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Growth modulation through anterior vertebral body tethering (AVBT) has emerged as a fusionless option for the treatment of progressive scoliosis. When tethering the main thoracic curve, the compensatory thoracolumbar/lumbar curve must correct indirectly as a result. The present study evaluated the response of these lumbar curves following AVBT of the main thoracic curves.Patients who underwent thoracic AVBT and who had a minimum follow-up of 2 years were included. Magnitudes of the thoracic and lumbar curves were recorded preoperatively and at the first-erect and 2-year postoperative visits. Lumbar curves were further stratified according to their lumbar modifier (A, B, or C). Analysis of variance (ANOVA) and repeated-measures ANOVA were performed to compare correction rates, and the Pearson coefficient was utilized to determine the correlation between the tethered thoracic curve and uninstrumented lumbar curve magnitudes.A total of 218 patients were included. Thoracic curve correction was 40% at the first-erect visit and 43% at 2 years (p = 0.012). Lumbar correction was 30%, 26%, and 18% at the first-erect visit (p0.001 for all compared with preoperatively) and minimally changed at 31%, 26%, and 24% at 2 years for lumbar modifiers A, B, and C, respectively. A total of 118 patients (54%) showed thoracic curve improvement between the first-erect and 2-year visits. In a subgroup analysis, these patients had a correction in lumbar curve magnitude from preoperatively to the first-erect visit of 30%, 22%, and 16% for lumbar modifiers A, B, C, respectively, that increased to 42%, 34%, and 31% at 2 years, with strong correlation to thoracic correction at 2-year follow-up (r = 0.557, p0.001).Although there was immediate lumbar correction following AVBT of a main thoracic curve, further improvement following initial correction was only observed among patients with growth modulation of the thoracic curve. Considering all patients, the uninstrumented lumbar curve corrected 30% at 2 years and the instrumented thoracic curve corrected 40%. As indications for AVBT are refined, these data will provide insight into the response of the uninstrumented lumbar curve.Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

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 (

BACKGROUND The purpose of the present study was to evaluate associations between changes in segmental vertebral coronal angulation (screw angulation) and overall height after anterior spinal growth tethering for the treatment of idiopathic scoliosis and to compare the rates of coronal angulation change using the preoperative Sanders stage. METHODS Patients with idiopathic scoliosis who underwent anterior spinal growth tethering between 2012 and 2016 and had ≥2 years of follow-up were retrospectively studied. We calculated each segment's screw angulation rate of change (degrees/month) and each patient's height velocity (cm/month) between each of the visits (3 to 12 visits/patient) and divided the visits into 4 groups by postoperative duration ( 2 to 3 years, >3 years). Patients were divided into 2 groups according to the preoperative Sanders stage. Generalized estimating equations and repeated-measures correlation were utilized for analyses with non-independent samples. RESULTS We analyzed 23 patients (16 female, 7 male) with a mean age (and standard deviation) of 12.2 ± 1.6 years who had right thoracic idiopathic scoliosis (mean, 53° ± 8°). All patients were immature at the time of surgery (Risser stage 0 or 1, Sanders stage 2 or 3). The mean duration of follow-up was 3.4 ± 1.1 years (range, 2 to 5 years). The rate of change for each segment's screw angulation after anterior spinal growth tethering was -0.16°, -0.14°, -0.05°, and 0.03° per month (with negative values indicating a reduction in scoliosis) for 2 to 3 years, and >3 years, respectively (p ≤ 0.001), and the mean height velocity was 0.65, 0.57, 0.30, and 0.19 cm per month for 2 to 3 years, and >3 years, respectively (p < 0.001). Changes in screw angulation correlated with height increases after anterior spinal growth tethering (r = -0.46, p < 0.001). Scoliosis correction for patients in the Sanders stage-2 group continued for 3 years (0.23°, 0.23°, and 0.09° per level per month for the first 3 years, respectively) and occurred at more than twice the rate for patients in the Sanders stage-3 group, for whom scoliosis correction ceased 2 years postoperatively (0.11° and 0.09° per level per month for the first 2 years, respectively). CONCLUSIONS Scoliosis correction was associated with overall height changes and occurred primarily within 2 to 3 years after surgery in this cohort of largely Risser stage-0 patients. The correction rate was 2.8° per segment per year for the first 2 years in the Sanders stage-2 group, compared with 1.2° per segment per year for the Sanders stage-3 group. Surgical timing that considers the patient's skeletal maturity is an important factor in generating proper postoperative correction after anterior spinal growth tethering. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

To identify curve/correction characteristics associated with adding-on at 2 years after posterior spinal fusion (PSF) in Lenke 1/2 AR curves. A prospective multicenter registry was queried to identify patients with adolescent idiopathic scoliosis (AIS), Lenke 1/2 AR curves, who underwent PSF with a minimum of 2-year follow-up. Patient characteristics as well as pre- and post- operative radiographic variables were evaluated using Classification and Regression Tree (CART) analysis to determine which factors contribute to adding-on. 253 patients treated with PSF were assessed for adding-on, of which 50 met our adding-on criteria. Univariate analysis revealed adding-on was associated several factors including: post-operative thoracic and lumbar curve magnitude (p > 0.001), first erect (FE) end instrumented vertebra (EIV) angulation (p = 0.009) and EIV translation (p = 0.001), younger age (p = 0.027), Risser stage (p = 0.024), and a more proximal lowest instrumented vertebra (LIV) (p 0.5°). In Lenke 1 and 2 AR curves, pre-operative LIV translation appears to be an independent risk factor for adding-on; and in those with

Energy healing (EH) is a part of the diverse group of Complementary and Alternative Medicines (CAM). The purpose of this study was to evaluate the effects of EH therapy prior to and following posterior surgical correction for adolescent idiopathic scoliosis (AIS) compared to controls. Patients were prospectively randomized to one of two groups: standard operative care for surgery (controls) vs. standard care with the addition of three EH sessions. The outcomes included visual analog scales (VAS) for pain and anxiety (0–10), days until conversion to oral pain medication, and length of hospital stay. For the experimental group, VAS was assessed pre- and post-EH session. Fifty patients were enrolled—28 controls and 22 EH patients. The controls had a median of 12 levels fused vs. 11 in the EH group (p = 0.04). Pre-operative thoracic and lumbar curve magnitudes were similar (p > 0.05). Overall VAS pain scores increased from pre- to post-operative (p

