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OBJECTIVE The focus of this modified Delphi study was to investigate and build consensus regarding the medical management of children with moderate and severe acute spinal cord injury (SCI) during their initial inpatient hospitalization. This impetus for the study was based on the AANS/CNS guidelines for pediatric SCI published in 2013, which indicated that there was no consensus provided in the literature describing the medical management of pediatric patients with SCIs. METHODS An international, multidisciplinary group of 19 physicians, including pediatric neurosurgeons, orthopedic surgeons, and intensivists, were asked to participate. The authors chose to include both complete and incomplete injuries with traumatic as well as iatrogenic etiologies (e.g., spinal deformity surgery, spinal traction, intradural spinal surgery, etc.) due to the overall low incidence of pediatric SCI, potentially similar pathophysiology, and scarce literature exploring whether different etiologies of SCI should be managed differently. An initial survey of current practices was administered, and based on the responses, a follow-up survey of potential consensus statements was distributed. Consensus was defined as ≥ 80% of participants reaching agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). A final meeting was held virtually to generate final consensus statements. RESULTS Following the final Delphi round, 35 statements reached consensus after modification and consolidation of previous statements. Statements were categorized into the following eight sections: inpatient care unit, spinal immobilization, pharmacological management, cardiopulmonary management, venous thromboembolism prophylaxis, genitourinary management, gastrointestinal/nutritional management, and pressure ulcer prophylaxis. All participants stated that they would be willing or somewhat willing to change their practices based on consensus guidelines. CONCLUSIONS General management strategies were similar for both iatrogenic (e.g., spinal deformity, traction, etc.) and traumatic SCIs. Steroids were recommended only for injury after intradural surgery, not after acute traumatic or iatrogenic extradural surgery. Consensus was reached that mean arterial pressure ranges are preferred for blood pressure targets following SCI, with goals between 80 and 90 mm Hg for children at least 6 years of age. Further multicenter study of steroid use following acute neuromonitoring changes was recommended.

It is introduced a new algebra $$(A, \otimes , \oplus , *, \rightharpoonup , 0, 1)$$ ( A , ⊗ , ⊕ , ∗ , ⇀ , 0 , 1 ) called $$L_PG$$ L P G -algebra if $$(A, \otimes , \oplus , *, 0, 1)$$ ( A , ⊗ , ⊕ , ∗ , 0 , 1 ) is $$L_P$$ L P -algebra (i.e. an algebra from the variety generated by perfect MV-algebras) and $$(A,\rightharpoonup , 0, 1)$$ ( A , ⇀ , 0 , 1 ) is a Gödel algebra (i.e. Heyting algebra satisfying the identity $$(x \rightharpoonup y ) \vee (y \rightharpoonup x ) =1)$$ ( x ⇀ y ) ∨ ( y ⇀ x ) = 1 ) . The lattice of congruences of an $$L_PG$$ L P G -algebra $$(A, \otimes , \oplus , *, \rightharpoonup , 0, 1)$$ ( A , ⊗ , ⊕ , ∗ , ⇀ , 0 , 1 ) is isomorphic to the lattice of Skolem filters (i.e. special type of MV-filters) of the MV-algebra $$(A, \otimes , \oplus , *, 0, 1)$$ ( A , ⊗ , ⊕ , ∗ , 0 , 1 ) . The variety $$\mathbf {L_PG}$$ L P G of $$L_PG$$ L P G -algebras is generated by the algebras $$(C, \otimes , \oplus , *, \rightharpoonup , 0, 1)$$ ( C , ⊗ , ⊕ , ∗ , ⇀ , 0 , 1 ) where $$(C, \otimes , \oplus , *, 0, 1)$$ ( C , ⊗ , ⊕ , ∗ , 0 , 1 ) is Chang MV-algebra. Any $$L_PG$$ L P G -algebra is bi-Heyting algebra. The set of theorems of the logic $$L_PG$$ L P G is recursively enumerable. Moreover, we describe finitely generated free $$L_PG$$ L P G -algebras.

Fungi in the order Chaetothyriales are renowned for their ability to cause human infections. Nevertheless, they are not regarded as primary pathogens, but rather as opportunists with a natural habitat in the environment. Extremotolerance is a major trend in the order, but quite different from black yeasts in Capnodiales which focus on endurance, an important additional parameter is advancing toxin management. In the ancestral ecology of rock colonization, the association with metabolite-producing lichens is significant. Ant-association, dealing with pheromones and repellents, is another mainstay in the order. The phylogenetically derived family, Herpotrichiellaceae, shows dual ecology in monoaromatic hydrocarbon assimilation and the ability to cause disease in humans and cold-blooded vertebrates. In this study, data on ecology, phylogeny, and genomics were collected and analyzed in order to support this hypothesis on the evolutionary route of the species of Chaetothyriales. Comparing the ribosomal tree with that of enzymes involved in toluene degradation, a significant expansion of cytochromes is observed and the toluene catabolism is found to be complete in some of the Herpotrichiellaceae. This might enhance human systemic infection. However, since most species have to be traumatically inoculated in order to cause disease, their invasive potential is categorized as opportunism. Only in chromoblastomycosis, true pathogenicity might be surmised. The criterion would be the possible escape of agents of vertebrate disease from the host, enabling dispersal of adapted genotypes to subsequent generations.

