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Study Design Biomechanical numerical simulation analysis of implant design and density in adolescent idiopathic scoliosis posterior instrumentation. Objectives To evaluate the combined effect of pedicle screw design and density on deformity correction and construct load-sharing capacity. Summary of Background Data Screw density is an area of popular study because of the impact of cost and potential patient morbidity of higher-density constructs. Using fewer screws raises concern about reduced correction and greater forces on each screw. Methods Personalized spinal numerical models were created for five patients. The correction techniques from five spine surgeons using both a high- and a low-density implant pattern (2 vs. 1.4 ± 0.22 screws/level) with uniaxial, multiaxial, and favored angle screws were simulated. The predicted correction and forces sustained by the implants were compared. The postoperative load-sharing capacity of a high- and a low-density construct, with or without crosslinks, was compared by simulating daily activities motions. Results The major coronal curve correction was similar with high- and low-density constructs (73% ± 10% vs. 72% ± 10%; p > .05) but was higher when using uniaxial (77% ± 8%) compared to multiaxial (69% ± 11%) and favored angle screws (71% ± 10%; p = .009). High- and low-density constructs sustained similar intraoperative peak forces (305 ± 61 N vs. 301 ± 73 N; p = .23) regardless of screw design (all p > .05). Multiaxial and favored angle screws reduced the peak axial force by 23% and 38% compared to uniaxial screws (p = .007). The high-density construct reduced the postoperative loads sustained by each implant by 31% (p = .006). Crosslinks had no effect on load sharing (p = .23). Conclusion High- and low-density implant patterns achieved similar coronal correction with equivalent capacity to share corrective forces regardless of the screw design. Increased degrees of freedom of the screw head reduces the capacity to correct coronal deformity but generates lower bone-screw forces. The reduced number of screws increased the postoperative forces sustained by each screw, but its effect on potential complications requires further investigations. Level of Evidence Level 4.

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

STUDY DESIGN Prospective cohort study. OBJECTIVE To prospectively compare radiographic, perioperative, and functional outcomes between anterior spinal instrumentation and fusion (ASIF) and posterior spinal instrumentation and fusion (PSIF) in Lenke 5C curves. SUMMARY OF BACKGROUND DATA Historically, ASIF has been the treatment of choice for treatment of thoracolumbar adolescent idiopathic scoliosis. More recently, PSIF has gained popularity for its ease, versatility, and amount of correction achieved. Current literature lacks a prospective comparative analysis between these two approaches to better aid treating surgeons in decision making when treating Lenke 5C curves. METHODS A prospective, longitudinal multicenter adolescent idiopathic scoliosis database was used to identify 161 consecutive patients with Lenke 5C curves treated by ASIF with a dual rod system, or PSIF with a pedicle screw-rod construct. Pre- and 2-year postoperative radiographic data, Scoliosis Research Society outcome scores, and perioperative comparisons were made between the two approaches. RESULTS A total of 69 patients were treated with ASIF and 92 patients with PSIF. Curve extent, magnitude, stable, and end vertebrae distribution before surgery were similar between the two groups. At 2-year follow-up, there were no significant differences in percentage correction of the main curve (ASIF: 59.1%, PSIF: 59.6%), C7 decompensation (ASIF: -0.6 ± 1.2, PSIF: -0.3 ± 1.4 cm), length of hospital stay (ASIF: 5.6 days, PSIF: 5.7 days), postoperative day conversion to oral pain medication (ASIF: 3.2 days, PSIF: 3.2 days), and SRS outcome scores (P = 0.560) between the two groups. The number of levels fused was significantly lower in ASIF group (ASIF: 4.7, PSIF: 6.3; P

Review of a prospective database registry.To compare the Scoliosis Research Society (SRS)-22 and SRS-24 outcomes instruments in terms of scores, rate of ceiling effects, and discriminant ability in patients with pre- and postoperative adolescent idiopathic scoliosis.Despite improvements noted with the SRS-22, the SRS-24 is still occasionally used prospectively and for comparisons with previous studies reporting SRS-24 scores. Previous work has demonstrated that postoperative scores from the 2 versions are not interchangeable.A multicenter prospective registry of patients who underwent surgical correction of adolescent idiopathic scoliosis was queried for preoperative and 2-year postoperative SRS-22 and SRS-24 scores. Scores were compared between versions and ceiling effects were identified. Groups of deformity severity were created to evaluate discriminant ability.829 patients were identified. The SRS-22 scores for pain and general function were significantly greater than SRS-24 scores (P0.001), whereas the SRS-22 scores were significantly lower than the SRS-24 for self-image (P0.001). Preoperative ceiling effect was only noted in 1 domain each. Both versions were able to discriminate between large (80°+) and small (45°) preoperative curves in all domains and total scores (P0.05). Postoperatively, the SRS-22 scores for all shared domains and total score were significantly greater than SRS-24 scores (P0.001). Ceiling effects in 5 of 5 domain scores were noted postoperatively for SRS-22 and in 4 of 7 for SRS-24. With a smaller range of deformity postoperatively, only the SRS-22 self-image domain was able to discriminate between large (29°+) and small (≤11°) residual curves (P0.05).Scores obtained by the SRS-22 and the SRS-24 are not translatable despite shared domains. Whereas both versions demonstrated preoperative discriminant ability, postoperative discrimination of residual deformity is lacking in both. Patient-reported outcomes of treatment are crucial in advancing treatment, and improvement in the ability to assess subjective outcomes is essential.3.

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.

BACKGROUND Obtaining accurate measurements of scoliosis from two-dimensional (2-D) radiographs can be challenging because of the three-dimensional (3-D) nature of the deformity. Previous studies have shown that the sagittal plane, in particular, is misrepresented on 2-D radiographs because of the influence of axial plane rotation. The purpose of the current study was to define a methodology for measuring the 3-D segmental sagittal alignment of the spine in patients with adolescent idiopathic scoliosis (AIS) and to assess the effect of axial plane rotation on differences between 3-D and 2-D measures of deformity. METHODS Preoperative and postoperative EOS images of 120 consecutive patients with AIS (primary thoracic curves) treated with segmental thoracic pedicle-screw instrumentation were analyzed in the "3-D sagittal plane." The technique measured 3-D kyphosis or lordosis in the specific plane of sagittal motion for each spinal motion segment. The kyphosis (+) and lordosis (-) values of the segments from T5 to T12 were summed to give the 3-D measurement of T5-T12 kyphosis. These values were compared with the standard 2-D measurements of T5-T12 kyphosis on lateral radiographs, and a correlation analysis with regard to axial plane rotation of the apex was performed. RESULTS The average age (and standard deviation) of the patients was 14 ± 2 years. The mean preoperative Cobb angle on the standard 2-D view was 55° ± 10° and on the 3-D view was 52° ± 9° (p ≤ 0.001). On the 3-D view, the mean preoperative T5-T12 kyphosis was 6° ± 14°, and the kyphosis significantly increased to 26° ± 6° postoperatively (p < 0.001). The T5-T12 kyphosis on the standard 2-D view measured 18° ± 13° preoperatively and 27° ± 6° postoperatively (p < 0.001). The difference between the 2-D and 3-D measurements of T5-T12 kyphosis strongly correlated with apical vertebral rotation (r = 0.85; p < 0.01). CONCLUSIONS Routine 2-D measurements of thoracic kyphosis erroneously underestimate the preoperative loss of kyphosis in AIS because of errors associated with axial plane rotation, an inherent component of thoracic scoliosis.

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. PURPOSE: To determine how the indications for anterior thoracoscopic release and fusion have evolved over time. OVERVIEW OF LITERATURE: Anterior release was commonly performed to correct severe spinal deformities before the advent of pedicle screw fixation. The thoracoscopic approach significantly reduced the morbidity, as compared to open thoracotomy procedures. METHODS: We reviewed charts and radiographs of pediatric spinal deformity patients who underwent thoracoscopic release/fusion for their deformity from 1994 to 2008. Indications for the thoracoscopic procedure were assigned to one of the following categories: hyperkyphosis, large/stiff scoliosis, crankshaft prevention, and 'other'. We analysed indications grouped in 3-year intervals to determine how the indications for this procedure evolved over the past 15 years. RESULTS: One hundred and thirty-eight patients (mean age, 15 years; range, 2-28 years) underwent the procedure, with 160 identified indications. The frequency of thoracoscopic anterior release/fusion decreased after peaking in the years 2000-2002. Initially, hyperkyphosis was the most frequent indication (15/33, 45%; 1994-1996), but declined to an intermittent indication since 2006. The use of thoracoscopy to prevent crankshaft has also declined, but remains an indication for the most immature cases (2/17, 12%; 2006-2008). Severe or rigid scoliosis is currently the most common indication for thoracoscopic release/fusion at our center (11/17, 65%; 2006-2008). CONCLUSIONS: The indications for a thoracoscopic anterior release/fusion has evolved with our increased understanding of this procedure and improved posterior fixation with pedicle screw instrumentation. Thoracoscopy in select spinal deformity patients still has an important role despite its less frequent use, as compared to the past decade.

