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Purpose: Cerebral Palsy (CP) often presents with a sweeping thoracolumbar scoliosis and pelvic obliquity. With severe pelvic obliquity, the ribs come into contact with the high side of the oblique pelvis, termed rib-on-pelvis deformity (ROP). ROP can result in costo-iliac impingement, or pain associated with ROP, and can also adversely affect breathing and sitting balance. The goal of this study was to evaluate whether CP patients with ROP have worse health-related quality of life (HRQOL) before surgery and a greater improvement in HRQOL after surgery., Methods: A retrospective analysis of a prospectively collected, multicenter, international registry was performed for all nonambulatory patients with CP treated with spinal fusion with at least two-year follow-up. HRQOL was measured via the Caregiver Priorities & Child Health Index of Life with Disabilities (CPCHILD) questionnaire domains (0 = most disability, 100 = least disability). ROP was defined as having a rib distal to the superior portion of the iliac crest on preop upright radiographs. The ROP group and control group without ROP were compared regarding six domain scores and total score of CPCHILD. Multiple linear regression was used to control for curve apex location, major coronal Cobb angle, type of tone, and pelvic obliquity., Results: 340 patients met inclusion criteria (52% female, mean age 14.0 years). The mean major coronal Cobb angle was 81 degrees and mean pelvic obliquity was 22 degrees. 176 patients (51.8%) had ROP while 164 patients (48.2%) did not. ROP was independently associated with worse preoperative Positioning/Transfers/Mobility (PTM), Comfort & Emotions (C&E), and total CPCHILD score via the CPCHILD questionnaire (p < 0.05). Patients with preoperative ROP experienced a greater improvement in the C&E and PTM domains as well as total CPCHILD score than patients without ROP (p < 0.05)., Conclusion: CP patients with rib-on-pelvis deformity experience more pain and worse HRQOL than patients without this deformity. These patients experienced a greater improvement in HRQOL after spinal fusion measured via the CPCHILD questionnaire., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background and Objectives: Anterior vertebral body tether (VBT) is a fusionless approach to treat idiopathic scoliosis, and surgeons are beginning to implement the technique into current practice. This study aims to evaluate the learning curve for single and double VBT., Methods: A retrospective review of 3 surgeons' first 40 single and 20 double VBT was performed. Skeletally immature patients with idiopathic scoliosis who underwent thoracic (single) or thoracolumbar (double) VBT were included. Thoracic VBT was done via video-assisted thoracoscopic surgery and lumbar VBT through a mini-open retroperitoneal approach. Primary outcomes of interest were operative time, radiation exposure, and radiographic correction. Pooled and individual-surgeon analyses were performed., Results: A total of 180 patients were included: 120 single and 60 double. Mean age was 12.7 years, and 87.8% were female. Mean segments tethered was 7.8 in single and 11.0 in double. Mean preoperative thoracic scoliosis was 51.5: single 50.5° and double 53.3°. Mean lumbar scoliosis was 36.4°: single 30.0° and double 49.0°. Average operating time was 276.2 minutes; double VBT was significantly longer (217.3 vs 394.0 minutes, P < .001). Mean blood loss was 198.5 mL, and mean fluoroscopy dose was 73.0 mGy. For single VBT, there was a decrease in operative time (283.3-174.8 minutes, P < .001) and fluoroscopy dose (70.1-53.5 mGy, P = .047) over time. Every 10 cases resulted in a 31.4 minute decrease in operative time (P < .001). There were no intraoperative complications. Single VBT resulted in 54.9% thoracic curve correction. Double VBT achieved 53.0% thoracic and 56.7% lumbar correction. There were no differences in curve correction across the learning curve., Conclusion: VBT is viable fusionless surgical option for scoliosis. As expected, increased experience resulted in shorter operative time; the threshold for such improvement seems to be 10 cases. Importantly, adequate and consistent curve correction can be achieved at the start of the learning curve while mitigating complications., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Background: Back pain, as a clinical marker in scoliosis, has been associated with underlying pathology for many years, warranting further magnetic resonance imaging (MRI). Failures of segmentation, mixed defects, female gender, rib anomalies, congenital thoracic anomalies, and neurocutaneous