BACKGROUND Despite tremendous efforts, the incidence of surgical site infection (SSI) following the surgical treatment of pediatric spinal deformity remains a concern. Although previous studies have reported some risk factors for SSI, these studies have been limited by not being able to investigate multiple risk factors at the same time. The aim of the present study was to evaluate a wide range of preoperative and intraoperative factors in predicting SSI and to develop and validate a prediction model that quantifies the risk of SSI for individual pediatric spinal deformity patients. METHODS Pediatric patients with spinal deformity who underwent primary, revision, or definitive spinal fusion at 1 of 7 institutions were included. Candidate predictors were known preoperatively and were not modifiable in most cases; these included 31 patient, 12 surgical, and 4 hospital factors. The Centers for Disease Control and Prevention definition of SSI within 90 days of surgery was utilized. Following multiple imputation and multicollinearity testing, predictor selection was conducted with use of logistic regression to develop multiple models. The data set was randomly split into training and testing sets, and fivefold cross-validation was performed to compare discrimination, calibration, and overfitting of each model and to determine the final model. A risk probability calculator and a mobile device application were developed from the model in order to calculate the probability of SSI in individual patients. RESULTS A total of 3,092 spinal deformity surgeries were included, in which there were 132 cases of SSI (4.3%). The final model achieved adequate discrimination (area under the receiver operating characteristic curve: 0.76), as well as calibration and no overfitting. Predictors included in the model were nonambulatory status, neuromuscular etiology, pelvic instrumentation, procedure time ≥7 hours, American Society of Anesthesiologists grade >2, revision procedure, hospital spine surgical cases

Purpose The purpose of this study was to investigate associations between the various definitions of adding-on identified in the literature and HRQoL at 10 years following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) to identify a clinically relevant definition. Methods In this retrospective cohort study, patients with Lenke type 1 or 2 AIS with 10-year follow-up after PSF were identified in a multicenter registry. Adding-on was identified independently using 5 published definitions and expert spine surgeons' visual confirmation. Worsening of HRQoL was defined as a preoperative to 10-year postoperative decrease in SRS-22 domain score ≥ the minimal clinically important difference (MCID). Results One hundred fifty patients were included, and 118 had HRQoL data available for the main analysis. Worsening pain was noted in 49 (41.5%) patients, appearance in 1 (0.8%), and activity in 70 (59.3%) from preoperative to postoperative. 4 of the 5 definitions of adding-on demonstrated no evidence of association with worsening HRQoL. By Cho's definition (either 1. ≥ 5° increase in Cobb angle AND increase in number of vertebrae in curve distally, or 2. ≥ 5° increase in angulation of 1st disc below LIV), adding-on (27 patients, 22.9%) was associated with an increased risk of worsening pain (59.3% vs. 36.3%, p = 0.033) and activity (77.8% vs. 53.8%, p = 0.026). There was no evidence of association with changes in appearance. Risk of worsening pain and activity was increased by 1.75 and 1.51 times (p = 0.023 and p = 0.002), respectively. Conclusion Cho's definition of adding-on was associated with worsening HRQoL at 10 years following PSF for Lenke type 1 and 2 AIS. Consistent use of this definition will allow us to compare studies and obtain meaningful information in this population. Level of evidence Level II.

Background Addressing operational inefficiencies in operating rooms (ORs) enhances patient access to care, reduces delays, and improves employee and patient satisfaction. The Comprehensive Unit-based Safety Program (CUSP) promotes patient safety through increased teamwork, empowerment of frontline staff, and utilization of science of safety principles. CUSP has demonstrated success in outpatient and inpatient settings to decrease complication rates and establish a culture of safety but has been used minimally in the perioperative setting. In this study, the CUSP methodology was utilized to improve perioperative efficiency in pediatric spine surgery, and preimplementation and postimplementation efficiency were compared, using the rate of first case on-time starts (FCOTS) as the primary metric. Methods A CUSP quality improvement workgroup including nurses, technicians, surgeons, anesthesiologists, and administrators sought feedback on opportunities for improvement and tracked key performance metrics in the OR from 2015 to 2020. Key interventions developed in response to feedback included standardizing and streamlining room setup and adjusting staffing models for greater efficiency. Univariate analysis was conducted to compare time periods pre-CUSP and post-CUSP implementation. Results First case on-time starts increased from 38% to a high of 81% after implementation. For more complex cases, the average patient in the room to anesthesia ready time improved by 31% with decreased variance over time, and average closure to patient out of room time improved by 45%. Improvements were sustained through Year 3, while CUSP remained a primary focus for the team. Conclusions CUSP is effective in enhancing perioperative efficiency, demonstrating strong improvement in on-time starts over 5 years. The results indicate that process improvement in ORs requires consistent attention to sustain gains over time. Engaging frontline staff in quality improvement fosters collaboration and provides employee buy-in to promoting a culture of safety and improving value in patient care. Level of evidence Level III-retrospective comparative study.