A prospective, longitudinal cohort was studied to determine the incidence, consequences, and risk factors of major perioperative complications in patients with cerebral palsy (CP) treated with spinal fusion. There is a wide variety of data available on the complications of spine surgery; however, little exists on the perioperative complications in patients with CP. A prospective multicenter dataset of consecutive patients with CP treated with spinal fusion was evaluated. All major perioperative complications were identified and stratified into categories: pulmonary, gastrointestinal, other medical, wound infection, neurological, instrumentation related, and unplanned staged surgery. Univariate and multivariate analyses were performed to identify various risk factors for major perioperative complications. 127 patients were identified with a mean age of 14.3 ± 2.6 years. Overall, 39.4 % of the patients had a major perioperative complication. Occurrence of a complication [no complication (NC), yes complication (YC)] resulted in significantly increased intensive care unit (ICU) (NC = 3.2 days, YC = 7.8 days, p

Study design Survey. Objective The aim of this study was to evaluate the surgeon's perspective on the potential impact of prolonged surgical waitlists on the surgical care and perioperative management of patients with scoliosis. Summary of background data The long waits for surgical treatment of scoliosis found in some countries may have serious implications for the complexity of surgery and perioperative care required if the curve progresses while waiting. The surgeon's perspective on this problem provides important information that needs to be taken into account during resource allocation. Methods Radiographs from 13 patients who had waited more than 6 months for scoliosis surgery were selected. Each patient had radiographs from the time of surgical booking and immediately preoperatively. The radiographs and a questionnaire were sent to 3 surgeons to canvass their surgical and postoperative plan. The surgeons were blinded to the fact that the radiographs were of the same patients at 2 time points. The patients' actual course of treatment was documented. Results Data for 11 patients were available for analysis. The average wait for surgery was 24 months (range, 17-30 mo). The mean curve progression was 25.3° while on the waitlist, from an average of 52° to 77°. By the time the patients had to undergo surgery, more anterior releases were added to posterior instrumentation alone in the surgical plan. Mean estimated operative time increased by 2.2 hours, mean estimated length of hospital stay increased by 1 day, and the estimated level of difficulty of surgery increased 2.33 grades. The predicted estimated blood loss also increased. Conclusion From the surgeon's perspective, lengthy waitlists have a significant negative impact on the perioperative and postoperative care of patients with scoliosis by increasing the complexity of surgery. The actual course of treatment corresponded to the responses from these different surgeons. Level of evidence N/A.

Retrospective, controlled, clinical study.To define the average values for sagittal spinopelvic parameters including pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS) in Scheuermann's kyphosis (SK); evaluate the differences in spinopelvic parameters among patients with SK and unaffected normal controls; and evaluate the correlation of various sagittal spinopelvic parameters to each other in SK and normal controls.Prospectively collected radiographic data from a study on SK were compared with those from previously published series of unaffected patients. Measures were made according to standard, defined measurement methods. Parameters measured included PT, PI, SS, thoracic kyphosis, lumbar lordosis, and radiographic sagittal alignment. Values were compared using independent-samples t test. Pearson correlation coefficient was used to analyze relationships between variables.A total of 47 patients with SK and 50 control patients, mean age 16.1 and 13.5 years, respectively, were included. In SK, average PI was 42°, average PT was 7°, and average SS was 35°. These values were not different from those of normal controls (PI, 46° [p = .084]; PT, 8° [p = .476]; SS, 37° [p = .162]). Pelvic incidence directly correlated with lordosis in both groups (p.005). T5-12 kyphosis correlated with lordosis in normal controls (p ≤ .05) but not in the SK group. Kyphosis in SK as quantified by greatest measurable Cobb angle did not correlate with PI or lordosis.Sagittal pelvic alignment in patients with SK is not different from that in normal subjects. Furthermore, in SK thoracic kyphosis did not correlate with any distal region of the spine (lumbar or pelvic). Further understanding of the relationship between sagittal spinopelvic alignment in various conditions causing spinal deformity will lead to better treatment of these conditions.

STUDY DESIGN Comparison of the Scoliosis Research Society-22 (SRS-22) questionnaire with a 7-item Rasch-derived questionnaire (SRS-7). OBJECTIVE To compare the construct and discriminant validity, internal consistency, responsiveness, and dimensionality of SRS-7 against SRS-22 in operatively treated children with adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA SRS-22 has not been shown to possess linearity or unidimensionality (internal validity). METHODS A multicenter database was queried for children with adolescent idiopathic scoliosis who underwent spinal fusion and answered all preoperative and 1-year postoperative SRS-22 questions. SRS-7 scores for the 685 patients were calculated from SRS-22 item responses. Traditional psychometric properties were assessed for both instruments (significance, P < 0.01). RESULTS SRS-7 and SRS-22 scores correlated preoperatively and postoperatively (r = 0.78, P < 0.001, and r = 0.78, P < 0.001, respectively). Both instruments showed good discriminant validity in segregating 4 groups of patients with adolescent idiopathic scoliosis by curve magnitudes (F = 8.36, P < 0.001, and F = 8.38, P < 0.001, respectively). Pre- and postoperative SRS-7 and SRS-22 had internal consistency Cronbach α values of 0.64 and 0.67, and 0.85 and 0.85, respectively. With SRS-7, mean postsurgical improvement was 18.7 points (46.6-65.3, P < 0.001), with effect size measures of Cohen d = 1.57, Hedge g = 1.57, and r = 0.62. With SRS-22, mean improvement was 11.6 points (84.5-96.1, P < 0.01), with effect size measures of Cohen d = 1.25, Hedge g = 1.25, and r = 0.53. Iterative principal factor analysis of pre- and postoperative SRS-7 and SRS-22 showed the presence of 1 dominant latent factor (unidimensionality) and 4 latent factors (multidimensionality), respectively. CONCLUSION SRS-7 shows good concurrent and discriminative validity, reasonable internal consistency, and excellent responsiveness. It has the advantages over SRS-22 of being short, unidimensional, and an interval scale. LEVEL OF EVIDENCE 4.

Study Design Mathematical modeling of normal sagittal spinal alignment. Objective To create a patient specific 3-dimensional (3D) model of normal adolescent spinal shape and alignment. Summary of Background Data Recreating normal sagittal balance is a key goal in spinal deformity surgery. Because of the variation in normal sagittal alignment based on inherent pelvic parameters, it is difficult to know what is normal for a given patient who presents with spinal deformity. Methods Simultaneous biplanar 2-dimensional digital radiographs were taken for pediatric patients with no known spinal disease using the EOS system. Three-dimensional reconstructions were produced using sterEOS and imported into custom MATLAB software. The researchers defined relationships to approximate orientations and positions of the vertebral bodies from patients' pelvic incidence (PI). The predicted spinal contour was then calculated to optimize congruence to patients' sagittal T1–sacrum offset, sagittal curve inflection point location, and predicted vertebral body orientations and positions. Results A total of 75 patients (26 male and 49 female) were included, mean age 14.5 ± 2.6 years. Baseline measurements were PI 46.7° ± 10.2°, sacral lope 40.2° ± 8.9°, T1–T12 kyphosis 39.8° ± 8.8°, and L1–L5 lordosis −37.1° ± 11.2°. Average difference in vertebral position in the anteroposterior direction between actual spines and their predicted models was 1.2 ± 1.2 mm and varied from an absolute minimum of 0.2 mm (T3) to an absolute maximum of 3.7 mm (L2). Conclusions This model uses an adolescent patient's PI to predict the normal sagittal alignment that best matches that patient's native sagittal curve. The model was validated on patients with no spinal deformity; average difference between actual sagittal positions of each vertebra and those predicted by the model was less than 5 mm at each vertebral level. This model may be useful in adolescent scoliotic patients with altered sagittal alignment to determine the magnitude of 3D deformity (compared with predicted normal values) and the completeness of 3D correction.

Retrospective review of prospectively collected data.To compare patients with operative cerebral palsy with and without an intrathecal baclofen pump (ITB) to determine whether an ITB increases the complexity of scoliosis surgery and/or increases the risk of wound complications.Options for baclofen pump placement include before, during, or after scoliosis surgery. There is some concern that prior placement of an ITB and catheter can further complicate cerebral palsy scoliosis surgery and increase the risk for wound complications.Prospectively collected cases from a multicenter cerebral palsy scoliosis database were reviewed for patients who underwent posterior spinal instrumentation and fusion for a major coronal deformity. These patients were then divided on the basis of whether they had ITB at the time of initial scoliosis surgery. The 2 groups were compared to determine differences in demographics, operative parameters, radiographical outcomes, and rates of wound complications.Of 187 patients identified, 32 had an ITB previously placed (ITB group) and 155 did not (non-ITB group). Both groups were similar in regard to age, sex, Gross Motor Function Classification Scale score, and preoperative Cobb magnitude. When comparing operative parameters, there were no differences in the total operating room time (ITB = 375 ± 127 min, non-ITB = 423 ± 178 min; P = 0.149) or total estimated blood loss (ITB = 2323 ± 1489 mL, non-ITB = 2081 ± 1572 mL; P = 0.424). Postoperatively, the 2 groups had similar correction rates (71% vs. 67%, P = 0.303). As for perioperative wound complications, there were no differences in rates (P = 0.546) between the ITB (16%) and non-ITB group (15%).Although it may be inconvenient for the surgeon, ITBs do not increase the complexity of surgery or the risk for wound complications. When counseling patients and their caregivers on the timing of pump placement, it does not seem to compromise the care of the patient if the baclofen pump is placed first. Further study is needed to evaluate the safety of pump placement during or after scoliosis surgery.4.