markers are known risk factors for abnormal MRI pathology findings in patients with congenital early-onset scoliosis (Congenital-EOS). Yet, back pain has not been evaluated as a risk factor for underlying MRI pathology in patients with Congenital-EOS. This study aimed to assess back pain as a risk factor for underlying pathology in Congenital-EOS using MRI as a diagnostic tool., Methods: A retrospective database review from the Pediatric Spine Study Group (PSSG) of all patients with Congenital-EOS who reported a back pain complaint, and underwent a spinal MRI study before surgical intervention was performed. Patients were divided into those with an underlying MRI pathology and those without. Demographics were compared between groups., Results: From a total of 2355 patients with Congenital-EOS registered in PSSG, 107 patients reported a back pain complaint, with only 42 patients fulfilling the inclusion criteria (being evaluated with an MRI study). Overall group mean age was 8.1±4.5 years, with 25 of the 42 patients (60%) being females. Twenty-four of 42 patients (57%) had a comorbidity reported such as cardiac problems, musculoskeletal complaints, neurological deficits/myelopathy, gastrointestinal symptoms, developmental delay, respiratory problems, craniofacial abnormalities, and chromosomal conditions. An underlying MRI pathology was found in 21 of 42 patients with Congenital-EOS (50%) with back pain. The underlying MRI pathologies found were tethered spinal cord, spinal canal stenosis, syringomyelia, Arnold-Chiari malformation, and arachnoid cyst., Conclusions: Abnormal MRI findings are common in patients with Congenital-EOS who report back pain. Gender, age, major coronal curve angle, thoracic or lumbar predominance deformity, and comorbidities type or amount were not associated with abnormal MRI findings., Level of Evidence: Level II-Prognostic study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Traditionally, less rigid fixation techniques have been applied to the pediatric cervical spine. There is a lack of long-term outcome data for rigid fixation techniques. The purpose of this study was to define the clinical outcome and safety of posterior instrumented fusion in the pediatric population using adult posterior instrumentation., Methods: A multicenter, retrospective review of pediatric patients who underwent posterior cervical fusion using a 3.5 mm posterior cervical system for any indication was performed. Outcome parameters included complications, revision and fusion rates, operative time (OR), blood loss, and postoperative neurologic status. Outcomes were compared between patient groups (posterior only versus anterior/posterior approach, short versus intermediate versus long fusion, and between different etiologies) using Mann-Whitney and chi-square test., Results: Seventy-nine patients with a mean age of 9.9 years and mean follow-up of 2.8 years were included. At baseline 44 (56%) had an abnormal neurologic exam. Congenital deformities and basilar invagination were the most common indications for surgery. Posterior-only surgery was performed in 71 (90%) cases; mean number of levels fused was 4 (range 1-15). Overall, 4 (5%) operative complications and 4 (5%) revisions were reported at an average postoperative time of 2.6 years. Neurologic status remained unchanged in 74%, improved in 23%, and worsened in 3%. When comparing outcome measures between the various groups, 2 significant differences were found: OR was longer in the anterior/posterior approach group and decline of neuro status was more frequent in the long fusion group., Conclusion: Posterior cervical fusion with an adult 3.5 mm posterior cervical system was safe in this cohort of 79 pediatric patients irrespective of surgical technique, fusion length, and etiology, resulting in a high fusion and low complication/revision rate., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Study Design: Multi-center, prospective, observational cohort., Objective: To compare myelopathic vs. non-myelopathic ambulatory patients in short- and long-term neurologic function, operative treatment, and patient-reported outcomes., Methods: Pediatric deformity patients from 16 centers were enrolled with the following inclusion criteria: aged 10-21 years-old, a Cobb angle ≥100° in either the coronal or sagittal plane or any sized deformity with a planned 3-column osteotomy, and community ambulators. Patients were dichotomized into 2 groups: myelopathic (abnormal preoperative neurologic exam with signs/symptoms of myelopathy) and non-myelopathic (no clinical signs/symptoms of myelopathy)., Results: Of 311 patients with an