The study sought to evaluate the utility of a single supine radiograph in determining curve flexibility in early-onset scoliosis (EOS) patients.EOS patients with upright (standing/seated), supine, and side-bending radiographs who underwent spinal deformity surgery were identified. Coronal parameters included: proximal thoracic (PT) curve, main thoracic (MT) curve, and thoracolumbar/lumbar (TL/L) curve. Each radiograph was measured twice by 2 different raters. Correlation coefficients were utilized to investigate associations between the different radiographs. Interrater Correlation Coefficient (ICC) assessed intrarater and interrater reliability.Thirty-seven EOS patients were identified (age at diagnosis: 7.0±2.9 y, preoperative age: 13.0±2.9 y; 73% female; etiologies: 54% idiopathic, 30% syndromic, and 16% neuromuscular). Supine PT and MT curve measurements were highly associated with corresponding side-bending measurements (PT: r=0.75, P0.001; MT: r=0.80, P0.001), and TL/L curves were very highly associated (TL/L: r=0.92, P0.001). The mean absolute differences between supine and side-bending measurements were PT: 11.3±7.8 degrees, MT: 14.8±8.3 degrees, and TL/L: 16.2±7.6 degrees, where the side-bending was on average smaller than the supine measurement. The intrarater reliabilities were excellent, with an ICC ranging from 0.93 to 0.96 for side-bending films and 0.94 to 0.97 for supine films. The interrater reliability was excellent with ICC value of 0.88 for side-bending films and 0.93 for supine films.A single, preoperative supine radiograph was highly predictive of side-bending radiographs in patients with EOS. Supine curves measured an average of 15 degrees larger than bending curves in the MT and TL/L region. A single supine film may eliminate the need for effort-related, dual side-bending radiographs.Level II-retrospective study.

We have made significant progress in minimizing the rate of surgical site infection (SSI) after pediatric spine surgery in the last 15 years. SSI are now uncommon in patients with adolescent idiopathic scoliosis, although still problematic in our patients with neuromuscular scoliosis with significant co-morbidities.1 A spike in SSI at my institution in 2008 led us to think critically about how we could do better for these patients. Our exploration revealed no “smoking gun” (these spikes are almost always multifactorial, related to breaks in systems that allow errors to propagate through the “Swiss cheese”), and thus, we began a series of investigations. Working with my friends at Children’s Hospital of Los Angeles and Children’s Hospital of Philadelphia, we quickly learned that gram-negative infections were accounting for a significant percentage of these infections—not only in our New York experience but much more broadly.2 Seeking to understand if there was a “best practice” for SSI prophylaxis, we performed a survey of POSNA members and discovered significant variability in practice patterns.3 Unexplained clinical variability usually means that at least some patients are receiving suboptimal care. We then formally examined the evidence in this space and, not surprisingly, found a lack of high-quality evidence to guide practice in this area.4 We became aware of the reality that significant practice variability and paltry evidence supported the current “best practices.” In order to gain consensus, we convened a group of experts and developed guidelines for best practices (BPG). The resulting BPG was published in JPO in 20135 and was the first of many such guidelines led by the Project for Safety in Spine Surgery (www.safetyinspinesurgery.com). The following year, our group experienced no SSI, leading us to reflect if infections should be a “never event.” Ten years later, rates of SSI remain much lower at our institution but also nationally as reflected in multiple papers using varying sources of data.6 Most recently, Sponseller et al. (with the Harms Study Group as part of the Project for Safety in Spine Surgery, 2022 Spine Surgery Safety Month) updated these guidelines reflecting some new evidence and also some new thinking (See Best Practice Guidelines - SSI Prevention & Treatment in High-risk Pediatric Surgery). In this JPOSNA® edition, Dr. Ryan Farmer shares a thoughtfully prepared quiz, and Dr. Ken Noonan provided me with an opportunity to reflect on where we have come from in the past and how we are doing now. The questions provided in this quiz point out some important issues and realities regarding our current understanding of what constitutes best practices for prophylaxis for the prevention of SSI. But while rates of SSI certainly seem lower than in the past, it is not exactly clear why this is. As supported by both the original and updated spine BPG, we have in many cases “thrown the kitchen sink” at the problem. For many reasons, we seem to pay more attention to SSI which may itself have a positive effect via the Hawthorne effect. Unfortunately, we actually do not have that much more high-quality evidence than we had 15 years ago. It should therefore be of no surprise that some of the “answers” in this quiz (which in some cases make intuitive sense) are not supported by consensus guidelines created by many of the “experts” in the aforementioned BPGs. SSI in pediatric spine is rare and often occurs as a result of a combination of complex interactive host, system, and clinical factors. Efforts to examine a single issue (e.g., comparative efficacy of CHG) are extremely limited by the biases which are essentially unavoidable in the design and conduct of this research. These methodological challenges to high-quality research in this area have led to some confusing findings resulting in mixed messaging about what the data is trying to tell us. When evidence is strong, it should always trump “expert opinion.” Unfortunately, the current evidence has not sufficiently improved upon knowledge present a decade ago when we were first confronted with this issue. Obviously, we need to be doing better in developing stronger evidence. Perhaps though, “res ipsa loquitur” (the thing speaks for itself). While rates of infection after spine surgery have certainly decreased, we can and should do better. We now have accurate models that allow us to identify higher-risk patients.7 And many of the proposed interventions have essentially no downside risk. To me, my obligation to the patient trumps my obligation to evidence. Until convinced otherwise, why not continue to change your gloves every 2 hours, place antibiotics in the wounds, keep temperature up, limit OR traffic, use topical skin disinfectant preoperatively, etc.?” As William Cowper said more than 200 years ago, “Absence of proof is not proof of absence.”