To evaluate associations between vertebrae and disc shape asymmetry and adolescent idiopathic scoliosis (AIS) curve severity. Analysis included normal screening referrals and patients with right, main thoracic AIS who underwent upright, biplanar radiographs with 3D reconstruction at a single institution from 2010 to 2015. Peri-apical anterior, posterior, right, and left vertebral body heights (aVBH, pVBH, rVBH, lVBH) and intervertebral disc heights (DH) were measured, and ratios of these measurements were calculated in sagittal and coronal planes. Correlations were performed between curve severity and height measurements. Sagittal and coronal plane components of these measurements were compared between normal controls with coronal curve measurements

To evaluate how 3D parameters of the instrumented thoracic spine relate to the uninstrumented lumbar spine following thoracic-only fusion (TOF) for adolescent idiopathic scoliosis (AIS) and determine the factors predictive of lumbar correction. A multi-center retrospective review was conducted of AIS patients with Lenke 1–4 B or C curves undergoing fusion of their thoracic spine only with minimum 2-year follow-up and 3D spine reconstructions from biplanar radiography. Pre-operative to 2-year post-operative differences were evaluated. Pearson’s correlations were used to identify 3D coronal, sagittal and axial relationships at 2 years post-operative. Multivariate linear regression was used to identify variables most predictive of lumbar curve correction. Eighty-four AIS patients met inclusion (54 B modifiers, 30 C modifiers). Average pre-operative thoracic and lumbar curves were 54 ± 9° and 41 ± 7° and corrected to 19 ± 7° and 21 ± 7°, respectively. 3D T5-T12 thoracic kyphosis increased from 6 ± 13° to 26 ± 8°. Thoracic and lumbar apical rotation decreased from − 14 ± 6° to -5 ± 6° and 13 ± 5° to 11 ± 6°, respectively. Thoracic curve correction correlated with lumbar curve correction (r = 0.67, p = 0.001) and decreased LIV tilt correlated with smaller residual lumbar curve magnitude (r = 0.63, p

Study design Observational. Objectives To report on the rate of major complications following spinal fusion and instrumentation to treat spinal deformity in patients with cerebral palsy (CP). Summary of background data Understanding the risk of major complications following the surgical treatment of spine deformities in patients with CP is critical. Methods A prospectively collected, multicenter database of patients with CP who had surgical correction of their spinal deformity (scoliosis or kyphosis) was reviewed for all major complications. Patients with ≥ 2 year follow-up or who died ≤ 2 years of surgery were included. A complication was defined as major if it resulted in reoperation, re-admission to the hospital, prolongation of the hospital stay, was considered life-threatening, or resulted in residual disability. Overall complication and revision rates were calculated for the perioperative (Peri-op; occurring ≤ 90 days postoperative) and delayed postoperative (Delayed; > 90 days) time periods. Results Two hundred and fifty-seven patients met inclusion. Seventy-eight (30%) patients had a major complication, 18 (7%) had > 1. There were 92 (36%) major complications; 64 (24.9%) occurred Peri-op. The most common Peri-op complications were wound (n = 16, 6.2%) and pulmonary issues (n = 28, 10.9%), specifically deep infections (n = 12, 4.7%) and prolonged ventilator support (n = 21, 8.2%). Delayed complications (n = 28, 10.9%) were primarily deep infections (n = 8, 3.1%) and instrumentation-related (n = 6, 2.3%). There were 42 additional surgeries for an overall unplanned return to the operating room rate of 16% (Peri-op: 8.6%, Delayed: 7.8%). Thirty-six (14.0%) reoperations were spine related surgeries (wound or instrumentation-related). Eleven (4.3%) patients died between 3 months to 5.6 years postoperatively; 4 occurred ≤ 1 year of surgery. Two deaths were directly related to the spinal deformity surgery. Conclusion Spinal deformity surgery in CP patients with greater than 2 years of follow-up have a postoperative major complication rate of 36% with a spine-related reoperation rate of 14.0%. Level of evidence Therapeutic-IV.

Retrospective study. To analyze the relationships between three-dimensional (3D) measurements of spinal deformity and Scoliosis Research Society-22 (SRS-22) scores in preoperative patients with major thoracic adolescent idiopathic scoliosis (AIS). Previous studies reported 2D measurements were not or only weakly correlated with preoperative SRS-22 scores. However, 2D measures do not always accurately represent the 3D deformity. A multicenter prospective registry of surgically treated AIS patients was reviewed for patients with right major thoracic AIS (Lenke type 1–4) who underwent biplanar radiography and completed the SRS-22 questionnaire preoperatively. For the 3D measurements, two reference frames were utilized: global (gravity/patient-based) and local (vertebra/disc-based). To obtain regional measurements, the individual segments in the appropriate reference plane were summed between the levels of interest. Patients were divided into two groups for each SRS-22 domain according to their scores: low (

Retrospective. Utilize three-dimensional (3D) measurements to assess the relationship between thoracic scoliosis severity and thoracic kyphosis in a large, multicenter cohort, and determine impact of 3D measurements on adolescent idiopathic scoliosis (AIS) curve classification. Research has demonstrated differences in two-dimensional (2D) and 3D assessment of the sagittal plane deformity in AIS. A prior smaller, single-institution study demonstrated an association between scoliosis severity and loss of 3D thoracic kyphosis. Data included retrospective compilation of prospectively enrolled bracing candidates and prospectively enrolled surgical candidates with thoracic AIS. Analysis included two groups based on thoracic curve magnitude: moderate (20–45°) and severe (> 45°). Imaging was performed using 2D radiographs. 3D thoracic kyphosis was calculated using a 2D to 3D conversion formula. Kyphosis was categorized according to the Lenke classification sagittal plane modifier. Analysis included 3032 patients. 2D kyphosis was significantly less in the moderate group (21 ± 12 vs 23 ± 14, p = 0.028). However, estimated 3D kyphosis was significantly greater in the moderate group (13 ± 10 vs 5 ± 12, p