average age of 14.7 ± 2.8 years, 29 (9.3%) were myelopathic and 282 (90.7%) were non-myelopathic. There was no difference in age ( P = 0.18), gender ( P = 0.09), and Risser Stage ( P = 0.06), while more patients in the non-myelopathic group had previous surgery (16.1% vs. 3.9%; P = 0.03). Mean lower extremity motor score (LEMS) in myelopathic patients increased significantly compared to baseline at every postoperative visit: Baseline: 40.7 ± 9.9; Immediate postop: 46.0 ± 7.1, P = 0.02; 1-year: 48.2 ± 3.7, P < 0.001; 2-year: 48.2 ± 7.7, P < 0.001). The non-myelopathic group had significantly higher LEMS immediately postoperative ( P = 0.0007), but by 1-year postoperative, there was no difference in LEMS between groups (non-myelopathic: 49.3 ± 3.6, myelopathic: 48.2 ± 3.7, P = 0.10) and was maintained at 2-years postoperative (non-myelopathic: 49.2 ± 3.3, myelopathic: 48.2 ± 5.7, P = 0.09). Both groups improved significantly in all SRS domains compared to preoperative, with no difference in scores in the domains for pain ( P = 0.12), self-image ( P = 0.08), and satisfaction ( P = 0.83) at latest follow-up., Conclusion: In severe spinal deformity pediatric patients presenting with preoperative myelopathy undergoing spinal reconstructive surgery, myelopathic patients can expect significant improvement in neurologic function postoperatively. At 1-year and 2-year postoperative, neurologic function was no different between groups. While non-myelopathic patients had significantly higher postoperative outcomes in SRS mental-health, function, and total-score, both groups had significantly improved outcomes in every SRS domain compared to preoperative.

Background: Prior "best practice guidelines" (BPG) have identified strategies to reduce the risk of acute deep surgical site infection (SSI), but there still exists large variability in practice. Further, there is still no consensus on which patients are "high risk" for SSI and how SSI should be diagnosed or treated in pediatric spine surgery. We sought to develop an updated, consensus-based BPG informed by available literature and expert opinion on defining high-SSI risk in pediatric spine surgery and on prevention, diagnosis, and treatment of SSI in this high-risk population., Materials and Methods: After a systematic review of the literature, an expert panel of 21 pediatric spine surgeons was selected from the Harms Study Group based on extensive experience in the field of pediatric spine surgery. Using the Delphi process and iterative survey rounds, the expert panel was surveyed for current practices, presented with the systematic review, given the opportunity to voice opinions through a live discussion session and asked to vote regarding preferences privately. Two survey rounds were conducted electronically, after which a live conference was held to present and discuss results. A final electronic survey was then conducted for final voting. Agreement ≥70% was considered consensus. Items near consensus were revised if feasible to achieve consensus in subsequent surveys., Results: Consensus was reached for 17 items for defining high-SSI risk, 17 items for preventing, 6 for diagnosing, and 9 for treating SSI in this high-risk population. After final voting, all 21 experts agreed to the publication and implementation of these items in their practice., Conclusions: We present a set of updated consensus-based BPGs for defining high-risk and preventing, diagnosing, and treating SSI in high-risk pediatric spine surgery. We believe that this BPG can limit variability in practice and decrease the incidence of SSI in pediatric spine surgery., Level of Evidence: Not applicable., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Cervical spine disorders in children are relatively uncommon; therefore, paradigms for surgical and nonsurgical clinical management are not well established. The purpose of this study was to bring together an international, multidisciplinary group of pediatric cervical spine experts to build consensus via a modified Delphi approach regarding the clinical management of children with cervical spine disorders and those undergoing cervical spine stabilization surgery., Methods: A modified Delphi method was used to identify consensus statements for the management of children with cervical spine disorders requiring stabilization. A survey of current practices, supplemented by a literature review, was electronically distributed to 17 neurosurgeons and orthopedic surgeons experienced with the clinical management of pediatric cervical spine disorders. Subsequently, 52 summary statements were formulated and distributed to the group. Statements