Background: Throughout the COVID-19 pandemic, decreases in health-related quality of life (HRQoL) have been observed in adults and children, with isolation, economic disruption, school closures, and health-related anxiety likely contributing. In this study, we evaluated the impact of COVID-19 on self-reported HRQoL of EOS patients and their caregivers using the Early Onset Scoliosis Questionnaire-24 (EOSQ-24). Methods: Patients with EOS and their caregivers enrolled in the Pediatric Spine Study Group (PSSG) registry with EOSQ scores from the year before the COVID-19 pandemic and the first year during COVID-19 were included. Two years of before-COVID-19 baseline EOSQ scores were recorded for each patient. We recorded patient medical demographics, scoliosis etiology, and comorbidities. Results: 618 patients met inclusion criteria (255 male, 363 female). All EOSQ subscores increased significantly from pre-COVID to early-COVID (p < 0.001, p < 0.05, respectively), though the mean difference was well below the proposed EOSQ-24 MCID. There was no evidence of change in Combined HRQoL or impact- and satisfaction-related scores between early COVID to late COVID (p > 0.37). When stratified by etiology, there was no evidence of decrease in the HRQoL combined score or other subscores in any subgroup between pre-COVID and during COVID. Conclusions: Overall, there was no evidence of negative impact on HRQoL by the COVID-19 pandemic for children with EOS or their caregivers. In the future, protective factors contributing to the resilience of this population may be explored further.

Typically, selection of lowest instrumented vertebra (LIV) in Adolescent Idiopathic Scoliosis (AIS) is based on the coronal radiograph; however, increasing evidence suggests that fusions proximal to the stable sagittal vertebrae (SSV) on the lateral radiograph can result in distal junctional kyphosis (DJK). The purpose of this study is to compare rates of DJK in patients with AIS that have a discordance between the Lowest Touched Vertebra (LTV) and the SSV and to identify risk factors for developing DJK. Patients with AIS Lenke type 1, 2 and 3 curves treated with a posterior spinal fusion were separated into two groups. Group 1 had SSV that was proximal to the LTV whereas group 2 had SSV that was distal to the LTV. Comparisons were made for patients that were fused to the SSV(a), LTV(b) or between(c). Distal junctional angle (DJA) > 5° and increasing kyphosis at the end of the fusion construct were evaluated as risk factors for DJK. The rate of DJK was 0.0% in group 1a, 1b, and 1c compared to 4.3%, 18.5% and 10.0% in groups 2a, 2b and 2c, respectively(p 5° versus 1.4% when the DJA

Biodeterioration is related to several biological systems and metabolic activities of fungi and bacteria. Fungal contamination is determined by the availability of water and temperature. Aspergillus is a fungus with great enzymatic capacity and with a high biodeterioration power. For this reason, it represents a threat to the conservation of cultural heritage objects. In this work, an exhaustive search of all the species involved was carried out, describing in detail the deterioration produced in different objects (wooden objects, glasses, paper, paintings, textiles, audiovisuals, glasses, human remains) as well preventive treatments. Like an opportunistic fungus it might cause some illness related to workers, a situation that is also addressed. Since the number of species increased from 180 to over 400 in the last 20 years, a taxonomy update has been done.

Retrospective, multicenter comparative. Our purpose was to compare early onset scoliosis (EOS) patients treated with ultra-low, low, and high implant density constructs when undergoing conversion to definitive fusion. Larson et al. demonstrated that implant density (ID) at fusion does not correlate with outcomes in the treatment of adolescent idiopathic scoliosis, but did not address growth-friendly graduates. EOS patients treated with growth-friendly constructs converted to fusion between 2000 and 2017 were reviewed from a multicenter database. ID was defined as number of pedicle screws, hooks, and sublaminar/bands per level fused. Patients were divided into ultra-low ID (

Shoulder balance is an important factor for patient satisfaction following surgery for idiopathic scoliosis (IS). There is no literature reporting the effect of anterior vertebral body tethering (AVBT) on shoulder balance. The purpose of this study was to report the prevalence of postoperative shoulder imbalance in patients undergoing AVBT for IS. In this retrospective case series, patients enrolled in a multicenter scoliosis registry who underwent AVBT from 2013 to 2017 in two Canadian centers were identified. The primary outcome was shoulder imbalance, defined as an absolute radiographic shoulder height of > 2 cm, at 2 years postoperatively (follow-up range: 22–30 months). Clavicular angle and T1 tilt angle were also investigated. Of the 50 patients identified (92% female; preoperative age: 11.9 ± 1.4 years), there were 43 (86%) patients with Lenke 1 and 7 (14%) patients with Lenke 2 curves. The mean Cobb angles of the proximal thoracic and main thoracic curves were 22.8° ± 8.8° and 49.4° ± 8.5° preoperatively and 13.1° ± 7.5° and 24.9° ± 9.5° at a mean follow-up time of 2.1 years. Absolute clavicular angle and T1 tilt angle were 2.8° ± 2.2° and 4.8° ± 3.5° preoperatively and 2.2° ± 1.7° and 4.7° ± 4.2° at 2-year follow-up. Preoperatively, absolute shoulder height averaged 15.6 ± 10.4 mm, and 15 (30%) patients had shoulder imbalance. At 2-year follow-up, absolute shoulder height averaged 11.2 ± 8.3 mm, and 8 (16%) patients had shoulder imbalance. Of the patients who had acceptable shoulder balance preoperatively, 4 (11.4%) became imbalanced at 2 years postoperatively. Postoperative shoulder imbalance in this early group of patients with IS undergoing AVBT was seen in 16% of patients, a reduction from 30% preoperatively. These results likely reflect the potential of the proximal thoracic curve to correct spontaneously following AVBT. Level III.