Background: Our goal was to analyze the relationship between patient size and the proportion of blood volume lost during spinal arthrodesis in patients with a diagnosis of adolescent idiopathic scoliosis, Scheuermann kyphosis, or cerebral palsy. We hypothesized that smaller patients (those with less blood volume) lose a greater proportion of circulating total blood volume during surgery. Methods: We reviewed a large, multicenter database, identifying patients with adolescent idiopathic scoliosis (1832), Scheuermann kyphosis (106), or cerebral palsy (196) who had undergone posterior spinal arthrodesis for spinal deformity. Blood volume (estimated from body weight) was used as a measure of patient size. Our primary outcome was the proportion of total circulating blood volume lost (intraoperative blood loss/blood volume, expressed as a percentage). Results: On multivariate analysis, there was a negative relationship between intraoperative blood loss/blood volume and blood volume in patients with adolescent idiopathic scoliosis (coefficient, −5.8; p < 0.001), Scheuermann kyphosis (coefficient, −2.5; p < 0.001), or cerebral palsy (coefficient, −20.3; p < 0.001), indicating that, despite adjustment for all other factors, smaller patients lost a greater proportion of their blood volume. In patients with adolescent idiopathic scoliosis or Scheuermann kyphosis, multivariate analysis showed that intraoperative blood loss/blood volume also increased significantly when the patient was male and with a greater number of levels fused. Conclusions: There is an inverse relationship between the proportion of blood volume lost during deformity correction surgery and size in patients with adolescent idiopathic scoliosis, cerebral palsy, or Scheuermann kyphosis. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Three-dimensional (3D) spinal assessment requires transverse plane images in addition to the posteroanterior and lateral projections provided by traditional radiography. Computed tomography has allowed 3D spine visualization as serial transverse radiographic images are acquired. New biplanar slot scanners allow patients to stand during radiograph acquisition and provide superior quality images at lower radiation than traditional x-rays. The 3D measurements, which were never before attainable from planar radiographs, are semiautomatically calculated using commercial software. These images may be further processed to allow additional 3D analyses. In this article, historic and newer innovative approaches to 3D spine assessment of adolescent idiopathic scoliosis are presented.

Neuromuscular scoliosis is often treated with posterior spinal fusion, with or without anterior release, and either a same-day or staged, 2-day procedure. We retrospectively reviewed 222 patients from a prospectively collected, multi-center database of patients with cerebral palsy scoliosis with 2-year follow-up. Baseline characteristics, perioperative, radiographic, and HRQoL measures were compared in six sub-analyses: (1) staged versus same-day surgeries, (2) posterior-only fusion (PSF) versus anterior–posterior spinal fusion (APSF), (3) same-day versus staged PSF, (4) staged versus same-day APSF, (5) same-day PSF versus same-day APSF, (6) staged PSF versus staged APSF. Staged patients had larger curves and more pelvic obliquity, longer anesthesia and surgical times, longer hospital and ICU stays (p

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.

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 Retrospective review; literature comparison. Objectives To review the literature on the relationship between lumbar lordosis (LL) and pelvic incidence (PI) and evaluate this relationship in asymptomatic adolescents while testing the validity of previously reported adult correlation models between LL and PI in an adolescent population. Summary of Background Data Accurate understanding of the normal spinopelvic relationship is critical when considering surgical fusion of the lumbar spine. Many studies have reported relationships between pelvic measurements and LL in adult populations, but data in pediatric populations is lacking. Methods A literature search was performed to identify previously reported relationships between pelvic parameters and LL in adults and pediatric patients. A cohort of 125 asymptomatic adolescent patients evaluated at our institution was evenly split into two cohorts for model development and validation. Linear regression between LL and PI was performed. The resultant regression model was tested in the validation cohort along with previously reported formulae with LL as a function of PI. Mean absolute error (MAE) was calculated and compared between prior models and the newly developed adolescent model using analysis of variance and post-hoc testing. Results In our adolescent cohort (mean age: 13 ± 2), there was a strong correlation between PI and LL (r = 0.53). Regression analysis in the development cohort produced the following predictive model: LL = 0.66(PI) + 24.2. Testing in the validation cohort revealed a good correlation between predicted and actual LL (r = 0.51) and an MAE of 8.3. All but three previously reported models functioned with similar accuracy in the adolescent population, with only two methods having an MAE over 10. Conclusions The majority of previously published formulae for predicting LL as a function of PI developed in adults can be extrapolated to adolescent populations. These relationships are important in understanding how to surgically restore the sagittal alignment in adolescents with spinal deformity. Level of Evidence Level IV.

Retrospective analysis of spine and rods 3D shape in the 2 years after adolescent idiopathic scoliosis (AIS) posterior surgical instrumentation.To evaluate spine and rod shape 3D changes in the 2 years after AIS instrumentation with different rod materials.Postoperative loss of correction has been reported with modern segmental instrumentation. The postoperative 3D rod shape changes of different rod materials and their implication in postoperative loss of correction have never been studied.A total of 42 Lenke 1 AIS cases who underwent surgery all with pedicle screws and 5.5 mm rods of three different materials were retrospectively reviewed (14 cases for each of the three rod material subgroups: titanium, cobalt-chromium, stainless steel). 3D reconstructions of the spine were performed using biplanar radiographs preoperatively, 1-week postoperatively (1WPO), and 2 years follow-up (2YFU). Rods 3D shape also was reconstructed at 1WPO and 2YFU. The spine and rods shapes were analyzed and compared between time points.An average of 1.93 implant per vertebra was used. The main thoracic curve (61° ± 9°) was corrected on average by 75% (15° ± 6°, P 0.01) with no change at 2YFU (17° ± 7°, P = 0.14). The apical vertebral rotation (23° ± 7°) was corrected by 44% (13° ± 9°, P 0.01) with no change at 2YFU (14° ± 9°, P = 0.64). The thoracic kyphosis (24° ± 12°) remained unchanged (P = 0.78). The orientation of the planes of maximal curvature with respect to the sagittal plane of the main thoracic curve (39° ± 15°) and of the rods (concave: 28° ± 23°, convex: 12° ± 10°) at 1WPO was unchanged at 2YFU (all P 0.05). Rod curvature and deflection also remained unchanged (all P 0.05). 3D curve correction was maintained in the 2YFU for all rod materials subgroups (all P 0.05). The lumbar lordosis changed from 1WPO (47° ± 8°) to 2YFU (56° ± 9°, P 0.01). At preoperatively, 57% of the cases had a balanced posture (sacral vertical axis/sacral femoral distance ≤0.5 and sacral vertical axis ≤0), 33% at 1WPO and 79% at 2YFU.There was no significant 3D shape change of the instrumented thoracic spine or of the rods postoperatively for any of the segmental pedicle screw constructs with titanium, stainless steel, and cobalt-chromium rods. Patients overall unbalanced sagittal posture documented immediately after surgery came back to balanced 2 years after surgery.3.

