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BACKGROUND AND CONTEXT:  In patients with adolescent idiopathic scoliosis (AIS) of main thoracic and lumbar spine regions, combined anterior thoracic vertebral body tethering and posterior lumbar spine tethering (ATVBT/PLST) is a novel non-fusion treatment option for growth modulation and conservation of motion. METHODS:  Fourteen patients with AIS who underwent ATVBT/PLST with at least 2-year follow-up were included. Primary outcomes included quality of life as assessed by SRS-22 instruments, radiographic analysis, and revision operations. We secondarily reported perioperative metrics and post-operative opiate morphine equivalents (OME). Clinical success was defined as patients who achieved skeletal maturity with ≤ 30° curve magnitude of both their main thoracic and thoracolumbar/lumbar curves and who did not undergo posterior spine instrumentation and fusion (PSIF). RESULTS: Patients had a mean age of 11.6 years (range 10-14 years), majority were girls (92%), and mean follow-up was 3.0 years (range 2-4.8 years). All patients were skeletally immature with a Risser ≤ 2. Included curves were Lenke 1C, 3C, or 6C. Mean preoperative curve magnitudes were 53° ± 8° (range 45°-65°) main thoracic and 49° ± 9° (range 40°-62°) thoracolumbar/lumbar curves. At most recent follow-up, patients had a mean main thoracic curve of 29° ± 8° (range 15°-40°) and a mean thoracolumbar/lumbar curve of 20° ± 15° (range 4°-35°). 50% required a revision operation. Cable breakage occurred in 43%, which did not always require revision. One patient progressed to thoracic fusion, but no patient underwent lumbar fusion. Patients had a mean SRS-22 outcome score of 4.2 ± 0.4. CONCLUSIONS: ATVBT/PLST is a potential alternative to spine fusion for select immature patients with AIS at a minimum 2-year follow-up. ATVBT/PLST potentially offers motion conservation at the cost of a higher revision rate. Further study and reporting of results are necessary to refine indications and techniques, which in turn will improve outcomes of this procedure. LEVEL OF EVIDENCE: Level IV-Case series without comparative group.

PURPOSE: While posterior spinal instrumentation and fusion (PSIF) for severe adolescent idiopathic scoliosis (AIS) is the gold standard, anterior vertebral body tethering (AVBT) is becoming an alternative for select cases. Several studies have compared technical outcomes for these two procedures, but no studies have compared post-operative pain and recovery. METHODS: In this prospective cohort, we evaluated patients who underwent AVBT or PSIF for AIS for a period of 6 weeks after operation. Pre-operative curve data were obtained from the medical record. Post-operative pain and recovery were evaluated with pain scores, pain confidence scores, PROMIS scores for pain behavior, interference, and mobility, and functional milestones of opiate use, independence in activities of daily living (ADLs), and sleeping. RESULTS: The cohort included 9 patients who underwent AVBT and 22 who underwent PSIF, with a mean age of 13.7 years, 90% girls, and 77.4% white. The AVBT patients were younger (p = 0.03) and had fewer instrumented levels (p = 0.03). Results were significant for decreased pain scores at 2 and 6 weeks after operation (p = 0.004, and 0.030), decreased PROMIS pain behavior at all time points (p = 0.024, 0.049, and 0.001), decreased pain interference at 2 and 6 weeks post-operative (p = 0.012 and 0.009), increased PROMIS mobility scores at all time points (p = 0.036, 0.038, and 0.018), and faster time to functional milestones of weaning opiates, independence in ADLs, and sleep (p = 0.024, 0.049, and 0.001). CONCLUSION: In this prospective cohort study, the early recovery period following AVBT for AIS is characterized by less pain, increased mobility, and faster recovery of functional milestones, compared with PSIF. LEVEL OF EVIDENCE: IV.

PurposeThe purpose of this study was to determine perspectives of surgeons regarding simultaneous surgery in patients undergoing posterior spine instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS).MethodsA survey was administered to orthopaedic trainees and faculty regarding simultaneous surgery for primary PSIF for AIS. A five-point Likert scale (1: 'Strongly Disagree' to 5: 'Strongly Agree') was used to assess agreement with statements about simultaneous surgery. We divided simultaneous surgery into concurrent, when critical portions of operations occur at the same time, and overlapping, when noncritical portions occur at the same time.ResultsThe 72 respondents (78.3% of 92 surveyed) disagreed with concurrent surgery for 'one of my patients' (response mean 1.76 (sd 1.03)) but were more accepting of overlapping surgery (mean 3.94 (sd 0.99); p < 0.0001). The rating difference between concurrent and overlapping surgery was smaller for paediatric and spine surgeons (-1.25) than for residents or those who did not identify a subspecialty (-2.17; p = 0.0246) or other subspecialty surgeons (-2.57; p = 0.0026). Respondents were more likely to agree with explicit informed consent for concurrent surgery compared with overlapping (mean 4.32 (sd 0.91) versus 3.44 (sd 1.14); p < 0.001).ConclusionOrthopaedic surgeons disagreed with concurrent but were more accepting of overlapping surgery and anaesthesia for PSIF for AIS. Respondents were in greater agreement that patients should be explicitly informed of concurrence than of overlap. The surgical community's evidence and position regarding simultaneous surgery, in particular overlapping, must be more effectively presented to the public in order to bridge the gap in perspectives.Level of evidenceIV.