STUDY DESIGN Retrospective. OBJECTIVE To evaluate the effect of preoperative rod shape on 3D spinal deformity correction. SUMMARY OF BACKGROUND DATA Differential rod contouring is a surgeon-dependent process based on an estimate of 3D deformity correction sought and the flexibility of the spine. An objective measure to this otherwise subjective scoliosis correction technique is lacking. METHODS A series of adolescent idiopathic scoliosis (AIS) patients with right, thoracic major curves, preoperative rod contour tracings, and EOS imaging was evaluated. All patients underwent posterior spinal fusion with 5.5 mm steel rods contoured prior to insertion. 3D reconstructions were generated pre- and postoperatively using sterEOS software (EOS Imaging) and imported into MATLAB (Mathworks) for analysis. A new measurement of the maximum perpendicular distance from the preinsertion concave rod contour to the preoperative 3D sagittal spinal reconstruction was defined as rod to 3D spine distance (RSD). Linear regressions were used to identify relationships between pre and postoperative parameters, including RSD and 3D thoracic kyphosis. RESULTS Ninety-nine patients were included. Average preoperative concave rod angle decreased from (48 ± 10°) preoperatively to 26 ± 6° postoperatively (P

Multiple studies have reported on the risks and preventative measures associated with acute surgical site infection (SSI) in patients with adolescent idiopathic scoliosis (AIS). Few studies have evaluated treatment and results. The purpose of this study was to evaluate the need for development of best practice guidelines based on the management of an acute SSI across 9 different centers. A prospectively collected, multicenter database of patients undergoing surgical correction of AIS was reviewed for all acute SSI. Infection characteristics, treatment methods, and outcomes were summarized. Twenty-three (0.6%) from a total of 3926 AIS patients were treated for an acute SSI, all of which resolved. Twenty patients had documentation of the infection treatment (10 deep infections, 10 superficial). All ten patients with deep infections underwent operative incision and drainage. Six patients ultimately found to have a superficial infection underwent I&D and another 3 had dressing changes in the office. In the deep group, one patient had instrumentation exchanged and seven patients had bone graft removed. All 16 patients who underwent operative I&D had cultures obtained with 11 positive cultures. All deep infection patients were started on IV antibiotics for 2 days to 6 weeks prior to conversion to oral antibiotics. Five of six operative superficial infections were begun on IV antibiotics with conversion to oral antibiotics. Total antibiotic administration ranged from 5 days to 7 months in the deep infection group and 1 to 6 weeks in the superficial group. While deep infections are consistently treated with I&D, there is significant variability in the surgical and medical management of acute SSI. Considering the universal resolution of the infection, there is opportunity for the development of BPG to minimize treatment morbidity and cost, while optimizing outcomes for this major complication. Therapeutic-IV.

As 2-year follow-up may not be sufficient to assess the risk of curve progression following fusion in immature patients with adolescent idiopathic scoliosis (AIS), this study reports on 5-year outcomes of AIS patients, factoring in maturity and surgical approach, to determine whether immature patients are at risk of continued curve progression beyond 2 years.A multicenter database was reviewed for AIS patients who underwent spinal fusion with pedicle screw fixation and who had both 2 and 5-year follow-up. Radiographic and SRS-22 scores were compared between three groups: open triradiate cartilage-posterior fusion (OTRC-P), OTRC-combined anterior/posterior fusion (OTRC-APSF), and closed TRC (CTRC, matched to OTRC-P group).142 subjects were included (67 OTRC-P, 8 OTRC-APSF, 67 CTRC). Main curve type (p = 0.592) and size (p = 0.117) were not different between groups at all timepoints. Compensatory curve size was similar at all timepoints for OTRC-P and CTRC, with a slight increase for OTRC-APSF from immediate postoperative to 5 years. At 5 years, OTRC-P had 10° loss of correction in 25% of patients, which was greater than in the CTRC (6%) and OTRC-APSF (0%) groups (p = 0.002). No significant differences were found in loss of correction of the compensatory curve or in SRS-22 scores between groups.Compared to those with CTRC and those treated with anterior/posterior fusion, patients with OTRC treated with posterior fusion had an increased risk of main curve progression greater than 10°, with some continued loss of correction after 2 years. This did not appear to affect patient-reported outcomes.

Prior work identified optimal outcomes at 2 years following selective thoracic fusion (STF) for adolescent idiopathic scoliosis (AIS) but it is unclear whether these published predictors represent what is required to achieve an optimal outcome with further time and potential growth. The purpose of this study was to determine the preoperative factors associated with optimal outcome of STF for AIS at 5 years.Patients with primary thoracic AIS (Lenke 1-4C curves) who underwent a STF and had minimum 5 years of follow-up were included. Optimal postoperative outcomes for a STF included a deformity-flexibility quotient (DFQ) 4, lumbar curve 26°, lumbar correction 37%, C7-CSVL 2 cm, lumbar prominence 5°, and trunk shift 1.5 cm. These outcomes were used to determine whether adhering to published recommendations for STF increased the likelihood of obtaining an optimal outcome at 5 years, which included: preoperative lumbar curve 45°, lumbar bend 25°, apical vertebral translation ratio 1.2, and thoracic/thoracolumbar Cobb ratio 1.2.127 patients met inclusion. A preoperative lumbar curve 45° was associated with an increased likelihood of achieving three of the optimal outcomes: DFQ 4, lumbar curve 26°, and lumbar prominence 5°. Following the 25° bend rule resulted in two optimal outcomes, while Cobb ratio 1.2 was only associated with one optimal outcome. AVT 1.2 was not significantly associated with any optimal outcome measures.This study found that at 5 years, performing a STF when there is a preoperative lumbar Cobb 45° remained the best guideline for increasing the likelihood of an optimal outcome.

Observational.To examine changes in patient-reported two-year postoperative outcomes via the Scoliosis Research Society (SRS)-24 Outcomes Instrument from 2001 through 2015.Techniques for correction of adolescent idiopathic scoliosis (AIS) have evolved over the years, but it is unclear how these changes have impacted patient-reported outcomes.AIS patients with two-year postoperative follow-up from a prospective multicenter registry were divided into three-year groups based on trends in surgical approach and construct type (2010-2014: 52% anterior, 43% posterior hybrids; 2005-2011: 3% anterior, 5% posterior hybrids; 2012-2015: 0% anterior, 0.2% posterior hybrids). Because of the ordinal scale (1-5) and bipolar nature of the response sets for the SRS-24, domain/total scores were categorized as ≤3 (predominantly negative) or 4-5 (predominantly positive). Variables were compared across the three groups.A total of 1,695 patients were analyzed; 172 (2010-2014), 926 (2005-2011), and 597 (2012-2015). Average age was 14.7 ± 2 years, the average primary curve was 55° ± 13°, and the group was primarily female (82%). There was a decline in the rate of positive scores for preoperative pain and self-image across the three groups (p.05). There was an increase in the rate of positive scores for two-year postoperative self-image after surgery, function after surgery, and satisfaction (p.05). Decreases in length of hospital stay, blood loss, surgical time, preoperative kyphosis, and postoperative trunk shift were observed (p.05). Increases were observed in levels fused, preoperative major coronal curve, preoperative rib prominence, preoperative trunk shift, percentage correction of major curve, kyphosis restoration, and the rate of double/triple curves (p.05).The percentage of patients with positive postoperative SRS scores has increased in the modern era, providing evidence that newer surgical techniques are resulting in improved outcomes based on the patients' perspectives. Interestingly, recent patients were more afflicted with negative pain and self-image before surgery.