BACKGROUND Loss of thoracic kyphosis has been associated with thoracic idiopathic scoliosis. Modern 3-dimensional (3D) imaging systems allow more accurate characterization of the scoliotic deformity than traditional radiographs. In this study, we utilized 3D calculations to characterize the association between increasing scoliosis severity and changes in the sagittal and axial planes. METHODS Patients evaluated in a scoliosis clinic and determined to have either a normal spine or idiopathic scoliosis were included in the analysis. All underwent upright, biplanar radiography with 3D reconstructions. Two-dimensional (2D) measurements of the magnitude of the thoracic major curve and the thoracic kyphosis were recorded. Image processing and MATLAB analysis were utilized to produce a 3D calculation of thoracic kyphosis and apical vertebral axial rotation. Regression analysis was performed to determine the correlation of 2D kyphosis, 3D kyphosis, and apical axial rotation with the magnitude of the thoracic major curve. RESULTS The 442 patients for whom 2D and 3D data were collected had a main thoracic curve magnitude ranging from 1° to 118°. Linear regression analysis of the 2D and 3D T5-T12 kyphosis versus main thoracic curve magnitude yielded significant models (p < 0.05). The 2D model had a minimally negative slope (-0.07), a small R value (0.02), and a poor correlation coefficient (-0.14). In contrast, the 3D model had a strongly negative slope (-0.54), a high R value (0.56), and a strong correlation coefficient (-0.75). Curve magnitude also had a strong correlation with loss of 3D T1-T12 kyphosis and increasing apical axial rotation. CONCLUSIONS Segmentally calculated 3D thoracic kyphosis had a strongly negative correlation with the magnitude of the main thoracic curve. With near uniformity, 3D thoracic kyphosis progressively decreased as scoliosis magnitude increased, at a rate of more than half the increase in the main thoracic curve magnitude. Analysis confirmed a surprisingly strong correlation between scoliosis severity and loss of 3D kyphosis that was absent in the 2D analysis. A similarly strong correlation between curve magnitude and apical axial rotation was evident. These findings lend further credence to the concept that scoliosis progresses in the coronal, sagittal, and axial planes simultaneously. CLINICAL RELEVANCE The findings of this study suggest that 3D assessment is critical for adequate characterization of the multiplanar deformity of idiopathic scoliosis and deformity in the sagittal plane is linked to deformity in the coronal plane. Increasing severity of coronal plane curvature is associated with a progressive loss of thoracic kyphosis that should be anticipated so that the appropriate intraoperative techniques for correction of idiopathic scoliosis can be applied in all 3 planes.

Delphi process with multiple iterative rounds using a nominal group technique.The aim of this study was to use expert opinion to achieve consensus on various aspects of postoperative care following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).Significant variability exists in postoperative care following PSF for AIS, despite a relatively healthy patient population and continuously improving operative techniques. Current practice appears based either on lesser quality studies or the perpetuation of long-standing protocols.An expert panel composed of 26 pediatric spine surgeons was selected. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were presented with a detailed literature review and asked to voice opinion collectively during three rounds of voting (one electronic and two face-to-face). Agreement80% was considered consensus. Interventions without consensus were discussed and revised, if feasible.Consensus was reached to support 19 best practice guideline (BPG) measures for postoperative care addressing non-ICU admission, perioperative pain control, dietary management, physical therapy, postoperative radiographs, surgical bandage management, and indications for discharge.We present a consensus-based BPG consisting of 19 recommendations for the postoperative management of patients following PSF for AIS. This can serve to reduce variability in practice in this area, help develop hospital specific protocols, and guide future research.5.

Background Recent biomechanical studies have evaluated the stability of various pin constructs for supracondylar humerus fractures, but limited data exist evaluating these constructs with clinical outcomes. The goal of this study was to review the surgical management of Gartland type II and III supracondylar fractures to see whether certain pin configurations increase the likelihood of loss of reduction (LOR). Methods A total of 192 patients treated with a displaced supracondylar fracture were evaluated. LOR was defined as a change >10 degrees in either plane from its intraoperative reduction. Fracture classification, comminution, and location were documented. Intraoperative films were assessed for number of pins, location of pins both medial and lateral, bicortical purchase, pin spread at the fracture site, and pin divergence. Results Ninety-four patients had type II fractures, and 98 had type III fractures. The average patient age was 5.7±2.3 years. Extension-type injuries represented 98% of fractures. LOR was noted in 4.2% of patients. Age (P=0.48) and sex (P=0.61) were not associated with LOR. Fracture characteristics including type (P=0.85), comminution (P=0.99), and location (P=0.88) were not associated with LOR. Fractures treated with lateral-entry pins only or with 2 pins were no more likely to lose reduction (P=0.88 and 0.91). Pin spread at the fracture site was associated with LOR with less spread increasing the likelihood of failure (P=0.02). Fractures that lost reduction had an average pin spread of 9.7 mm [95% confidence interval (CI), 6.3-13.2) or 28% (95% CI, 26-31) of the humerus width compared with 13.7 mm (95% CI, 13-14.4) or 36% (95% CI, 13-60) of the humerus width for those that remained aligned. Conclusions LOR after percutaneous fixation of supracondylar fractures occurs relatively infrequently at a rate of 4.2%. This study suggests that pin spread is an important factor associated with preventing LOR with a goal of pin spacing at least 13 mm or 1/3 the width of the humerus at the level of the fracture. Level of evidence Retrospective study; level II.

Retrospective study.To examine the characteristics of Lenke type 1 curves based on the level of the apical vertebra.The Lenke classification is the most used system for adolescent idiopathic scoliosis, with approximately 50% of the curves falling into the Lenke 1 curve type category.A total of 611 Lenke 1 curves in a prospectively collected multicenter adolescent idiopathic scoliosis study were analyzed. Minimum follow-up was ≥ 2 years. Curves were subdivided into 3 groups according to their apex: the typical Lenke 1 curve group included apices from T7/8 to T10 (511 patients), the proximal group included apices from T4 to T7 (45 patients), and the distal group included apices from T10/11 to T11/12 (50 patients). Preoperative and postoperative radiographic and clinical outcomes were compared among the 3 groups.The proximal and distal groups included significantly more left thoracic curves (proximal: 29%; typical: 1.8%; distal: 19%; p.01). Flexibility of the main thoracic curve was significantly different among the 3 groups (proximal: 32% ± 17%; typical: 46% ± 18%; distal: 57% ± 18%; p.001). The distal group included significantly more "A" lumbar modifiers (proximal: 29%; typical: 53%; distal: 96%; p.01) and had curves characteristics similar to King type 4 curves (L4 tilted to the right: Lenke 1AR). The average lowest instrumented vertebra was significantly lower in the distal group (proximal: T12; typical: L1; distal: L2; p.01). The proximal group had significantly greater thoracic kyphosis (proximal: 30° ± 18°; typical: 20° ± 13°, distal: 20° ± 10°; p.001) and more fusion segments (proximal: 10; typical: 9; distal: 9; p.03).Curves categorized as Lenke 1 curves were less homogeneous than expected. Using only the Lenke type 1 designation to define a study population may introduce unintended bias to the study design.

Study Design Retrospective review of prospectively collected data. Objectives To evaluate blood loss associated with posterior spinal fusion in adolescent idiopathic scoliosis patients performed with and without the use of an ultrasonic bone scalpel (UBS). Summary of Background Information After using an ultrasonic-powered bone-cutting device with recent Food and Drug Administration approval for use in the spine, the authors perceived a reduction in bone bleeding associated with the cut boney surfaces. Methods The first 20 patients with adolescent idiopathic scoliosis who underwent posterior spinal fusion using the UBS by a single surgeon were compared with 2 control groups: 1) the 20 most recent prior cases of the same surgeon before beginning use of the bone scalpel; and 2) 20 cases of the same surgeon before using the bone scalpel matched based on Cobb angle magnitudes. Both cases and controls had Ponte-type posterior apical releases; none had an anterior procedure. Patient demographic and surgical data were analyzed using analysis of variance (p Results Preoperatively, the UBS group was similar to both control groups in terms of primary and secondary curve magnitudes, number of levels fused, number of levels with Ponte release, antifibrinolytic use, and patient age (p > .05). The UBS group had significantly less estimated blood loss (EBL) (550 ± 359 mL), Cell Saver blood transfused (94 ± 146 mL), and EBL per level fused (48 ± 30 mL) than the most recent controls (EBL: 799 ± 376 mL; Cell Saver: 184 ± 122 mL; EBL/level fused: 72 ± 28 mL) and Cobb-matched controls (EBL: 886 ± 383 mL; Cell Saver: 198 ± 115 mL; EBL/level fused: 78 ± 30 mL) (p Conclusions The use of an ultrasonic bone scalpel to perform the bone cuts associated with facetectomies and apical Ponte-type posterior releases resulted in significantly less bleeding compared with cuts made with standard osteotomes and rongeurs, limiting overall blood loss by 30% to 40%.