Fungal infections have increased in recent years due to host factors, such as oncohaematological and transplant-related disorders, immunosuppressive therapy, and AIDS. Additionally, molecular and proteomic facilities have become available to identify previously unrecognizable opportunists. For these reasons, reports on less-known and recalcitrant mycoses, such as those caused by black fungi, hyaline filamentous fungi, coelomycetes, Mucorales, and non-Candida yeasts have emerged. In this review, novel taxonomy in these groups, which often are multi-resistant to one or several classes of antifungals, is discussed. Clinical presentations, diagnosis and current treatment of some major groups are summarised.

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

Resume En decembre 2015, le Club des utilisateurs des automates pharmaceutiques (CUAP) avait emis ses premieres recommandations concernant la preparation des doses administrees automatisees. Ce document etait le fruit du travail et de la reflexion de pharmaciens hospitaliers ayant mis en place, dans leurs pharmacies a usage interieur (PUI), une demarche de dispensation avec delivrance nominative par preparation de la dose a administrer a l’aide d’automates pharmaceutiques necessitant un deconditionnement prealable des specialites. Depuis, le groupe s’est enrichi de professionnels hospitaliers s’etant engages dans une demarche similaire de preparation automatisee robotisee avec surconditionnement des medicaments. Ces nouvelles recommandations sont, non seulement une actualisation des donnees 2015 pour les automates de deconditionnement, mais egalement l’integration des specificites des automates de surconditionnement. Ces bonnes pratiques ciblent les produits concernes par une automatisation, le personnel, les locaux, le materiel, la preparation automatisee en elle-meme, le transport et la livraison du produit fini ainsi que la gestion de la qualite et la documentation.

The 24-question Early-Onset Scoliosis Questionnaire (EOSQ-24) is a proxy measure assessing health-related quality of life (HRQoL) among patients with early-onset scoliosis (EOS). There exists an increasing need to assess HRQoL through a child's own perspective, particularly for older children and adolescents with EOS. The purpose of this study was to develop and validate a self-reported questionnaire, the Early-Onset Scoliosis Self-Report Questionnaire (EOSQ-SELF), to assess HRQoL in older children and adolescents with EOS.A literature review, an expert focus group, and patient interviews were used to generate a preliminary survey of appropriate domains and question items. This survey was provided to English-speaking patients with EOS who were 8 to 18 years of age and capable of answering survey questions. Content validity was assessed for clarity and relevance of questions. Confirmatory factors analysis was performed to reduce the number of items and determine domains that fit items. Reliability was evaluated by measuring the internal consistency of items and test-retest reliability. Construct validity was evaluated by convergent, discriminant, and known-group validity.The literature review, expert focus group, and patient interviews identified 59 questions in 14 domains. Psychometric analysis reduced these to 30 questions across 12 domains: General Health, Pain/Discomfort, Pulmonary Function, Transfer, Physical Function/Daily Living, Participation, Fatigue/Energy Level, Sleep, Appearance, Relationships, Emotion, and Satisfaction. The final questionnaire was found to have good content and construct validity and adequate reliability.The EOSQ-SELF is a valid and reliable instrument for measuring self-reported HRQoL among older children and adolescents with EOS (ages 8 to 18 years). This will serve as an important research outcome measure and enhance clinical care by providing a better understanding of HRQoL for these patients.Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Appropriately measuring and classifying surgical complications is a critical component of research in vulnerable populations, including children with early-onset scoliosis (EOS). The purpose of this study was to assess the inter- and intra-rater reliability of a modified Clavien-Dindo-Sink system (CDS) classification system for EOS patients among a group of pediatric spinal deformity surgeons.Thirty case scenarios were developed and presented to experienced surgeons in an international spine study group. For each case, surgeons were asked to select a level of severity based on the modified CDS system to assess inter-rater reliability. The survey was administered on two occasions to allow for assessment of intra-rater reliability. Weighted Kappa values were calculated, with 0.61 to 0.80 considered substantial agreement and 0.81 to 1.00 considered nearly perfect agreement.11/12 (91.7%) surgeons completed the first-round survey and 8/12 (66.7%) completed the second. Inter-observer weighted kappa values for the first and second survey were 0.75 [95% CI 0.56-0.94], indicating substantial agreement, and 0.84 [95% CI 0.70-0.98], indicating nearly perfect agreement, respectively. Intra-observer reliability was 0.86 (range 0.74-0.95) between the first and second surveys, indicating nearly perfect agreement .The modified CDS classification system demonstrated substantial to nearly perfect agreement between and within observers for the evaluation of complications following the surgical treatment of EOS patients. Adoption of this reliable classification system as a standard for reporting complications in EOS patients can be a valuable tool for future research endeavors, as we seek to ultimately improve surgical practices and patient outcomes.Level V.