that reached near consensus or that were of particular interest were then discussed during an in-person meeting to attain further consensus. Consensus was defined as ≥ 80% agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree)., Results: Forty-five consensus-driven statements were identified, with all participants willing to incorporate them into their practice. For children with cervical spine disorders and/or stabilization, consensus statements were divided into the following categories: A) preoperative planning (12 statements); B) radiographic thresholds of instability (4); C) intraoperative/perioperative management (15); D) postoperative care (11); and E) nonoperative management (3). Several important statements reaching consensus included the following recommendations: 1) to obtain pre-positioning baseline signals with intraoperative neuromonitoring; 2) to use rigid instrumentation when technically feasible; 3) to provide postoperative external immobilization for 6-12 weeks with a rigid cervical collar rather than halo vest immobilization; and 4) to continue clinical postoperative follow-up at least until anatomical cervical spine maturity was reached. In addition, preoperative radiographic thresholds for instability that reached consensus included the following: 1) translational motion ≥ 5 mm at C1-2 (excluding patients with Down syndrome) or ≥ 4 mm in the subaxial spine; 2) dynamic angulation in the subaxial spine ≥ 10°; and 3) abnormal motion and T2 signal change on MRI seen at the same level., Conclusions: In this study, the authors have demonstrated that a multidisciplinary, international group of pediatric cervical spine experts was able to reach consensus on 45 statements regarding the management of pediatric cervical spine disorders and stabilization. Further study is required to determine if implementation of these practices can lead to reduced complications and improved outcomes for children.

Purpose: Pulmonary function and quality of life (QOL) are important outcome measures for patients with early-onset scoliosis (EOS) undergoing rib-based growing system (RBGS) implantation. The Assisted Ventilation Rating (AVR) measures ventilator requirements in this population. A higher, more severe, score implies negative changes in QOL. The EOS Questionnaire (EOSQ) is a validated outcome measure. Paired measurements for both ratings were compared to clarify correlation between ventilator status and QOL. Secondary analysis aimed at defining QOL between more broad subgroups defined by ventilator use., Methods: AVR and EOSQ scores were extracted from the Pediatric Spine Study Group database for patients 10 years of age and under. Instances were excluded if the time between AVR and EOSQ assessment was greater than 6 months. Scores were compared using Spearman correlation coefficient. Subgroup analysis included control for age, gender, and etiology. Secondary analysis was performed for broad functional grouping using ranked analysis of variance for repeated measures using median scores., Results: Two thousand five hundred and forty-two instances of paired EOSQ and AVR in 329 patients were analyzed. A statistically significant weak correlation between AVR and EOSQ was identified in Child's Health Related QOL and Family Impact sections, in nine subsets. Subgroup analysis showed little variation, except increased correlation in female patients to near moderate level. Analysis of variance for demonstrated decreased medians for all subdomains when comparing those mechanically ventilated to patients who did not require ventilation., Conclusion: Ventilator status tracks with QOL were measured by EOSQ. A more severe AVR is negatively correlated with most domains of the EOSQ for patients with EOS who have undergone RBGS implantation. The strength of this correlation is weak, and so AVR alone may be insufficient to precisely determine QOL in this population., Level of Evidence: Level-III, Retrospective., (© 2022. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background Context: Since the study of Thompson, et al in 2005, use of dual-growing rod constructs have become the gold standard for operative treatment in early-onset scoliosis. However, use of dual-growing rod constructs may not be possible, due to patient size and the type, location and severity of the spinal deformity., Purpose: The purpose of this study is to: (1) describe the deformities treated with single-growing rod constructs, and (2) report the outcomes of single-growing rods since 2005., Study Design: Observational, descriptive case series METHODS: A prospective, multi-center, international database of early-onset scoliosis patients were queried to identify all patients with single traditional growing rods (sTGR) or magnetically-controlled growing rods (sMCGR) since the 2005. Patients were excluded if there were greater than 1 rod or if there was less than 2 years of follow-up postoperatively. Twenty-five patients (13 female, 12 male) were identified from the database query, which satisfied the inclusion and exclusion criteria., Results: Mean age at index surgery was 4.7 years (1.3 to 9.3 years) and mean follow-up was 4.3 years (2.0 to 10.6 years). Eleven patients were classified as congenital (all mixed-type), six neuromuscular, five idiopathic and three syndromic. Proximal foundations were ribs in 23 patients and pedicle screws in two patients. The distal foundations were the spine in 25 patients and three pelvic S-hooks. All single rods were on the concave side of the deformity. Interpretation of preoperative radiographs determined in 72% (18/25) of cases dual growing rods would be difficult and/or suboptimal due to patient size (longitudinal a/o weight) and/or kyphosis/kyphoscoliosis with severe rotation. Maximal coronal deformity improved 30% (83.9 degrees to 58.6 degrees) at latest follow-up. Maximal kyphosis increased 17% (45.6 degrees to 57.4 degrees). Postoperative length increase: T1-T12, 17.0 mm (4.6 mm/year); T1-S1, 34 mm (9.4 mm/year). Total secondary surgeries for TGRs were 100: 66 lengthenings, 32 revisions, two unknown. 10 MCGRs secondary surgeries occurred in nine patients (seven for maximized actuators and three for foundation migration). At latest follow-up 20 continued with lengthenings (five TGR & 15 MCGR), four underwent definitive fusions, and one completed lengthening (implants retained)., Conclusions: Treatment of severe EOS with single rods demonstrated a 30% coronal correction. T1-S1 length increased at 9.4 mm/year and T1-T12 length at 4.6 mm/year, which are comparable to published reports on dual MCGRs. Single TGRs and MCGRs in EOS can provide acceptable short-term outcomes when dual rods are not deemed appropriate., Clinical Significance: The use of single growing rod constructs, in the 4-8 years old patient with EOS, can achieve reasonable short-term radiographic outcomes., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Cervical traction in pediatric patients is an uncommon but invaluable technique in the management of cervical trauma and deformity. Despite its utility, little empirical evidence exists to guide its implementation, with most practitioners employing custom or modified adult protocols. Expert-based best practices may improve the care of children undergoing cervical traction. In this study, the authors aimed to build consensus and establish best practices for the use of pediatric cervical traction in order to enhance its utilization, safety, and efficacy., Methods: A modified Delphi method was employed to try to identify areas of consensus regarding the utilization and implementation of pediatric cervical spine traction. A literature review of pediatric cervical traction was distributed electronically along with a survey of current practices to a group of 20 board-certified pediatric neurosurgeons and orthopedic surgeons with expertise in the pediatric cervical spine. Sixty statements were then formulated and distributed to the group. The results of the second survey were discussed during an in-person meeting leading to further consensus. Consensus was defined as ≥ 80% agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree)., Results: After the initial round, consensus was achieved with 40 statements regarding the following topics: goals, indications, and contraindications of traction (12), pretraction imaging (6), practical application and initiation of various traction techniques (8), protocols in trauma and deformity patients (8), and management of traction-related complications (6). Following the second round, an additional 9 statements reached consensus related to goals/indications/contraindications of traction (4), related to initiation of traction (4), and related to complication management (1). All participants were willing to incorporate the consensus statements into their practice., Conclusions: In an attempt to improve and standardize the use of cervical traction in pediatric patients, the authors have identified 49 best-practice recommendations, which were generated by reaching consensus among a multidisciplinary group of pediatric spine experts using a modified Delphi technique. Further study is required to determine if implementation of these practices can lead to reduced complications and improved outcomes for children.