PurposeTo describe a patient with Cobb Syndrome, a rare congenital disorder characterized by cutaneous and spinal arteriovenous malformations, who was found to have bilateral optic nerve pits.ObservationsA 15-year-old boy diagnosed with Cobb Syndrome, manifesting as a large cutaneous port-wine stain associated with an underlying left paraspinous arteriovenous malformation resulting in severe scoliosis, presented for a screening ophthalmological exam. The patient had no visual symptoms. On examination, his visual acuity was 20/20 in each eye; however, bilateral optic disc pits were discovered on biomicroscopy and confirmed by spectral-domain optical coherence tomography.Conclusion and importanceThe unusual finding of bilateral optic disc pits in this rare congenital neurocutaneous disorder represents the first report of ophthalmic abnormalities in association with Cobb syndrome. Patients with Cobb Syndrome may be considered for screening ophthalmological exam for the detection of subclinical optic nerve abnormalities.

The objective of this study is to evaluate whether the artery of Adamkiewicz localization with preoperative CT angiography influences anterior spinal instrumentation.MethodsChildren with idiopathic scoliosis who underwent anterior instrumentation and with a preoperative CT angiography were evaluated retrospectively. Data included curve type, artery of Adamkiewicz level/laterality, surgical approach laterality, number of instrumented levels and segmental vessels ligated, intraoperative neuromonitoring changes, and postoperative neural complications.ResultsThirty-nine girls and eight boys (mean age 12 years [6.7 to 16.8 years]) were analyzed. Instrumented curves indicate 28 thoracic, 14 thoracolumbar, and seven double major. The artery of Adamkiewicz: T6 (left-1), T8 (left-1), T9 (left-4/right-2), T10 (left-11/right-4), T11 (left-4/right-4), T12 (left-1/right-2), L1 (left-2/right-1), and L2 (left-3/right-2). Four had bilateral dominant segmentals, whereas in nine patients, none was identified. T10 (32%) and left side (57%) were most frequent. On average, 7.1 (4 to 11) segmentals were ligated per case (total 355). Dominant vessels were ipsilateral to/within instrumentation levels in 30%.DiscussionIn children with idiopathic scoliosis who underwent anterior instrumentation, the artery of Adamkiewicz was identified on the left in >50% and at T10 in 32%. In one-third of the patients, the artery was within intended surgical levels and resulted in instrumentation modification.

Study designProspective cross-sectional survey.ObjectiveTo determine the perspectives of parents of patients undergoing posterior instrumented fusion for adolescent idiopathic scoliosis (AIS) regarding simultaneous surgery and trainee participation.Summary of background dataSimultaneous ("at the same time") surgery is under scrutiny by the public, government, payers, and the medical community. The objective of this study is to determine the perspectives of parents of patients undergoing posterior instrumented fusion for adolescent idiopathic scoliosis. Our goal is to inform the national conversation on this subject with real patient and family voices.MethodsA survey was prospectively administered to 31 consecutive parents of patients undergoing posterior instrumented fusion for adolescent idiopathic scoliosis at a large academic medical center. "Overlapping" was defined as simultaneity during "noncritical" parts of an operation. "Concurrent" was defined as simultaneity that includes "critical" part(s) of an operation. Participants were asked to provide levels of agreement with overlapping and concurrent surgery and anesthesia, as well as with trainee involvement.ResultsOn average, respondents "strongly agree" with the need to be informed about overlapping or concurrent surgery. They "disagree" with both overlapping and concurrent scheduling, and "disagree" with trainees operating without direct supervision, even for "noncritical" parts. Informing parents about the presence of a back-up surgeon or research demonstrating safety of simultaneous surgery did not make them agreeable to simultaneous scheduling.ConclusionParents have a strong desire to be informed of simultaneous spinal surgery and anesthesia as part of consent on behalf of their children. Their disagreement with simultaneous surgery, as well as with trainees operating without direct supervision, suggests discordance with current guidelines and practice and should inform the national conversation moving forward.Level of evidenceN/A.