Background: Although the efficacy of bracing for adolescent idiopathic scoliosis has been debated, recent evidence indicates a strong dose-response effect with respect to preventing curve progression of ≥6°. The purpose of this study was to investigate whether bracing, prescribed with use of current criteria, prevents surgery and how many patients must be treated with bracing to prevent one surgery. Methods: Of 126 patients with adolescent idiopathic scoliosis measuring between 25° and 45° and with a Risser sign of ≤2, 100 completed a prospective study in which they were managed with a Boston brace fitted with a heat sensor that measured brace wear. Noncompliant patients were compared both with highly compliant patients and with the entire cohort, with the end point of progression to surgery. The absolute risk reduction (ARR) was calculated and used to calculate the number needed to treat (NNT) to prevent one surgery. Results: Bracing was not effective in preventing surgery unless the patient was highly compliant with brace wear. For patients who were considered to be highly compliant, based on the hours per day that they wore the brace, the NNT was 3 (95% confidence interval [CI], 2 to 7). Conclusions: Within the limitations of a nonrandomized prospective study design, bracing for adolescent idiopathic scoliosis was found to substantially decrease the risk of curve progression to a range requiring surgery when patients were highly compliant with brace wear. Since many patients avoid surgery without wearing a brace, current indications appear to lead to marked overtreatment. Bracing appears to decrease the risk of curve progression to a magnitude requiring surgery, but current bracing indications include many curves that would not have progressed to a magnitude requiring surgery even if the patient had not worn the brace, and overall compliance with brace wear is low. Identifying these lower-risk patients and improving the compliance of those likely to have curve progression could substantially improve bracing results. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Study Design. Combinations of metal implants (stainless steel (SS), titanium (Ti), and cobalt chrome (CC)) were placed in porcine spines. After 12 months, tissue response and implant corrosion were compared between mixed and single metal junctions.Objective.Model development and an attempt to determine any detriment of combining different metals in posterior spinal instrumentation.Methods. Yucatan mini-pigs underwent instrumentation over five unfused lumbar levels. A SS rod and a Ti rod were secured with Ti and SS pedicle screws, SS and Ti crosslinks, SS and CC sublaminar wires, and Ti sublaminar cable. The resulting 4 SS/SS, 3 Ti/Ti, and 11 connections between dissimilar metals per animal were studied after 12 months using radiographs, gross observation, and histology (foreign body reaction (FBR), metal particle count, and inflammation analyzed).Results. Two animals had constructs in place for 12 months with no complications. Histology of tissue over SS/SS connections demonstrated 11.1 ± 7.6 FBR cells, 2.1 ± 1.7 metal particles, and moderate to extensive inflammation. Ti/Ti tissue showed 6.3 ± 3.8 FBR cells, 5.2 ± 6.7 particles, and no to extensive inflammation (83% extensive). Tissue over mixed components had 14.1 ± 12.6 FBR cells and 13.4 ± 27.8 particles. Samples surrounding wires/cables versus other combinations demonstrated FBR (12.4 ± 13.5 versus 12.0 ± 9.6 cells,P= 0.96), particles (19.8 ± 32.6 versus 4.3 ± 12.7,P= 0.24), and inflammation (50% versus 75% extensive,P= 0.12).Conclusions. A nonfusion model was developed to study corrosion and analyze biological responses. Although no statistical differences were found in overlying tissue response to single versus mixed metal combinations, galvanic corrosion between differing metals is not ruled out. This pilot study supports further investigation to answer concerns when mixing metals in spinal constructs.

A multicenter, prospective study of consecutively enrolled surgical patients with Scheuermann kyphosis (SK).To evaluate the impact of SK on preoperative pulmonary function and to determine which radiographic criteria may help predict pulmonary impairment.Pulmonary function in SK is not well studied. Previous studies on adolescent idiopathic scoliosis revealed that certain factors, including the magnitude of the thoracic curve and the number of vertebrae involved, significantly affect pulmonary function.A total of 64 patients with SK were evaluated. Absolute and percent predicted forced vital capacity (FVC), forced expiratory volume in 1 second, and total lung capacity were collected preoperatively. Subjects were divided according to kyphosis apex (thoracic or thoracolumbar) and kyphosis magnitude groups, and compared. Correlation analysis was performed to evaluate the impact of gender, age, kyphosis magnitude, and apex on pulmonary function. American Thoracic Society guidelines were used to classify patients according to the severity of pulmonary impairment.Mean age was 16 years (range 13-24 years), with 42 males. The percent predicted forced vital capacity was 95.8%, percent forced expiratory volume in 1 second was 92.5%, and percent total lung capacity was 106.2%. The percent predicted FVC differed significantly between the 71°-80° and 81°-90° groups (105% vs. 83%, respectively; p = .016) and the 71°-80° and greater than 90° groups (105% vs. 73%, respectively; p = .009). For percent predicted TLC, patients with greater than 90° had significantly lower average values than those in the 71°-80° range (79% vs. 115%, respectively; p = .016). Greatest kyphosis showed a fairly weak (r = -.24; p .10) but significant correlation with percent predicted FVC. The percentage of patients with moderate to severe impairment (4%) was lowest in the 71°-80° range, which increased with increasing ranges of kyphosis magnitude: 81°-90° (11%) and greater than 90° (50%).

Background: As more adults undergo surgical fixation of clavicle fractures, there is a renewed interest in the management of adolescent fractures. While the medial clavicular physis does not fuse until 23-25 years, literature reports limited residual growth of the clavicle during adolescence. The aim of this study is to evaluate the longitudinal clavicular growth on serial thoracic radiographs in adolescents and young adults. Methods: A review was performed on two cohorts of patients: 1. Scheuermann’s Kyphosis patients and 2. A prospectively collected adolescent idiopathic scoliosis registry. Patients, 10-25yrs old, were included if they had serial thoracic radiographs over 5 years with at least 3 serial radiographs capturing the entire length of at least one clavicle. Radiographs were excluded for malrotation. Known surgical implant dimensions were utilized to normalize measurements. The measurements were organized into 3 groups: 12-15yrs, 16-19yrs and =20yrs. The overall growth, the growth per year and the growth percentage per year were calculated for each clavicle. Results: Fifty-seven patients met the inclusion criteria (22 males and 35 female). For male patients, age 12-15yrs, the clavicular growth was 5.2 mm/yr and 4.2%/yr, age 16-19yrs: 3.0 mm/yr or 2.3%/yr and for ages 20-25yrs: 1.7mm/yr or 1.4%/yr. For female patients, 12-15yrs, there was 4.6mm/yr and 3.9%/yr, 16-19yrs: 2.0mm/yr or 1.6%/yr, and for age 20-25yrs: 0.8mm/yr or 0.6%/yr. We were unable to detect an age of terminal growth for either gender because residual growth was still ongoing in most patients of the oldest group. Conclusion/Significance: This study suggests that there is continued growth potential of the clavicle after the age of 18yrs and as such more remodeling potential during adolescence than may have otherwise been appreciated. It is unclear how this data will influence surgical decision making in clavicle fracture treatment.

Anterior vertebral body tethering to effect scoliosis correction in a growing spine has been shown to work with varying degrees of success. This report describes the mid-term results of this technique using a new device composed of a braided ultra-high molecular weight polyethylene (UHMWPE) cord anchored to bone screws applied without segmental compression. Methods This was a single-center prospective observational study of an investigational device. Five female patients aged 9 to 12 years with thoracic scoliosis underwent thoracoscopic insertion of the UHMWPE tether. Radiographs and magnetic resonance imaging (MRI) were performed, and the Scoliosis Research Society (SRS)-22 was administered, preoperatively and at regular intervals after surgery, with a minimum of 4 years of follow-up. Results All tethering devices spanning the end vertebrae (range, 7 to 8 vertebrae) were implanted successfully. Mean blood loss was 136 mL, and the mean operative time was 205 minutes. The mean preoperative main thoracic Cobb angle was 40.1°. Curve correction of the tethered segment ranged from 0% to 133.3% at 4 years. We observed greater correction in 2 patients with open triradiate cartilage (TRC), achieving full scoliosis correction at 2 years and 121.5% at 4 years. MRI showed improvement in periapical disc wedging morphology and 55% improvement of rotation at 3 years. There were 20 adverse events, of which 16 were mild and 4 were moderate in severity. The 4 moderate events of pneumonia, distal decompensation, curve progression, and overcorrection occurred in 3 patients, 2 of whom required fusion. Conclusions Anterior vertebral body tethering resulted in scoliosis deformity correction in the coronal and axial planes, with preservation of curve flexibility. Actual correction by growth modulation was noted only in patients with open TRC, whereas curve stabilization was noted in patients with closed TRC. Overcorrection, curve progression, and distal decompensation are problems with this technique. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Study design Prospective cohort. Objective To (1) calculate the rate of deep wound infection in children with cerebral palsy (CP) after spinal fusion surgery; (2) identify factors (patient, laboratory, and surgical) associated with deep wound infection development; and (3) report causative organisms. Summary of background data Wound infection after spine fusion for CP is more common than after spine fusion for most other diagnoses. Methods We prospectively gathered data on 204 consecutive pediatric patients with CP who underwent surgery at 7 institutions. Univariate and multivariate regression analysis was performed to analyze patient, laboratory, and surgical characteristics to identify factors that were significantly associated with infection development. Statistical significance was set at a value of P less than 0.05. Results Deep wound infection developed in 13 (6.4%) children. The mean time to infection development was 34.2 ± 60.2 days. On univariate analysis, older age, larger curve size, presence of gastrostomy/gastrojejunostomy tube, higher preoperative serum white blood cell count, and longer operative time were significantly associated with deep wound infection. On multivariate analysis, only the presence of a gastrostomy/gastrojejunostomy tube remained significant (1.9-fold risk of deep wound infection compared with patients without tubes). Escherichia coli was the most common organism cultured from the wound sites (5 patients). Other infective agents were: Pseudomonas aeruginosa (2), methicillin-susceptible Staphylococcus aureus (1), Proteus mirabilis (1), and polymicrobial organisms (4). Conclusion Deep wound infection occurred in 6.4% of children with CP after spinal fusion. The presence of a gastrostomy/gastrojejunostomy tube was a significant predictor of infection. Gram-negative organisms were the most common causative agents. Surgeons should be cognizant of these factors when treating children with CP and may consider Gram-negative antibiotic prophylaxis.