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.

Retrospective review of prospective data.To delineate a curve threshold where further delay of surgery significantly increased the risks for patients with cerebral palsy (CP) scoliosis.Two approaches exist in the management of CP scoliosis: a proactive one where surgery is recommended once there is a risk of progression (Cobb50°) and a reactive one where surgery is recommended after the patient/caregiver may have significant challenges caused by a large deformity.A prospectively collected CP scoliosis surgical registry was queried for patients with minimum two years of follow-up. Three groups were delineated based on the distribution of curve magnitudes:70° (proactive), 70°-90°, and90° (reactive). Radiographic, surgical, and quality of life outcome data were compared between the groups using analysis of variance and chi-square analyses.There were 38 patients in the70° group, 44 in the 70°-90° group, and 42 in the90° group. They were similar in age. The90° group had significantly longer operative time (p.001), a higher percentage of anterior/posterior procedures (31% vs 5%), and a higher infection rate requiring ID (16.7%) than the other groups (70°: 5.3%; 70°-90°: 6.8%; p.05). The percentage blood volume loss was significantly higher in the90° group compared to70°. There were no differences in length of hospitalization or intensive care unit stay. Preoperatively, the Caregiver Priorities and Child Health Index of Life with Disabilities (CPchild) QOL score was significantly higher for the70° group. At two years, the70° and 70°-90° groups reached similar QOL scores, whereas the90° trended toward a lower postoperative QOL.Being proactive (Cobb70°) has no advantage in terms of decreasing risks or improving outcomes compared to curves 70°-90°. However, delaying surgery to a curve greater than 90° increases the risk of infection, blood loss, and the need for anterior/posterior procedures. Ideally, surgery should be recommended for curves less than 90°.

Study Design Retrospective review of a prospective cohort. Objective To identify patient and surgical factors that alter the length of postoperative intensive care unit (ICU) stays after spinal fusion/instrumentation in patients with neuromuscular scoliosis secondary to cerebral palsy (CP). Summary of Background Data High perioperative complication rates in patients with CP contribute to the practice of utilizing the ICU postoperatively for monitoring. However, this is costly and little is known regarding which patients truly need this increased acuity of care. Methods A prospective, multicenter database was queried for patients with CP who underwent spinal fusion and instrumentation. Patients with an ICU length of stay (LOS) ≤1 day were assumed to not have required postoperative ICU admission. Demographic and surgical characteristics were compared between those with ICU LOS of ≤1 day versus >1 day. A classification and regression tree (CART) analysis was utilized to create a decision algorithm for postoperative ICU admission. Results Three hundred twenty-four patients were identified with a mean ICU LOS of 4.7 days (range 0-47). Sixty-eight patients (21%) had an ICU LOS ≤1 day and 256 patients (79%) had an ICU LOS >1 day. CART analysis demonstrated that the institution where the surgery was performed was the primary predictor with two groups: sites that almost routinely had ICU stay >1 day (92%) and those that were split (50.5% >1 day). In the latter group, an operative time greater than 4 hours was a risk factor for a longer ICU stay. Conclusion Because of their heterogeneous makeup, CP patients should be evaluated individually and their postoperative disposition should not be based on institutional tradition but instead on objective surgical factors. For those patients with surgical times less than 4 hours, discussions should be held regarding the safety of a postoperative disposition to a regular floor. Level of Evidence Level III.

Retrospective review of three-dimensional (3D) imaging from a multicenter database of surgically treated adolescent idiopathic scoliosis (AIS) patients. To use 3D analysis software to compare Lenke 1AR and 1AL curves in the coronal, sagittal, and axial planes. The Lenke 1AR and AL curve patterns have been shown to be two distinct curve types, with 1AL curves being more likely to add on after fusion. Analysis in 3D may help define some of the intricacies of these two curves. Ninety-four AIS patients with Lenke 1A curves and upright biplanar scanned radiographs were reviewed. Analysis was performed using 3D reconstruction software to evaluate the 3D coronal, sagittal and axial plane deformities. Coronal L4 tilt was used to distinguish between the two curve patterns. The main thoracic Cobb was not significantly different between the AR (n = 43) and AL (n = 51) curves (52° ± 8° vs. 50° ± 5°; p = .25). The thoracolumbar/lumbar Cobb was significantly smaller in the AR curves (28° ± 8° vs. 32° ± 7° ; p = .02). In the sagittal plane, T5–T12 kyphosis and T12–S1 lordosis were not significantly different (p > .2); however, the T10–L2 alignment was significantly more lordotic in the AR curves (11° ±8° vs. 4° ± 10° lordosis; p

To evaluate 3D growth of the periapical vertebrae and discs in the 2 years after anterior vertebral body tether (AVBT) placement in patients with idiopathic scoliosis (IS).Patients with IS treated with AVBT, ≥ 2 years of follow-up, and 3D spine reconstructions created from simultaneous, biplanar radiographs were studied. Patients were divided into two groups: progressive scoliosis correction (PC) or no/limited correction (NPC). The average of the 3 apical vertebral and disc heights and angular measures were made. The rate of change for each measure (mm/mo, °/mo) from first erect to 2-year follow-up was compared between groups.Fourteen (Risser 0, Sanders 2-3) patients aged 11.4 ± 1.4 years with right thoracic scoliosis of 52 ± 9° were included. There were 7 patients per group (6F, 1M). Mean follow-up was 3.6 ± 1.1 (range 2-5) years. PC left-sided vertebral height increased 0.13 mm/months compared to 0.05 mm/mo in the NPC group (p = 0.001). Right (tethered side) vertebral growth was not different (PC: 0.07 mm/mo, NPC: 0.05 mm/mo, p = 0.2). Coronal vertebral wedging occurred at - 0.11°/mo compared to - 0.02°/mo for the PC and NPC groups, respectively (p = 0.004). Coronal disc angulation change was - 0.12°/mo in the PC group and - 0.04°/mo in the NPC group (p = 0.03), and was associated with loss of right disc height (PC: - 0.06 mm/mo) with little effect on the left disc height (PC: -0.01 mm/mo).AVBT in immature patients with thoracic scoliosis can asymmetrically modulate growth of the periapical vertebrae and discs. Progressive reduction in scoliosis after AVBT was associated with greater concave growth rates in the vertebrae and loss of disc height on the convex side.

