313), respectively. More than 50% of DD occurred at the second (35.5%) and third (20%) disc caudal to the LIV. LIV of L4 compared with more cephalad LIV had the highest risk of developing significant DD (27.3%; p=.0267). It was found that disc wedging subjacent to the LIV (≥5°) and LIV translation (≥2 cm) lead to a sixfold increase in significant DD (odds ratio=6.71 and 6.13, respectively). Severity of DD was not associated with the number of levels fused (p=.2131), the surgical approach (p=.8245), or the construct type (p=.2922). No significant association was established between 10-year CRS and SRS-22 scores. In the first study of its kind, we found that only 7.3% of patients had significant DD 10 years after surgical correction of AIS. Rates of DD increased over time. Our data provide evidence to support recommendations to save as many caudal motion segments as possible, to avoid fusing to L4, and maintain the LIV tilt angle below 5° and LIV translation less than 2 cm.

Study Design Consensus-building using the Delphi and nominal group technique. Objective To establish best practice guidelines using formal techniques of consensus building among a group of experienced spinal deformity surgeons to avert wrong-level spinal deformity surgery. Summary of Background Data Numerous previous studies have demonstrated that wrong-level spinal deformity occurs at a substantial rate, with more than half of all spine surgeons reporting direct or indirect experience operating on the wrong levels. Nevertheless, currently, guidelines to avert wrong-level spinal deformity surgery have not been developed. Methods The Delphi process and nominal group technique were used to formally derive consensus among 16 fellowship-trained spine surgeons. Surgeons were surveyed for current practices, presented with the results of a systematic review, and asked to vote anonymously for or against item inclusion during three iterative rounds. Agreement of 80% or higher was considered consensus. Items near consensus (70% to 80% agreement) were probed in detail using the nominal group technique in a facilitated group meeting. Results Participants had a mean of 13.4 years of practice (range: 2–32 years) and 103.1 (range: 50–250) annual spinal deformity surgeries, with a combined total of 24,200 procedures. Consensus was reached for the creation of best practice guidelines (BPGs) consisting of 17 interventions to avert wrong-level surgery. A final checklist consisting of preoperative and intraoperative methods, including standardized vertebral-level counting and optimal imaging criteria, was supported by 100% of participants. Conclusion We developed consensus-based best practice guidelines for the prevention of wrong-vertebral-level surgery. This can serve as a tool to reduce the variability in preoperative and intraoperative practices and guide research regarding the effectiveness of such interventions on the incidence of wrong-level surgery. Level of Evidence Level V.

SummaryBackground Idiopathic scoliosis is a condition that may require surgical correction. Limitations of previous surgical modalities, however, created the need for novel methods of repair. One such technique, a newer form of anterolateral scoliosis correction, has shown considerable promise, which our center has had substantial experience performing. Aim In this article, we present the case details of our first 105 patients for the purposes of describing the evolution and details of the anesthetic management and considerations for this procedure. Methods A retrospective review of medical records for 105 patients undergoing anterolateral instrumentation procedure for idiopathic scoliosis correction done at a single institution from May 2014 to June 2016 was performed. The details of perioperative management as well as surgical technique were reported for all patients. Results The mean age for patients was 14.8 years (range 10-18); the mean weight was 49.9 kg (range 25-82). Unilateral procedures were performed on 46.7%, with bilateral and hybrid procedures performed on 50.5% and 4.7%, respectively. The median number of levels corrected was 8 (interquartile range [IQR] 7-9) for unilateral, right 7 (IQR 6-7) and left 5 (IQR 4-5) for bilateral, and 4 (IQR 4-4.5) for hybrids. The average estimated blood loss (EBL) was 310 mL±138, with cell salvaged blood transfused in 61% of patients, and allogenic blood transfusion required in only two patients. Conclusions The described anesthetic and analgesic management provides a framework for delivering perioperative care for this challenging procedure, which is gaining popularity as a modality for scoliosis correction.