Multicenter review of prospectively collected data.To determine the frequency and outcome of intraoperative neuromonitoring (IONM) alerts during surgical correction of idiopathic scoliosis (IS).Providing corrective action after identifying IONM events will ideally prevent neurologic complication.Prospectively gathered clinical data and IONM reports recorded during spinal surgery for IS were analyzed. Patients were divided into 2 groups: those with clear IONM changes and those with no IONM events. A neuromonitoring event was defined as a change from baseline transcranial motor evoked potentials or somatosensory evoked potentials in the lower extremities. The risk, rate, cause, and outcome of each neuromonitoring alert were assessed.A total of 579 IS cases were analyzed. Twenty-one cases (3.6%) had an IONM event. In 18 of the 21 cases (86%), the potentials returned to baseline after corrective action. Of the 3 with remaining abnormalities, 2 (0.3%) awoke with deficits (1 unilateral weakness and 1 unilateral sensory change). In 12 cases, the changes were thought to result from low blood pressure; all responded to elevation of the mean arterial pressure. Five changes were associated with misplaced screws (in 4, the monitoring returned after removal or redirection; all 5 were normal postoperatively). Traction was the cause in 2 cases, both of which responded to reduction in traction. In 4 cases, the cause was unclear. Two remained abnormal and awoke with neurologic deficit. There were no postoperative neurologic deficits in any cases with normal neuromonitoring. Surgical time (416 vs. 291 minutes; p.001) and percent estimated blood volume lost (64% ± 47% vs. 31% ± 26%; p.001) were significantly increased in cases in which intraoperative events were observed.The rate of neuromonitoring changes was 3.6% when using both transcranial motor evoked potential and somatosensory evoked potential monitoring. When a cause was identified and corrective action was taken, there were no postoperative neurologic deficits.

Study Design Multicenter review of prospectively collected data. Objectives To identify the frequency of an opposite high shoulder in Lenke 5 patients and evaluate factors that influence preoperative and postoperative shoulder balance. Summary of Background Data A high left shoulder is an indication to extend the fusion proximally in a right thoracic curve. Some apply a similar rule to high right shoulders in patients with left thoracolumbar/lumbar curves. Methods A prospective multicenter adolescent idiopathic scoliosis database was queried for patients with Lenke 5 curves and minimum 2-year follow-up. Preoperative and postoperative shoulder height differences were recorded and categorized by the opposite shoulder (right shoulder in a left thoracolumbar curve) as high (greater than 1 cm), level (0–1 cm), and low (less than 1 cm). Preoperative and postoperative radiographic variables and Scoliosis Research Society questionnaire scores were evaluated. Results Of the 104 patients identified, 37% had level shoulders and 53% had a high opposite shoulder. A high shoulder was associated with a greater mean thoracic Cobb (31°) than a level (24°) or low shoulder (26°) (p = .008). Postoperatively, 64% of patients had level shoulders (less than 1 cm); 93% had a shoulder difference less than 2 cm. Preoperative lumbar Cobb was a significant predictor of postoperative shoulder height (p = .051). A slightly greater proportion of preoperative high shoulders (36%) had a nonselective fusion than those with level (27%) or low (9%) shoulders. Among the 29 patients with a preoperative moderate or significant high shoulder (greater than 2 cm), 3 continued to have a high shoulder greater than 2 cm that was not influenced by fusing the thoracic spine. There were no significant differences in preoperative or postoperative Scoliosis Research Society scores based on shoulder height (p > .05). Conclusions Half of all Lenke 5 curves have a high opposite shoulder that is influenced by the size of the compensatory thoracic curve. Postoperatively, most patients had level shoulders. Inclusion of the thoracic spine did not influence postoperative shoulder balance.

Review of a prospective database registry of surgical patients with adolescent idiopathic scoliosis (AIS).The purpose of this study was to examine the prevalence of postoperative pain and its impact on patient-reported postoperative outcomes using the Scoliosis Research Society (SRS)-22 outcomes questionnaire.Although reportedly rare, postoperative pain can be a devastating situation for the patient with AIS. Most recent studies examining outcomes in AIS surgical treatment use the SRS Pain domain score to assess pain in this population.A prospectively enrolled multicenter database was queried. Patients with minimum 2-year follow-up and 2-year SRS scores were included. Postoperative pain after the acute phase of recovery when reported by the patient to the treating surgeon/clinical team in follow-up is recorded as a complication in the database. Patients included in this series were grouped as either reporting pain or not to the surgeon/clinical team postoperatively. Pre- and postoperative SRS scores were then compared between these 2 groups using analysis of variance (P0.05).Five hundred and eighty-four patients meeting the inclusion criteria were identified. Sixty-one (11%) reported pain at sometime between 2 weeks and 2 years postoperatively. Thirteen were within the 6-month postoperative period. Of the remaining 48 reporting pain between 6 and 24 months postoperatively, 41 (7% of the total cohort) had no obvious cause for their pain. More than half of these patients (26/41) were referred for further treatment (physical therapy, referral to pain specialist, further imaging). These 41 patients had significantly decreased 2-year SRS scores in the domains of Pain, Self-image, Mental health, and Total score (P0.05). The patients with postoperative pain were found to have significantly lower preoperative Pain domain scores (P0.001), indicative of greater pain preoperatively, yet there were no other domains effected preoperatively. For this group the pre- to postoperative SRS pain scores did not show significant change (P0.05).Unexplained pain after the 6-month postoperative period occurred in 7% of the cohort. The results indicate that patients reporting pain to their surgeons/clinical team postoperatively have lower pain scores on a subjective outcome instrument thus further validating the SRS-22 outcome tool. This reported pain seems to be associated with decreases in other SRS-22 domains. Interestingly, these patients also have lower preoperative pain scores than those without postoperative pain. Study into causes of pain in AIS and whether preoperative education and expectations targeted at this population would positively impact outcomes is warranted, especially because on average patients after AIS surgery have less pain.3.

Loss of coronal correction has been reported in the presence of a solid posterior fusion mass in patients who are skeletally immature. Significant increases in postoperative coronal curvature are typically attributed to the presence of pseudarthrosis, loss of instrumentation fixation, or adding-on. We evaluated the clinical and radiographic factors associated with a loss of correction that was not attributed to these etiologies as well as the impact of pedicle screw fixation on loss of correction.A prospective, longitudinal study database was retrospectively queried for patients with at least 2 years of follow-up who underwent surgery for adolescent idiopathic scoliosis. Loss of correction was defined (1) clinically, as a5 degree increase in the inclinometer reading at any time interval after surgery, excluding preoperative values; or (2) radiographically, as an increase of ≥ 10 degrees in the coronal Cobb angle of an instrumented curve. Patients with pseudarthrosis, adding-on, or loss of fixation were excluded.Ninety-three of 800 patients (11.6%) had loss of deformity correction. Twenty-one patients (2.5%) had5 degrees of inclinometer change and 76 patients (9.5%) had ≥10 degrees of Cobb change, with a mean loss of 10.85±4.2 degrees. When comparing pedicle screw constructs only, 10% of patients developed loss of correction as opposed to 20% of the patients with hybrid constructs (P=0.036). Factors associated with loss of correction were: age, hybrid construct, magnitude of thoracic curve, thoracic apical translation, and T1 tilt angle.This study reports a high percentage of loss of coronal correction (12%) after 2 years of follow-up that was not associated with infection, adding-on, or apparent pseudarthrosis. Larger magnitude thoracic curves with apical deviation and hybrid constructs were associated with an increased likelihood of loss of curve correction where use of pedicle screw fixation seems to decrease its incidence.III.