Video lecture capture is one of the most attractive e-tools that has been introduced to support students learning and assist with grasping difficult concepts. A variety of benefits is offered through this system introduced at our institution nearly a decade ago. We evaluated lecture capture viewings for professional undergraduate pharmacy courses in the Fall and Spring semesters over three academic years and analyzed data for one cohort of students. Each course within the pharmacy program was analyzed and viewing figures downloaded through the Echo360 management system. The average number of views per lecture, per semester was summarized. We observed that junior students viewed lecture capture most frequently with the number of views highest at the beginning of the academic year (Fall semester). Analysis of 18 courses which occurred 48 times over the three academic years studied, showed that 21 course occurrences had an average number of views per lecture equal to or higher than the number of students enrolled in the course, indicating that only 44% of courses had on average, at least, one student viewing each lecture recording. Of particular note, year 1 students had the highest percentage of courses viewed by a number equal to or higher than students enrolled (9 occurrences out of 16 or 56%), followed by year 2 students (9 occurrences out of 21 or 43%), and finally year 3 students (3 occurrences out of 11 or 27%). This pattern of lecture recording viewing was further underscored by longitudinally following-up the class of 2020 (24 students) over three academic years. To ensure optimal use of the system by both students and faculty for a multitude of learning and teaching styles and methods, we propose to implement professional development sessions for faculty to showcase the advantages of the lecture capture system and maximize the benefits from its availability. Further quantitative and qualitative studies are warranted to fully grasp the motivations for use, attitudes and perceptions towards the system.

© 2015 Lin et al.; licensee BioMed Central. Background: To describe grey-scale sonographic findings in lower extremity entheses in healthy children. Methods: Healthy patients referred to Orthopedic Surgery or Adolescent Medicine outpatient clinics or their siblings ages 5-18 years were recruited. Grey-scale ultrasound was performed on 3 entheseal sites bilaterally, the proximal patellar ligament insertion (PPL), distal patellar ligament insertion (DPL), and Achilles tendon insertion (AT). Entheseal thickness and quality were recorded. Comparison of thickness between contralateral sites was evaluated to determine within subject site variability. Results: 702 entheses were examined in 117 children. Age had a weak positive correlation with thickness with large variability. Weight had the strongest correlation to thickness. Contralateral sites are comparable in thickness; a difference of 28%, 26%, and 18% between bilateral PPL, DPL, and AT, respectively, falls within the 95th percentile of the healthy pediatric population in this study. The patellar ligament contour evolved with age from a curved to linear contour. Conclusions: Weight is the best predictor of entheseal thickness in children although there is a large degree of variability. Contralateral entheses are comparable in thickness. A difference below 28%, 26%, and 18% between bilateral PPL, DPL, and AT, respectively, falls within the 95th percentile.

ObjectiveTo assess the effectiveness of an experimental curriculum on teaching first-year medical students the musculoskeletal exam as compared to a traditional curriculum.BackgroundMusculoskeletal complaints are common in the primary care setting. Practitioners are often deficient in examination skills and knowledge regarding musculoskeletal diseases. There is a lack of uniformity regarding how to teach the musculoskeletal examination among sub-specialists. We propose a novel web-based approach to teaching the musculoskeletal exam that is enhanced by peer practice with pathophysiology-focused cases. We sought to assess the effectiveness of an innovative musculoskeletal curriculum on the knowledge and skills of first-year medical students related to musculoskeletal physical diagnosis as compared to a traditional curriculum. The secondary purpose of this study was to assess satisfaction of students and preceptors exposed to this teaching method.MethodsThis quasi-experimental study was conducted at a single LCME-accredited medical school and included a convenience sample from 2 consecutive classes of medical students during the musculoskeletal portion of their physical diagnosis class. We conducted a needs assessment of the traditional curriculum used to teach musculoskeletal examination. The needs assessment informed the development of an experimental curriculum. One class (control group) received the traditional curriculum while the second class (experimental group) received the experimental curriculum, consisting of a web-based musculoskeletal tutorial, pathophysiology-focused cases, and facilitator preparation. We used multiple-choice questions and musculoskeletal OSCE scores to assess differences between knowledge and skills in the 2 groups.ResultsThe sample consisted of 140 students in each medical school class. There were no statistically significant differences between the 2 groups. One hundred seven students from the control group and 120 students from the experimental group took the multiple-choice examination. The average score was 66% (95% CI= 59.7-72.3) for the control group and 66% (95% CI = 60.5-71.5) for the experimental group. There was no difference between the median musculoskeletal OSCE scores between the 2 groups. The experimental group was satisfied with the new teaching method and gained the additional benefit of a persistent resource.ConclusionsThis web-based experimental curriculum was as effective as the traditional curriculum for teaching the musculoskeletal exam. Additionally, users were satisfied with the web-based training and benefited from a persistent resource.