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

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

Study design 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.

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

To evaluate associations between vertebrae and disc shape asymmetry and adolescent idiopathic scoliosis (AIS) curve severity.Analysis included normal screening referrals and patients with right, main thoracic AIS who underwent upright, biplanar radiographs with 3D reconstruction at a single institution from 2010 to 2015. Peri-apical anterior, posterior, right, and left vertebral body heights (aVBH, pVBH, rVBH, lVBH) and intervertebral disc heights (DH) were measured, and ratios of these measurements were calculated in sagittal and coronal planes. Correlations were performed between curve severity and height measurements. Sagittal and coronal plane components of these measurements were compared between normal controls with coronal curve measurements 11° and patients with moderate (11°-49°) and severe curves (≥ 50°), with tolerance intervals established for the normal controls.The analysis included a total of 397 patients. Patients with AIS had coronal curve measurements ranging from 11° to 101°. Greater coronal curve severity strongly correlated with smaller pVBH relative to aVBH and moderately correlated with smaller pDH relative to aDH (r = - 0.643, r = - 0.305, respectively). aVBH was greater for larger curves; pVBH remained stable. Scoliosis severity strongly correlated with right relative to left VBH and DH ratios (r = 0.919, r = 0.865 respectively). In comparison of normal controls to severe curves, severe curves had significantly greater aVBH and aDH, while pVBH was not significantly different and pDH was significantly less. Nearly half (46.9%) of the severe curves were below the range of normal for PA vertebral height ratio.In right, main thoracic AIS, greater main thoracic curve severity is associated with greater sagittal and coronal plane asymmetry of both the vertebral bodies and the discs. Severity more strongly correlates with vertebral changes in symmetry than with disc changes, though both are present.

BACKGROUND Anterior vertebral body tethering (AVBT) has been introduced as a means of correcting scoliosis without fusion. The purpose of this study was to compare outcomes for patients with thoracic idiopathic scoliosis between a group of patients who underwent AVBT and a matched cohort of patients treated with posterior spinal fusion and instrumentation (PSF). METHODS A retrospective study of patients who underwent AVBT and PSF for idiopathic scoliosis was conducted. The inclusion criteria were determined on the basis of the AVBT cohort: primary thoracic idiopathic scoliosis with a curve magnitude between 40° and 67°, Risser stage of ≤1, age of 9 to 15 years, no prior spine surgery, index surgery between 2011 and 2016, and minimum follow-up of 2 years. Demographic, radiographic, clinical, and patient-reported outcomes and revisions were compared between groups. RESULTS There were 23 patients in the AVBT cohort and 26 patients in the PSF cohort. The mean follow-up (and standard deviation) was similar between groups: 3.4 ± 1.1 years for the AVBT group and 3.6 ± 1.6 years for the PSF group (p = 0.6). Preoperatively, the groups were similar in all measurements of radiographic and clinical deformity, with mean main thoracic curves of 53° ± 8° for the AVBT group and 54° ± 7° for the PSF group (p = 0.4). At the time of final follow-up, the AVBT cohort had significantly more residual deformity, with a mean thoracic curve of 33° ± 18° compared with 16° ± 6° for the PSF group (p < 0.001). There were 9 revision procedures in the AVBT cohort (with 3 conversions to PSF and 3 more pending) and none in the PSF cohort. Revisions occurred at a mean postoperative time of 2.3 years (range, 1.2 to 3.7 years). Twelve patients (52%) had evidence of broken tethers; of these patients, 4 underwent revision. The post-intervention patient-reported outcomes were similar. CONCLUSIONS Both AVBT and PSF resulted in postoperative correction; however, 2-year correction was better maintained in the PSF group. There were no differences in post-intervention patient-reported outcomes. AVBT resulted in less deformity correction and more revision procedures than PSF, but resulted in the delay or prevention of PSF in the majority of patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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

To evaluate how 3D parameters of the instrumented thoracic spine relate to the uninstrumented lumbar spine following thoracic-only fusion (TOF) for adolescent idiopathic scoliosis (AIS) and determine the factors predictive of lumbar correction.A multi-center retrospective review was conducted of AIS patients with Lenke 1-4 B or C curves undergoing fusion of their thoracic spine only with minimum 2-year follow-up and 3D spine reconstructions from biplanar radiography. Pre-operative to 2-year post-operative differences were evaluated. Pearson's correlations were used to identify 3D coronal, sagittal and axial relationships at 2 years post-operative. Multivariate linear regression was used to identify variables most predictive of lumbar curve correction.Eighty-four AIS patients met inclusion (54 B modifiers, 30 C modifiers). Average pre-operative thoracic and lumbar curves were 54 ± 9° and 41 ± 7° and corrected to 19 ± 7° and 21 ± 7°, respectively. 3D T5-T12 thoracic kyphosis increased from 6 ± 13° to 26 ± 8°. Thoracic and lumbar apical rotation decreased from - 14 ± 6° to -5 ± 6° and 13 ± 5° to 11 ± 6°, respectively. Thoracic curve correction correlated with lumbar curve correction (r = 0.67, p = 0.001) and decreased LIV tilt correlated with smaller residual lumbar curve magnitude (r = 0.63, p 0.001). Increasing 3D kyphosis of the instrumented segment correlated with increased percentage lumbar curve correction (r = 0.29, p = 0.009). Multivariate linear regression showed LIV tilt and thoracic curve magnitude as the most predictive variables of post-operative residual lumbar curve magnitude, and percent correction of the thoracic curve and change in 3D instrumented kyphosis as most predictive of percent correction of the lumbar curve.Analysis of 3D data highlights several considerations for AIS patients undergoing TOF. Maximizing thoracic curve correction, leveling the LIV, and to a lesser extent, restoring kyphosis in the instrumented segment are the factors most likely to result in greater correction of the instrumented lumbar curve following thoracic-only fusions in Lenke 1-4 B and C curves.