Due to a combination of poor respiratory muscle control and mechanical lung compression secondary to spine and chest wall deformities, patients with neuromuscular (NM) early-onset scoliosis (EOS) are at a high risk for pulmonary complications including pneumonia. The purpose of this study is to examine the effect of surgical intervention on the prevalence and risk of postoperative pneumonia in patients with NM EOS.In this retrospective cohort study, pediatric (18 y old and below) patients with NM EOS undergoing index fusion or growth-friendly instrumentation from 2000 to 2018 were identified. Patients were then categorized into 2 groups: those with ≥50% curve correction and those with50% curve correction of the coronal deformity at the first postoperative visit. The primary outcome of interest was postoperative pneumonia occurring between 3 weeks and 2 years postoperatively. Manual chart review was supplemented with phone call surveys to ensure all occurrences of preoperative/postoperative pneumonia (ie, in-institution and out-of-institution visits) were accounted for.A total of 35 patients (31% female, age at surgery: 10.3±4.3 y) with NM EOS met inclusion criteria. Twenty-three (66%) patients experienced at least 1 case of preoperative pneumonia. Twenty-six (74%) patients had ≥50% and 9 (26%) patients had50% immediate postoperative curve correction. In total, 12 (34%) patients experienced at least 1 case of postoperative pneumonia (7 in-institution, 5 out-of-institution). Seven (27%) patients with ≥50% curve correction versus 5 (56%) with50% curve correction experienced postoperative pneumonia. Relative risk regression demonstrated that patients with50% curve correction had increased risk of postoperative pneumonia by 2.1 times compared with patients with ≥50% curve correction (95% confidence interval: 0.9; 4.9, P =0.099).The prevalence of preoperative and postoperative pneumonia is high in patients with NM EOS. This study presents preliminary evidence suggesting that percent curve correction is associated with the occurrence of postoperative pneumonia in patients with NM EOS undergoing surgical correction.

The outcomes of congenital scoliosis (CS) patients undergoing hemivertebra (HV) resection surgery with a 2-level fusion versus a2-level fusion are unclear. We hypothesized that CS patients undergoing HV resection and a2-level fusion have decreased curve progression and reoperation rates compared with 2-level fusions.Retrospective review of prospectively collected data from a multicenter scoliosis database. Fifty-three CS patients (average age 4.5, range 1.2 to 10.9 y) at index surgery were included. Radiographic and surgical parameters, complications, as well as revision surgery rates were tracked at a minimum of 2-year follow-up.Twenty-six patients had a 2-level fusion while 27 patients had a2-level fusion with similar age and body mass index between groups. The HV was located in the lumbar spine for 69% (18/26) 2-level fusions and 30% (8/27)2-level fusions ( P =0.006). Segmental HV scoliosis curve was smaller in 2-level fusions compared to2-level fusions preoperatively (38 vs. 50 degrees, P =0.016) and at follow-up (25 vs. 34 degrees, P =0.038). Preoperative T2-T12 (28 vs. 41 degrees, P =0.013) and segmental kyphosis (11 vs. 23 degrees, P =0.046) were smaller in 2-level fusions, but did not differ significantly at postoperative follow-up (32 vs. 39 degrees, P =0.22; 13 vs. 11 degrees, P =0.64, respectively). Furthermore, the 2 groups did not significantly differ in terms of surgical complications (27% vs. 22%, P =0.69; 2-level fusion vs.2-level fusion, respectively), unplanned revision surgery rate (23% vs. 22%, 0.94), growing rod placement or extension of spinal fusion (15% vs. 15%, P =0.95), or health-related quality of life per the EOS-Questionnaire 24 (EOSQ-24). Comparison of patients with or without the need for growing rod placement or posterior spinal fusion revealed no significant differences in all parameters analyzed.Two-level and2-level fusions can control congenital curves successfully. No differences existed in curve correction, proximal junctional kyphosis or complications between short and long-level fusion after HV resection. Both short and long level fusions are viable options and generate similar risk of revision. The decision should be individualized by patient and surgeon.

The selection of lowest instrumented vertebra (LIV) in adolescent idiopathic scoliosis (AIS) is determined by coronal and sagittal plane indicators. Failure to properly select the LIV can lead to suboptimal outcomes and the need for revision surgery. A subset of patients have discordant coronal last touched vertebra (cLTV) and stable sagittal vertebra (SSV) which complicates the choice of LIV. The purpose of this study is to report the incidence of discordant cLTV and SSV when choosing LIV and investigate the association between length of fusion and patient-reported outcomes (PROs) and distal junctional kyphosis (DJK). This retrospective multicenter cohort study included AIS patients with discordant pre-operative cLTV and SSV. Patients fused only to include the proximal cLTV were compared to patients fused to include the distal SSV. Primary outcomes included DJK and PROs measured by SRS-22. Eight hundred and fifty-six patients were identified of which 114 (13.3%) had discordant SSV and cLTV. The DJK incidence was 7.7% and 45.5% in patients fused to include the SSV versus short of the SSV, respectively. Lenke Modifier type B and C patients with fusions short of the SSV had a 9.2 times increased risk of developing DJK at 2 years compared to patients with fusions including the SSV (95% CI 2.8, 29.7; p

Physiotherapeutic Scoliosis-Specific Exercise (PSSE) is a conservative approach for management of adolescent idiopathic scoliosis (AIS). Although there is Level I evidence for the efficacy of PSSE, compliance in the teenage population remains in question. The purpose of this study is to investigate the association between completion of formal PSSE training and compliance to prescribed home exercise programs (HEP). Patients with AIS evaluated at our institution between 2013 and 2015 with a minimum of one PSSE session were enrolled. A chart review and questionnaire completed by caregivers was utilized to assess HEP compliance following the final PSSE session at 1 week, 3 months, 1 year, and 2 years. Patients were divided into two groups, those completing formal training (10 or more PSSE sessions), and those who did not complete formal training (fewer than 10 sessions). 81 patients were identified (mean age of 13.1 years; major curve of 31.3°). Patients who completed training demonstrated 50% compliance at 1 week (vs. 25.6% for non-completers, Odds Ratio (OR): 2.9, p = 0.027), 41.2% at 3 months (vs. 18.9% for non-completers, OR: 3.0, p = 0.044), 23.5% at 1 year (vs. 13.5% for non-completers, OR: 2.0, p = 0.281), and 25.7% at 2 years (vs. 13.5% for non-completers, OR: 2.2, p = 0.197). The mean HEP duration (minutes) in patients who completed training was higher at 1 week (80.8 vs. 48, p = 0.010), 3 months (64.6 vs. 23.7, p ≤ 0.001), 1 year (35.3 vs. 22.7, p = 0.270), and 2 years (34.3 vs. 18.9, p = 0.140). Patients who completed PSSE training maintained higher HEP compliance.