STUDY DESIGN: A review of a multicenter, prospective registry of patients surgically treated for adolescent idiopathic scoliosis. OBJECTIVE: To investigate preoperative and postoperative distribution of coronal decompensation in Lenke 1C curves and to determine whether a selective thoracic fusion (STF) affects the results of coronal decompensation. SUMMARY OF BACKGROUND DATA: Numerous causes of postoperative coronal decompensation in Lenke 1C curves have been reported; however, there are few reports focusing on preoperative decompensation and its relation to postoperative decompensation in Lenke 1C curves. METHODS: Patients with Lenke 1C prospectively collected from a multicenter study were analyzed. Preoperatively, patients were grouped as decompensated (C7-CSVL > 2 cm) or balanced (C7-CSVL within 2 cm, where CSVL is central sacral vertical line). Preoperative distribution and factors for postoperative coronal decompensation were investigated. RESULTS: Seventy-one patients (53 STF, 18 nonselective fusions) were included. Preoperatively, coronal balance was skewed to the left (-17 ± 13 mm). Of the 21 STF decompensated to the left preoperatively, 12 (57%) remained to the left at 2 years. Postoperative thoracic correction was significantly better in those balanced postoperatively (57%) compared with those who remained decompensated (46%; P < 0.05). There were 32 STF patients who were balanced preoperatively, with 10 of these (31%) decompensated to the left at 2-year follow-up. This rate (31%) was significantly less than the group that was decompensated preoperatively (57%, P = 0.04). In the nonselective fusion group, 16 out of 18 patients (89%) were balanced at 2-year follow-up, independent of preoperative balance. CONCLUSION: Patients with Lenke 1C tended to be decompensated to the left preoperatively. In those decompensated preoperatively who underwent a STF, the majority remained greater than 2 cm to the left at 2-year follow-up. Patients with both thoracic and lumbar curves fused had better coronal balance at 2 years than selectively treated patients. Although not a contraindication to performing a selective fusion, treating surgeons should be prepared for modest coronal decompensation in 40% of patients with Lenke 1C treated with selective fusion of the thoracic curve alone. LEVEL OF EVIDENCE: 3.

Comparative in vitro, biomechanical study.Compare the effect of rod curvature and material properties on rod flattening and correctional forces.Traditional methods of correction for large progressive deformities involve 3-dimensional correction, performed with an attempt to reach a balanced correction in all planes, spinal instrumentation, and fusion. Increasing attention to the transverse plane correction has developed after the introduction of segmental pedicle screws into the treatment of idiopathic scoliosis. Approximation of the spine (pedicle screws or hooks) to the rods remains the heart of many deformity procedures. Therefore, it is crucial that the instrumentation used provide and maintain the initial correction of the spinal deformity while minimizing potential intraoperative failures.Two experiments were performed using 80 rods made from 4 different materials namely: stainless steel (SS), titanium (Ti), cobalt chromium (CoCr), and ultrahigh strength stainless steel (UHSS). Half of the rods were contoured to 20 degrees, whereas the reaming contoured to 30 degrees. Half of the rods were approximated to a synthetic spine models to measure the flattening of the rods when approximated to highly rigid spine. The other half was used to measure the correctional forces produced by each rod type and curvature.For the 20-degree pre-bend rods, Ti was the best in maintaining its original shape followed by UHSS, SS, and CoCr of 90%, 77%, 62.5%, and 54.4%, respectively. The 30-degree pre-bend showed exactly a similar trend with 80.7% for Ti, 71% for UHSS, 54.6% for SS, and 48.1% for the CoCr rods. For 30-degree pre-bend CoCr and UHSS rods, the intraoperative reduction forces were almost 42% and 10% higher than the Ti and SS rods, respectively. The correctional force produced by the Ti 30-degree pre-bend rod was approximately 67% that of a CoCr and UHSS rods.CoCr and UHSS rods have the ability to produce the highest correction forces, however, both can plastically deform in a very rigid curves. Therefore, it is critical to have sense of the quality of the bone fixation as well as the curve flexibility when selecting for appropriate rod size material and contouring the rod to the desired shape.

STUDY DESIGN: Multicenter; review of prospectively collected data. OBJECTIVE: To determine the risks and potential benefits of nonselective versus selective fusion in a matched set of patients with Lenke 5 curves. SUMMARY OF BACKGROUND DATA: The Lenke classification suggests a limited thoracolumbar/lumbar fusion for type 5 curves, although many experienced adolescent idiopathic scoliosis surgeons, at times, include a fusion of the thoracic curve. METHODS.: Prospectively collected cases from a multicenter database were analyzed. Patients with Lenke type 5 scoliosis curves were divided into 2 groups: 109 selective or short (only thoracolumbar/lumbar curve fused), and 41 nonselective or long (both thoracolumbar/lumbar and thoracic curves fused). Patients were then matched on the basis of the preoperative radiographical and clinical measures. Two-year postoperative radiographical and clinical outcomes were compared, using analysis of variance, with Bonferroni correction (P < 0.008). RESULTS: Twenty-nine matched pairs (58 patients) with Lenke 5 curves were identified. There were no preoperative differences between groups in age, thoracic or lumbar Cobb angle, curve flexibility, thoracic kyphosis, clinical trunk flexibility, or Scoliosis Research Society outcomes questionnaire scores. Postoperatively, patients in the nonselective group exhibited greater coronal correction for thoracic (residual Cobb; 22° vs. 12°) and lumbar curves (residual Cobb; 19° vs. 13°). However, the longer fusions had significantly less thoracic kyphosis (27° vs. 18°), truncal side bending (14 vs. 10 cm), and rotational flexibility (53° vs. 42°). There was no difference in clinical balance or Scoliosis Research Society questionnaire, version 22, scores. CONCLUSION: Adolescent idiopathic scoliosis surgeons attempt to achieve balanced correction with the fewest motion segments fused. Our data suggest that fusion of the thoracic curve in primary thoracolumbar scoliosis may improve coronal correction, but at the cost of decreased thoracic kyphosis and clinical flexibility 2 years postoperatively.

Background: The Gross Motor Function Classification System (GMFCS) of cerebral palsy categorizes patients by mobility. Patients at GMFCS level 5 are considered the most disabled and at high risk of hip and spine problems, yet they represent a wide spectrum of function. Our aim was to subclassify patients at GMFCS level 5 who underwent spinal arthrodesis on the basis of central neuromotor impairments and to assess whether subclassification predicted postoperative complications and changes in health-related quality of life. Methods: Using a prospective cerebral palsy registry, we identified 199 patients at GMFCS level 5 who underwent spinal arthrodesis from 2008 to 2013. Patients were assigned to subgroups according to preoperative central neuromotor impairments: the presence of a gastrostomy tube, a tracheostomy, history of seizures, and nonverbal status. Nine percent of patients had 0 impairments (GMFCS level 5.0), 14% had 1 impairment (level 5.1), 26% had 2 impairments (level 5.2), and 51% had 3 or 4 impairments (level 5.3). The Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaire was used for preoperative and postoperative health-related quality-of-life outcome assessments, and major complications were recorded. Results: The rate of major complications increased significantly with higher GMFCS level-5 subtype (p = 0.002), with 12% at level 5.0, 21% at level 5.1, 31% at level 5.2, and 49% at level 5.3. Five of the 7 patients who died within the follow-up period were at level 5.3. No significant differences were found among subgroups with respect to the magnitude of correction of the major coronal curve or pelvic obliquity. Preoperative and final follow-up CPCHILD total scores decreased significantly from GMFCS level 5.0 to level 5.3. However, no significant differences were found by subgroup with respect to the magnitude of improvement in CPCHILD total scores from the preoperative to the final follow-up evaluation (p = 0.597). Conclusions: Stratification based on central neuromotor impairments can help to identify patients with cerebral palsy at GMFCS level 5 who are at higher risk for developing complications after spinal arthrodesis. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

STUDY DESIGN This was a retrospective study of patients with Chiari I (CM I) and Chiari II (CM II) malformations, tethered cord syndrome, and syringomyelia examining the effect of neurosurgery on scoliosis. OBJECTIVE The aim of this study was to determine the factors affecting spinal deformity progression in patients with diseases of the neural axis following neurosurgical management. SUMMARY OF BACKGROUND DATA There have been attempts to explain which factors influence the spinal deformity in diseases of the neural axis with varying results. Debate still exists as to the effectiveness of neurosurgery in curve stabilization. METHODS The medical records for patients treated over the past 10 years were reviewed. The spinal deformity surgical group consisted of patients who received surgery or progressed to surgical range (50°) and the nonsurgical group those who did not undergo fusion. RESULTS Fifteen patients (eight females and seven males) with scoliosis who underwent neurosurgical intervention were identified. Ten had tethered cord, six CM II, four CM I, and 11 syrinx. Average age at the time of neurosurgery was 7 ± 4 years (range 0.7-14 yrs). Following neurosurgery, no patients experienced improvement in their curves (defined as >10° decrease in Cobb angle), eight patients experienced stabilization ( 10° increase). The group that went on to spinal deformity surgery possessed larger curves before neurosurgery (mean 42°, range 20°-63°) than the nonsurgical group (19°, range 15°-26°; P = 0.004). CM II patients had the greatest magnitude of curve progression, mean of 49°, compared with patients with CM I (6°) or tether cord without CM I or II (11°, P = 0.01). CONCLUSION Neurosurgical intervention may prevent curve progression in patients with scoliosis and Cobb angles