Retrospective.Utilize three-dimensional (3D) measurements to assess the relationship between thoracic scoliosis severity and thoracic kyphosis in a large, multicenter cohort, and determine impact of 3D measurements on adolescent idiopathic scoliosis (AIS) curve classification. Research has demonstrated differences in two-dimensional (2D) and 3D assessment of the sagittal plane deformity in AIS. A prior smaller, single-institution study demonstrated an association between scoliosis severity and loss of 3D thoracic kyphosis.Data included retrospective compilation of prospectively enrolled bracing candidates and prospectively enrolled surgical candidates with thoracic AIS. Analysis included two groups based on thoracic curve magnitude: moderate (20-45°) and severe ( 45°). Imaging was performed using 2D radiographs. 3D thoracic kyphosis was calculated using a 2D to 3D conversion formula. Kyphosis was categorized according to the Lenke classification sagittal plane modifier.Analysis included 3032 patients. 2D kyphosis was significantly less in the moderate group (21 ± 12 vs 23 ± 14, p = 0.028). However, estimated 3D kyphosis was significantly greater in the moderate group (13 ± 10 vs 5 ± 12, p 0.001). In the moderate group, the rate of normokyphosis was 78% with 2D measures and 61% with 3D measures of T5-T12 kyphosis. In the severe group, this rate changed from 72 to 32% with use of 2D and 3D measures, respectively. In the moderate group, 16% of patients were classified as hypokyphotic using 2D measures while this rate increased 38% with 3D measures (p 0.001). In the severe group, this rate changed from 18 to 68% using 2D and 3D measures, respectively (p 0.001).Increased coronal curve severity was associated with decreased thoracic kyphosis. Hypokyphosis was more pronounced in 3D. 2D radiographs increasingly underestimate kyphosis with increasing coronal severity. Assessment of sagittal alignment from 2D radiographs can be improved with a 2D-3D conversion formula. Findings indicate potential for classification system improvement with use of 3D sagittal plane measurements.IV.

Energy healing (EH) is a part of the diverse group of Complementary and Alternative Medicines (CAM). The purpose of this study was to evaluate the effects of EH therapy prior to and following posterior surgical correction for adolescent idiopathic scoliosis (AIS) compared to controls.Patients were prospectively randomized to one of two groups: standard operative care for surgery (controls) vs. standard care with the addition of three EH sessions. The outcomes included visual analog scales (VAS) for pain and anxiety (0-10), days until conversion to oral pain medication, and length of hospital stay. For the experimental group, VAS was assessed pre- and post-EH session.Fifty patients were enrolled-28 controls and 22 EH patients. The controls had a median of 12 levels fused vs. 11 in the EH group (p = 0.04). Pre-operative thoracic and lumbar curve magnitudes were similar (p 0.05). Overall VAS pain scores increased from pre- to post-operative (p 0.001), whereas the VAS anxiety scores decreased immediately post-operative (p 0.001). The control and pre-EH assessments were statistically similar. Significant decreases in VAS pain and anxiety scores from pre to post-EH assessment were noted for the EH group. Both groups transitioned to oral pain medication a median of 2 days post-operative (p = 0.11). The median days to discharge was four in the controls and three in the EH group (p = 0.07).In this pilot study, EH therapy resulted in a decrease in patient's pre-operative anxiety. Offering this CAM modality may enhance the wellbeing of the patient and their overall recovery when undergoing posterior surgical correction for AIS.Therapeutic Level II.

STUDY DESIGN A prospective multicenter study. OBJECTIVE To evaluate the effects of sparing lumbar motion segments on spinal mobility and Scoliosis Research Society-22 scores at 10 years after spinal fusion for major thoracic adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA In surgical correction for major thoracic AIS, the long-term benefits of sparing lumbar motion segments remain unclear. METHODS A prospective multicenter registry was reviewed and patients with major thoracic AIS (Lenke types 1-4) and availability of both preoperative and 10-year postoperative mobility data were included. Spinal fusions ending at L1 or above were defined as thoracic fusions (T), and at L2 or below as thoracic and lumber fusions (T + L). Spinal mobility was evaluated with a measuring tape. The excursions between the starting and ending positions were measured using the distance from the spinous processes of C7 to S1 for forward flexion (FF), and the distance from the tip of the middle finger to the floor for lateral flexion (LF). Substantial reduction of mobility was defined as a reduction rate (a ratio of postoperative change divided by preoperative mobility) of 40% or more. Motion data were correlated with lowest instrumented vertebra levels and group comparisons were performed. RESULTS We identified 151 patients (average age, 25.1 years). The spinal mobility decreased with more distal lowest instrumented vertebrae (FF, rho = 0.208; right LF, 0.257; left LF, 0.371; P ≤ 0.01). Consequently, the incidence of substantial reduction of mobility was lower in the T group (n = 109) than in the T + L group (n = 42) (FF: 17.4% vs. 50%, LF: 14.8% vs. 51.2%; P

BACKGROUND Anterior spinal growth tethering (ASGT) has been shown to alter spinal growth with the potential to correct scoliosis while maintaining spine flexibility. The purpose of this study was to report the 2 to 4-year outcomes of ASGT in skeletally immature patients with thoracic scoliosis. METHODS We conducted a retrospective review of patients with thoracic scoliosis who underwent ASGT with a minimum of 2 years of follow-up. Patient demographics, perioperative data, and radiographic outcomes are reported. A "successful" clinical outcome was defined as a residual curve of

Retrospective review of prospective data.To evaluate the relationship between absolute apical vertebral rotation (AVR) evaluated with upright 3D imaging and angle of trunk rotation (ATR) before and after surgery for thoracic and lumbar curves in adolescent idiopathic scoliosis (AIS).New imaging technology allows for improved radiographic assessment of the degree of AVR pre- and postoperatively through 3D spine models created from biplanar, simultaneous spine radiographs.A prospective registry was queried and identified 55 AIS patients with major thoracic or major thoracolumbar/lumbar curves who underwent posterior spinal fusion. All patients had biplanar upright imaging of their spine and ATR measurements assessed via scoliometer pre- and postoperatively.There were 33 major thoracic and 22 major lumbar curves. The mean Cobb angles for thoracic and thoracolumbar/lumbar curves were 54° ± 10° and 47° ± 8° preoperatively, and 11 ± 6° and 12 ± 7° postoperatively. The differences in the mean preoperative ATR measurements for both major curve types was not statistically significant; however, the difference in AVR between thoracic curves (13 ± 6°) and lumbar curves (22 ± 7°) was significant (p.001). There was a significant decrease in the ATR and AVR for both thoracic and thoracolumbar/lumbar curves (p.001) postoperatively. A significant correlation between ATR and AVR was found only for the major thoracolumbar/lumbar curves (p.001). The relationship between ATR and AVR changes for both curves was not statistically significant.ATR measured via scoliometer strongly correlates with 3D measurements of AVR in both thoracic and lumbar curves before and after surgery for AIS. No significant relationship was found between the changes in ATR and AVR due to surgery. Postoperatively, greater clinical rotational deformity remains in the thoracic spine compared to the lumbar spine, despite greater apical vertebra axial plane correction in thoracic curves.Level II, diagnostic.