To investigate outcomes of ambulatory pediatric patients fused to the sacrum with pelvic fixation. Retrospective cohort. Historically in the pediatric spinal deformity literature, long fusions to the sacrum with pelvic fixation have been limited to non-ambulatory patients with pelvic obliquity. This analysis assesses the impact of how long fusions that include pelvic fixation in ambulatory pediatric patients. Consecutive pediatric patients undergoing fusion to the sacrum with pelvic fixation with any ambulatory capacity at a tertiary academic pediatric spine program from 2016 to 2018 were included in this review. Patient demographics, surgical details, and postoperative results were collected and analyzed to identify the impact on postoperative gait and ambulation function. Outcomes were determined from PROMIS, Parent Proxy Mobility questionnaires, as well as an institution specific pediatric gait questionnaire. 25 patients met inclusion criteria. 96.0% of patients had non-idiopathic scoliosis. 48% (12/25) of patients had previous spinal surgery. Median fusion levels were 17.0. 40% (10/25) had preoperative motor and gait deficits and only one patient with a documented decline at postoperative clinical examination. All 25 patients retained ambulatory capacity following their spinal fusion to the sacrum with pelvic fixation. 64% (16/25) of patients or family members completed the postoperative gait questionnaire. The mean PROMIS T-score was 43.4 (95% CI 36.5–50.0) for intact patients. The postoperative gait questionnaires revealed that 75% (6/8) of neurologically intact patients stated they would have the surgery again. 100% (8/8) of these patients noted an improved posture and 25% (2/8) reported a subjective decrease in ambulatory capacity status/post fusion to the sacrum. 100.0% (8/8) of limited ambulatory patients stated they would have the surgery again and noted improved posture with only 25% (2/8) noting a subjective decrease in ambulation postoperatively. In appropriately selected pediatric spinal deformity patients fusion to the sacrum using pelvic fixation can maintain ambulation with high overall surgical satisfaction. III.

The purpose of this study was to utilize the National Readmission Database (NRD) to determine estimates for complication rates, 90-day readmission rates, and hospital costs associated with spinal fusion in pediatric patients with Marfan syndrome. The 2012–2015 NRD databases were queried for all pediatric (

Study Design: Retrospective cohort. Objective: To provide a national-level assessment of the short-term outcomes after spinal deformity surgery in pediatric patients with cerebral palsy. Methods: A national, prospectively collected database was queried to identify pediatric (≤18 years) patients with cerebral palsy, who underwent spinal fusion surgery from 2012 to 2017. Separate multivariate analyses were performed for the primary outcomes of interest including extended length of stay (>75th percentile, >8 days), and readmissions within 90 days after the index admission. Results: A total of 2856 patients were reviewed. The mean age ± standard deviation was 12.8 ± 2.9 years, and 49.4% of patients were female. The majority of patients underwent a posterior spinal fusion (97.0%) involving ≥8 levels (79.9%) at a teaching hospital (96.6%). Top medical complications (24.5%) included acute respiratory failure requiring mechanical ventilation (11.4%), paralytic ileus (8.2%), and urinary tract infections (4.6%). Top surgical complications (40.7%) included blood transfusion (35.6%), wound complication (4.9%), and mechanical complication (2.7%). The hospital cost for patients with a length of hospital stay >8 days ($113 669) was nearly double than that of those with a shorter length of stay ($68 411). The 90-day readmission rate was 17.6% (mean days to readmission: 30.2). The most common reason for readmission included wound dehiscence (21.1%), surgical site infection (19.1%), other infection (18.9%), dehydration (16.9%), feeding issues (14.5%), and acute respiratory failure (13.1%). Notable independent predictors for 90-day readmissions included preexisting pulmonary disease (odds ratio [OR] 1.5), obesity (OR 3.4), cachexia (OR 27), nonteaching hospital (OR 3.5), inpatient return to operating room (OR 1.9), and length of stay >8 days (OR 1.5). Conclusions: Efforts focused on optimizing the perioperative pulmonary, hematological, and nutritional status as well as reducing wound complications appear to be the most important for improving clinical outcomes.