Previous research has shown that with certain idiopathic scoliosis curve types, performing a selective thoracic fusion (STF) is associated with an increased risk of coronal decompensation post-operatively. The purpose of the current study was to determine the influence of curve correction and fusion level on post-operative balance in STF for adolescent idiopathic scoliosis patients with pre-operative coronal decompensation. A multicenter database was queried for subjects with right Lenke 1–4C curves, pre-operative left coronal imbalance, and 2-year follow-up who underwent STF (caudal fusion level of L1 or proximal). Rates of decompensation were compared between groups with different levels of fusion. Thoracic and lumbar curve correction as well as Scoliosis Research Society-22 outcome scores were compared between groups that were post-operatively balanced or persistently decompensated. 121 patients were identified with average thoracic and lumbar curves of 53° and 41°. Mean pre- and post-operative decompensations were 2.4 ± 1.0 and 1.8 ± 1.1 cm, respectively. Eighteen patients were fused short, 62 to, and 41 were fused past the stable vertebra. Ten patients were fused short, 32 to, and 78 were fused past the neutral vertebra. Incidence of post-operative decompensation was 41%. No differences in post-operative decompensation relative to the stable or neutral vertebra were noted (p = 0.66, p = 0.74). Post-operatively, those patients who were balanced had similar thoracic curve correction (58%) to those decompensated (54%, p = 0.11); however, patients balanced post-operatively had greater SLCC (45 vs 40%, p = 0.04). No differences in SRS-22 outcome scores were noted between groups (p > 0.05). There was a high rate of post-operative decompensation in patients with pre-operative coronal decompensation undergoing STF. Fusion to or past the stable or neutral vertebra did not affect the risk of persistent decompensation. Attempts to improve SLCC could reduce post-operative decompensation.

Background: Confidence in intraoperative neurophysiologic monitoring (IONM) data can allow scoliosis surgeons to proceed with surgery even after a monitoring alert, assuming the recovery of signals. We sought to determine the outcomes of surgical treatment of adolescent idiopathic scoliosis (AIS) after a notable IONM alert. Methods: We identified 676 patients who underwent arthrodesis with use of IONM for the treatment of AIS. The patients were divided into 2 cohorts: those who experienced a lower-extremity IONM alert and those who did not. An alert was defined as a notable change in IONM data, specifically, a ≥50% drop in somatosensory evoked potentials (SSEPs) and/or in transcranial motor evoked potentials (tcMEPs). Results: Of the 676 patients, 36 (5.3%) experienced IONM alerts. Those patients had a larger preoperative major Cobb angle (mean of 61° ± 13° compared with 55° ± 12° for the no-alert group; p < 0.01), a greater number of levels fused (mean of 12 ± 2 compared with 11 ± 2; p < 0.01), a longer operative duration (mean of 357 ± 157 minutes compared with 298 ± 117 minutes; p < 0.01), a higher estimated blood loss (1,857 ± 1,323 mL compared with 999 ± 796 mL; p < 0.01), and a greater volume of autologous blood transfused (mean of 527 ± 525 mL compared with 268 ± 327 mL; p < 0.01). Among patients who experienced an alert and had a completed operation (34 of 36 patients), mean postoperative radiographic measurements were similar to those of the no-alert group in terms of the percentage of correction of the major Cobb angle (alert, 66% ± 13%; no alert, 64% ± 19%; p = 0.53) and of rib prominence (alert, 49% ± 36%; no alert, 47% ± 46%; p = 0.83) and measurement of thoracic kyphosis (alert, 23° ± 10°; no alert, 22° ± 2°; p = 0.58). The Scoliosis Research Society (SRS)-22 outcome scores were also similar between the 2 cohorts. Conclusions: Notable IONM changes occurred in 5.3% of the patients who underwent arthrodesis for AIS. Those patients had larger preoperative deformity, a longer operative duration, a greater number of levels fused, a higher estimated blood loss, and a greater volume of autologous blood transfused. Return of IONM data guided the surgeon to safely complete the procedure in 34 of 36 patients, with correction similar to that of patients who did not experience an alert. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction Recent healthcare reforms have raised the importance of cost and value in the management of disease. Value is a function of benefit and cost. Understanding variability in resources utilized by individual surgeons to achieve similar outcomes may provide an opportunity for cutting costs though greater standardization. The purpose of this study is to evaluate differences in use of implants and hospital resources among surgeons performing adolescent idiopathic scoliosis (AIS) surgery. Methods A multicenter prospective AIS operative database was queried. Patients were matched for Lenke curve type and curve magnitude, resulting in 5 surgeons and 35 matched groups (N = 175). Mean patient age was 14.9 years and curve magnitude 50°. Parameters of interest were compared between surgeons via ANOVA and Bonferroni pairwise comparison. Results There was no significant difference in percentage curve correction or levels fused between surgeons. Significant differences between surgeons were found for percentage posterior approach, operative time, length of stay (LOS), estimated blood loss (EBL), cell saver transfused, rod material, screw density, number of screws, use of antifibrinolytics, and cessation of intravenous analgesics. Despite differences in EBL and cell saver transfused, there were no differences in allogenic blood (blood bank) use. Conclusion Significant variability in resource utilization was noted between surgeons performing AIS operations, although radiographic results were uniform. Standardization of resource utilization and cost containment opportunities include implant usage, rod material, LOS, and transition to oral analgesics, as these factors are the largest contributors to cost in AIS surgery.

The minimal clinically important difference (MCID) of the Appearance domain of the SRS-22 questionnaire is an increase ≥1.0 in surgically treated patients with adolescent idiopathic scoliosis (AIS). However, no study has sought to identify the factors associated with an SRS-22 Appearance score increase greater than the MCID at 2 years. A retrospective analysis was performed on a prospectively collected multicenter database of 1020 surgically treated AIS patients with a minimum 2-year follow-up. Patients were divided into two cohorts: “I” = Improved after surgery (Δ Appearance ≥1.0) and “NI” = Not improved after surgery (Δ Appearance

Study Design Retrospective review of prospective registry. Objectives To assess the following in children with cerebral palsy (CP) who develop deep surgical site infection (DSSI) after spinal fusion: (1) rate of infection recurrence after treatment; (2) treatments used; (3) radiographic outcomes; and (4) differences in Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) scores versus those of children with no infection (NI). Summary of Background Data Studies show high rates of surgical site infection in patients with CP but do not address late recurrence or quality-of-life effects. Methods One hundred fifty-one children with CP underwent spinal fusion surgery from 2008 through 2011 and had ≥2-year follow-up. Patients who developed DSSI were compared with patients with NI. Student t tests were used to analyze deformity; analysis of variance was used to analyze CPCHILD scores in both groups preoperatively and at final follow-up. Results Eleven patients developed DSSI. Causative organisms were polymicrobial infection (5 cases), Escherichia coli (2 cases), and Proteus mirabilis , Staphylococcus aureus , Enterococcus faecalis , and Peptostreptococcus (1 case each). All patients underwent irrigation and debridement and received at least 6 weeks of antibiotics. Six had negative-pressure-dressing-assisted wound closure; 5 had primary closure. At mean 4-year follow-up (range, 3–5 years) no patient had recurrent infection. From immediate postoperative to final follow-up, no patient had significant loss of coronal curve (p = .77) or pelvic obliquity (p = .71) correction. However, at final follow-up, comfort and emotions, overall quality-of-life, and total CPCHILD scores in the DSSI group were significantly lower compared with the NI group (p = .005, .022, and .026, respectively). Conclusions In children with CP who developed DSSI after spinal fusion, there was no recurrence of infection or deformity after infection treatment. CPCHILD scores in patients with DSSI were lower compared with the NI group.

Retrospective analysis of the prospectively collected data.To investigate the relationship between the axial rotation of the unfused lumbar spine and the parameters of the instrumented thoracic spine at varying time points after selective thoracic fusion (STF) in Lenke 1B and 1C adolescent idiopathic scoliosis (AIS).The impact of STF on the spontaneous lumbar curve correction in AIS has been studied mainly in the frontal planes. The relationship between the spontaneous transverse plane correction of the lumbar spine and the parameters of the fused thoracic spine is not well documented.Twenty-one Lenke 1B and 1C patients who had received STF with minimum two years' follow-up were selected. Thoracic and lumbar Cobb angles, kyphosis, lordosis, and thoracic and lumbar apical vertebrae rotations were measured at preoperative, first-erect, six-month, one-year, and two-year follow-ups. The association between the lumbar apical vertebral rotation and other thoracic and lumbar variables at different time points were determined using regression analysis. The variables significantly predicting the lumbar axial rotation correction at two years were determined from the preceding follow-up visits.Kyphosis, thoracic Cobb, thoracic apical vertebral rotation, and lumbar Cobb were significantly different between the preoperative and all the postoperative follow-ups (p.05). At the two-year follow-up, a decrease in thoracic rotation and lumbar Cobb and a higher residual thoracic Cobb were associated with an improved spontaneous lumbar rotation (RSpontaneous lumbar curve rotation correction correlated to the fused and unfused spinal parameters in the three anatomic planes. The relationship between thoracic and lumbar rotation persist up to two years after STF. Thoracic derotation is an important factor determining the lumbar rotation correction at two years after STF.