BACKGROUND In juveniles with progressive curves, there is debate regarding the use of growth friendly implants versus definitive fusion. This study presents outcomes of juvenile cerebral palsy (CP) scoliosis patients who underwent definitive fusion before age 11. METHODS A review of a prospective, multicenter registry identified patients 10 years and younger who had a definitive posterior fusion for their CP scoliosis. Preoperative and postoperative demographic and radiographic changes were evaluated with descriptive statistics. Repeated measures analysis of variance were utilized to compare outcome scores. RESULTS Fourteen children with a mean age of 9.7 years (8.3 to 10.8 y) and a minimum of 2 years follow-up (range 2 to 3 y) were identified. The mean preoperative curve magnitude and pelvic obliquity was 84±25 degrees (range 63 to 144 degrees) and 25±14 degrees, respectively. All patients were skeletally immature with open triradiate cartilage. Three patients had unit rods with wires while the rest incorporated pedicle screws. Immediately postoperation, the average major curve was 25±17 degrees (P≤0.001, 71% correction rate). At most recent follow-up, the average major curve increased to 30±18 degrees (P≤0.001) for a 65% correction rate. Pelvic obliquity improved to 4±4 degrees (84% correction, P≤0.001) immediately postoperation and to 6±5 degrees (P=0.002) at latest follow-up for a 76% correction rate. None of the patients required revision surgery for progression. From pre to most recent follow-up, the CPchild Health outcome scores improved from 47 to 58 (P=0.019). One patient had a deep infection, and 1 patient had a broken rod that did not require any further treatment. CONCLUSIONS Progressive scoliosis in juvenile CP patients requires the surgeon to balance the need for further growth with the risks of progression or repeated surgical procedures. Our study demonstrates that definitive fusion once the curves approach 90 degrees results in significant radiographic and quality of life improvements, but further follow-up is needed to determine whether those results remain after skeletal maturity. LEVEL OF EVIDENCE Level IV-therapeutic.

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 Retrospective review of prospectively collected data. OBJECTIVE To determine whether the last substantially touched vertebra (LSTV) is a valid lowest instrumented vertebra (LIV) for both Lenke 1 and 2 curve patterns with AR lumbar modifiers, and to identify preoperative risk factors of distal adding-on. SUMMARY OF BACKGROUND DATA Previous studies have recommended selecting the LSTV as the LIV for Lenke 1AR curves (main thoracic curve with A lumbar modifier and L4 tilt to the right (thoracic overhang/King type IV curve). METHODS One-hundred sixty patients with a Lenke 1 or 2 curve pattern and AR lumbar modifier who underwent posterior spinal fusion between 2008 and 2012 were reviewed. All patients had minimum 2-year follow up. Patients were identified with distal adding-on between first erect radiographs and 2-year follow up based on previously defined parameters. Factors predictive of the adding-on phenomenon were identified in a multivariate binary logistic regression model. RESULTS Twenty-seven patients (17%) were identified as having distal adding-on of their primary thoracic curve; however, only 8 of 89 patients (9%) fused to the LSTV developed adding-on (P = 0.005). Three variables were found to be significant predictors of adding-on: LIV proximal to LSTV (odds ratio, OR 3.63; P = 0.01), Risser zero (OR 4.93; P = 0.02), and C7-CSVL distance

Retrospective study.To analyze the relationships between three-dimensional (3D) measurements of spinal deformity and Scoliosis Research Society-22 (SRS-22) scores in preoperative patients with major thoracic adolescent idiopathic scoliosis (AIS). Previous studies reported 2D measurements were not or only weakly correlated with preoperative SRS-22 scores. However, 2D measures do not always accurately represent the 3D deformity.A multicenter prospective registry of surgically treated AIS patients was reviewed for patients with right major thoracic AIS (Lenke type 1-4) who underwent biplanar radiography and completed the SRS-22 questionnaire preoperatively. For the 3D measurements, two reference frames were utilized: global (gravity/patient-based) and local (vertebra/disc-based). To obtain regional measurements, the individual segments in the appropriate reference plane were summed between the levels of interest. Patients were divided into two groups for each SRS-22 domain according to their scores: low ( 4) and high (≥ 4) score groups. Group differences and correlations with SRS-22 scores were analyzed with p 0.01 as the threshold for significance.There were 405 eligible patients (mean age, 14.4 years). The mean 3D thoracic curve was 59° (45°-115°). The only significant group difference of 3D measurements occurred in the local lumbar lordosis (LL) with a small mean difference (- 3.4°, p = 0.008) in the mental health domain. In the correlation analyses, global and local thoracic kyphosis (TK) and TK/LL ratio demonstrated significant, but weak, correlations with function and total scores (|r| 0.2, p 0.01).3D measurements of scoliosis severity have only weak associations with preoperative SRS-22 scores, which might indicate a limit to the discriminative capacity of the SRS-22 within surgical range major thoracic AIS curves. Interestingly, the sagittal plane was the principle 3D plane in which significant correlations existed.II, prognostic.