Currently, there is significant equipoise regarding the selection and placement of growing spinal instrumentation when treating patients with early-onset scoliosis (EOS). The primary purpose of this study was to compare complications following surgery in patients receiving rib-based versus spine-based proximal anchors as a part of posterior growing instrumentation in the management of EOS. Retrospective cohort study. Inclusion criteria required: age 3–10 years old, diagnosis of EOS, treatment with a growing construct that utilized rib- or spine-based proximal anchors, and a major coronal curve larger than 40 degrees. The primary outcome analyzed was postoperative complications. Secondary outcomes included coronal major curve correction and patient reported outcomes measured by the Early-Onset Scoliosis 24-item Questionnaire (EOSQ-24). Subjects were categorized into rib- or spine-based proximal fixation groups for comparison. Of 104 patients included in the study, 76 (73.1%) were treated with rib-based constructs and 28 (26.9%) were treated with spine-based constructs. 24 (31.6%) patients with rib-based constructs and 9 (32.1%) patients with spine-based constructs experienced at least one implant related complication (p = 0.956). Rod fracture was observed more often in spine-based groups than rib-based groups for both patients with congenital/idiopathic EOS (rib: 0 (0%) vs. spine: 3 (13.6%), p = 0.009) and neuromuscular/syndromic EOS (rib: 0 (0%) vs. spine: 2 (33.3%), p = 0.002). Furthermore, surgical site infection was found to be more frequent in rib-based than spine-based groups for neuromuscular/syndromic patients (rib: (13) 27.15 vs. spine: (1) 4.5%, p = 0.029). The most commonly reported complication was device migration. In patients with rib-based constructs, 2 (12.5%) patients with ≥ 5 anchors and 13 (21.7%) patients with

STUDY DESIGN Retrospective review. OBJECTIVE The aim of this study was to analyze the political contributions and strategies of the Political Action Committee (PACs) lobbying for the political interests of spine surgeons. SUMMARY OF BACKGROUND DATA In 2016, a presidential election year, $514,224,628 was spent on health care lobbying. Only 16% ($85,061,148) was on behalf of health professionals providing care. Below we chronicle the overlapping contributions between the three different physician-based Political Action Committee (PAC) lobbying entities as it relates specifically to spine surgery. METHODS Data were abstracted for the PACs of the American Association of Neurological Surgeons (AANS), American Association of Orthopedic Surgeons (AAOS), and the North American Spine Society (NASS). These data were obtained using OpenSecrets (opensecrets.org), and the Federal Election Commission (fec.gov) website. All data points were collected biannually from 2006 to 2018 and statistically analyzed as appropriate. RESULTS In 2016, the AAOS PAC contributed $2,648,218, the AANS PAC $348,091, and the NASS PAC $183,612. After accounting for respective group size, the AAOS spent >2.34 times that of the AANS. Orthopedists were 3.84 times (95% confidence interval 3.42-4.3) more likely to donate to their PAC than neurosurgeons (P

Retrospective cohort study. To assess the effectiveness of two infection-reducing programs in mitigating the incidence of post-operative surgical site infections (SSI) in pediatric patients after spinal deformity surgery at our institution. Infections following spinal deformity surgery are associated with higher morbidity as well as significantly increased healthcare costs. SSI in patients with neuromuscular etiologies is especially high, exceeding 8 percent for myelodysplasia patients and 6 percent for cerebral palsy patients. Manual chart review was conducted for 1934 pediatric spine procedures in 1200 patients at our institution between 2008 and 2018. Patients between the ages of 0 and 21 having any spinal surgical procedure including lengthening of growing rods were included. Institution of two separate infection-reducing programs reduced risk of SSI in this population by 65.4%, when adjusted for age and number of instrumentation levels (risk ratio [RR] = 0.3, 95% confidence interval [CI] = 0.2; 0.6, p = 0.001). Patients undergoing Initial Instrumentation demonstrated 68.8% less risk of SSI compared to those who had other types of surgical procedures, after adjusting for age and the number of level instrumented (RR = 0.3, 95% CI 0.2; .6, p = 0.002). It was observed that the effect of each of these infection-reducing programs diminished with time. This effect was also observed with prior programs implemented at our institution. The incidence of SSI decreased following the implementation of two infection-reducing programs especially in patients undergoing Initial Instrumentation procedures. However, time-series analysis suggests these programs may have maximal effect immediately following institution that diminishes with time. Level III.

Multicenter retrospective cohort study. To compare pre-operative and post-operative EOSQ-24 scores in magnetically controlled growing rods (MCGR) and traditional growing rod (TGR) patients. Since the introduction of MCGR, early-onset scoliosis patients have been afforded a reduction in the number of surgeries compared to the TGR technique. However, little is known about (health-related quality of life) and burden of care outcomes between these surgical techniques. This is a retrospective cohort study using a multicenter registry on patients with EOS undergoing MCGR or TGR between 2008 and 2017. The EOSQ-24 was administered at preoperative and postoperative 2-year assessments. The EOSQ-24 scores were compared between MCGR and TGR as well as preoperatively and postoperatively within each procedure. 110 patients were analyzed in this study (TGR, N = 32; MCGR, N = 78). There were no significant differences in preoperative age, gender, etiology, main coronal curve or maximum kyphosis between TGR and MCGR groups. Patients with TGR had averaged 3.9 surgical lengthenings and MCGR had averaged 7.7 non-invasive lengthenings by the 2-year follow-up. When changes in preoperative to postoperative scores were compared, MCGR had more improvements in pain, emotion, child satisfaction and parent satisfaction than TGR although there were no statistical significance. When analyzed separately, MCGR cohort had improvement in scores for all four domains and four sub-domains; while, TGR cohort only had improvement in financial burden domain and pulmonary function sub-domain. Although there was no statistical significance, the improvement in pain, emotion and satisfaction scores was larger in MCGR than TGR. Since these areas can be influenced more by mental well-being than other sub-domains, the results may prove our hypothesis that compared to TGR, MCGR with reduced number of surgeries have better psychosocial effects. III.