Prospective registry. The evolution of spinal instrumentation has provided better outcomes in adolescent idiopathic scoliosis (AIS); however, there is a paucity of reliable prospective information on 10-year post-operative outcomes of modern surgical techniques. A prospective multicenter registry of patients who had surgical correction of AIS was reviewed. Patients with major thoracic scoliosis (Lenke types 1–4) operated on between 1997 and 2007, with 10-year post-operative follow-up data were included. Radiographic and clinical outcomes including Scoliosis Research Society (SRS)-22 scores and revision surgeries were evaluated. One hundred and seventy-four patients (mean 25.0 years of age at most recent evaluation) were included. Pedicle screw constructs were used in 102 patients (58%), hook or hybrid constructs in 22 (13%), and anterior screw-rod constructs in 50 (29%). The mean pre-operative thoracic Cobb angle was corrected from 53° to 18° initially. At 10-year follow-up, the mean thoracic curve was 22° (mean 57% correction), with 29 patients (16.7%) having loss of correction (LOC) ≥ 10°. There were a total of 14 revision surgeries performed in 13 patients (7.5%). SRS-22 pain (p = 0.035), self-image (p

To evaluate the three-dimensional (3D) characteristics of spine deformity in patients with non-idiopathic scoliosis compared with those observed in patients with adolescent idiopathic scoliosis (AIS). A retrospective chart review was conducted to identify patients with non-idiopathic scoliosis. Twenty-eight patients with neural axis (NA) abnormalities (Chiari 1, syrinx) and 20 patients with connective tissue disorder (CTD) (Marfan’s, Beal’s, Ehlers-Danlos syndrome, mixed) were identified. The 3D parameters of the coronal, sagittal, and axial plane were compared with 284 AIS patients with a similar range of coronal deformity. The average coronal curve was similar between all three groups (AIS 48 ± 15°, CTD 43 ± 22°, and NA 49 ± 18°; p = 0.4). The NA patients had significantly greater 3D thoracic kyphosis (20 ± 18° vs 10 ± 15°, p = 0.001) and less thoracic apical vertebral rotation (− 5 ± 18° vs − 12 ± 10°, p = 0.003) when compared with AIS. The CTD group’s 3D thoracic kyphosis (p = 0.7) and apical vertebral rotation (p = 0.09) did not significantly differ from AIS. Significant negative correlations were found in all three groups between thoracic kyphosis and coronal curve magnitude (AIS r = − 0.49, CTD r = − 0.772, NA r = −0.677, all p

Retrospective. To define normal values and distributions for sagittal, coronal, and shoulder balance among healthy adolescents, both for traditional radiographs and biplanar radiography. Our understanding of spine balance, especially in the sagittal plane, has expanded rapidly in recent years. Additionally, there has been growing use of simultaneous biplanar radiography which requires slightly different patient positioning. However, the normal ranges of several commonly used parameters have not yet been defined, either in traditional or biplanar radiography. Radiographs were retrospectively reviewed of 273 patients aged 10–18 years seen in spine clinics at two high-volume centers and not diagnosed with any spine pathology. One center utilized traditional radiography and the other biplanar radiography. Coronal, sagittal, and shoulder balance were measured for each patient. Intra-observer reliability and normal values with distributions were reported for each parameter. Intra-observer reliability was excellent (intra-class correlation coefficients ≥ 0.98). Each parameter was normally distributed at each institution based on Kolmogorov–Smirnov testing. Sagittal balance was more negative at the institution using traditional radiographs (− 3.4 ± 4.2 vs. 0.3 ± 2.2, p

Retrospective comparative cohort study.To compare radiographic parameters between adolescents with a greater body mass index (BMI) percentile to underweight individuals.Increased BMI percentile has been associated with increased complications after surgical correction of adolescent idiopathic scoliosis (AIS). However, association between BMI percentile and preoperative sagittal plane alignment has not been evaluated. The purpose of this study was to evaluate the effect of BMI percentile on sagittal alignment in AIS patients compared with nonscoliotic adolescents.Posterior-anterior and lateral spinal radiographs of 1,551 AIS patients with a thoracic major curve (Lenke 1-4) and 70 nonscoliotic adolescent patients were compared. BMI percentile was determined based on age and sex, and patients were divided into four categories: underweight (5th percentile), normal-weight (5th-85th percentile), overweight (85th-95th percentile), and obese (≥95th percentile).Coronal plane deformity magnitude was not significantly different between the 4 categories of AIS patients (p = .51). Increased BMI percentile was associated with increased thoracic kyphosis globally (T2-T12: p.005) as well as segmentally (T2-T5: p.001; T5-T12: p.001) in patients with AIS. This was also true in obese adolescents without spinal deformity (p.04). Lumbar lordosis, pelvic incidence, and pelvic tilt were not significantly different between AIS patients in the four BMI percentile categories (p.07). Pelvic incidence was significantly greater in AIS patients compared with nonscoliotic adolescents (54 ± 13 vs. 46 ± 11; p = .01).Increased BMI percentile is associated with increased thoracic kyphosis in AIS patients and nonscoliotic adolescents. Excess weight may reduce anterior vertebral growth. AIS patients have an increased pelvic incidence compared with nonscoliotic adolescents; however, this variable is not influenced by body mass. These relationships should be taken into account when planning sagittal plane deformity correction or considering neuro axis disorders (also associated with increased kyphosis) in patients with scoliosis.Level II.

Utilizing 2D measurements, previous studies have found that in AIS, increased thoracic Cobb and decreased thoracic kyphosis contribute to pulmonary dysfunction. Recent technology has improved our ability to measure and understand the true 3D deformity in AIS. The purpose of this study was to evaluate which 3D radiographic measures predict pulmonary dysfunction. One hundred and sixty-three surgically treated AIS patients with preoperative PFTs (FEV, FVC, TLC) and EOS® imaging were identified at a single center. Each spine was reconstructed in 3D to obtain the true coronal, sagittal, and apical rotational deformities. These were then correlated with the patient’s preoperative PFT measurements. Regression analysis was performed to determine the relative effect of each radiographic measure. There were 124 thoracic and 39 lumbar major curves. The range of preoperative thoracic and lumbar 3D coronal angle was 11–115° and 11–98°, respectively. The range of preoperative thoracic 3D kyphosis (T5–T12) and thoracic apical vertebral rotation was −56 to 44° and 0–29°, respectively. Increasing thoracic 3D Cobb and thoracic vertebral rotation and decreasing thoracic 3D kyphosis most significantly correlated with decreasing pulmonary function, especially FEV. In patients with the largest degree of thoracic deformity (3D Coronal Cobb > 80°, 3D thoracic lordosis >20°, and absolute apical rotation >25°), the majority of patients had moderate to severe pulmonary impairment (≤65 % predicted). 3D thoracic kyphosis was the most consistent predictor of FEV (r 2 = 0.087), FVC (r 2 = 0.069), and TLC (r 2 = 0.098) impairment. Larger thoracic coronal, sagittal, and axial deformities increase the risk of pulmonary impairment in patients with AIS. Of these, decreasing 3D thoracic kyphosis is the most consistent predictor. This information can guide surgeons in the decision making process for determining which surgical techniques to utilize and which component of the deformity to focus on.