Study Design: Cross-sectional reliability study., Objective: The deformity angular ratio (DAR) is a means of quantifying magnitude of the coronal (C-DAR) and sagittal (S-DAR) plane of deformity curves to produce a total DAR (T-DAR). It has been shown to predict the risk of spinal cord monitoring alerts and actual neurologic deficits. We sought to assess the reliability of determining the C-DAR and S-DAR among pediatric spinal deformity surgeons., Methods: Twelve preoperative anterior-posterior (AP) and lateral X-rays from the Fox multi-center pediatric deformity study were de-identified and sent to7 pediatric spinal deformity surgeons. Each surgeon measured: coronal/sagittal Cobb angles, upper/lower endplate vertebrae (UEV/LEV), apices, and number of vertebrae included in the main curve. The C-DAR and S-DAR were then calculated by dividing the Cobb angles by the number of vertebrae included in the curve. Intra- and interobserver reliability was calculated using interclass correlation (ICC)., Results: The mean C-DAR was 14.9 (range 1.3-51.5) with a mean Cobb angle of 88.8° (range 15.0-163.0) over a mean of 7.5 (range 2.0-14.0) levels. The mean S-DAR was 8.6 (range 1.0-19.6), with a mean Cobb angle of 68.0° (range 10.0-137.0) over a mean of 7.5 (range 3-11) levels. The intraobserver reliability of the C-DAR was ICC = 0.908 (range 0.846-0.960) and the S-DAR 0.914 (range 0.815-0.961). The interobserver reliability of the C-DAR was ICC = 0.868 (range 0.846-0.938), and the S-DAR was ICC = 0.848 (range 0.815-0.961). Despite poor reliability among UEV, LEV, and apex selection (aggregated range 0.340-0.724), the C-DAR and S-DAR were demonstrated to be reliable in our study CONCLUSIONS: Reliability was good to excellent for C-DAR and S-DAR, despite poor to moderate reliability among UEV, LEV, and apex selection. These data support the use of the C-DAR, S-DAR, and combined T-DAR as a means of quantifying deformity magnitude.

Objective: Hypermobility of the craniocervical junction (CCJ) in patients with Down syndrome (DS) is common. Whereas atlantoaxial (C1-2) hypermobility is well characterized, occipitoatlantal (Oc-C1) laxity is recognized but poorly defined. A clear understanding of the risks associated with DS-related hypermobility is lacking. Research efforts to address the topic of axial cervical spine instability in the patient with DS require a reliable and reproducible means of assessing CCJ mobility. The authors conducted a pilot study comparing two methods of quantifying motion of the CCJ on dynamic (flexion/extension) plain radiographs: the delta-condyle-axial interval (ΔCAI) and the delta-basion-axial interval (ΔBAI) methods., Methods: Dynamic radiographs from a cohort of 10 patients with DS were evaluated according to prescribed standards. Independent movement of Oc-C1, C1-2, and Oc-C2 was calculated. Interrater and intrarater reliability for CCJ mobility was then calculated for both techniques., Results: Measurement using the ΔCAI technique had excellent fidelity with intraclass correlation coefficients (ICCs) of 0.77, 0.71, and 0.80 for Oc-C1, C1-2, and Oc-C2, respectively. The ΔBAI technique had lower fidelity, yielding respective ICCs of 0.61, 0.65, and 0.50., Conclusions: This pilot study suggests that ΔCAI is a superior measurement technique compared to ΔBAI and may provide reliable assessment of the mobility of the CCJ on dynamic radiographs in the pediatric patient with DS. The use of reliable and reproducible measurement techniques strengthens the validity of research derived from pooled database efforts.

Study Design: Prospective cohort., Objective: To compare preoperative hemoglobin levels to postoperative hemoglobin levels in patients with early-onset scoliosis (EOS)., Summary of Background Data: Elevated hemoglobin (Hgb) may be a marker for preoperative hypoxia in patients with EOS and thoracic insufficiency syndrome (TIS). The changes in Hgb level after treatment may be a surrogate marker for improved oxygenation., Methods: Because normal levels of Hgb vary with patient age, Hgb z scores were calculated by dividing age-adjusted mean Hgb levels by the age-adjusted standard deviation. Elevated Hgb was defined by a hemoglobin z score >1. Patients with a baseline Hgb value measured before initial implantation with at least one follow-up measurement, at 6, 12, or 18 months, were included in longitudinal analysis. Change in Hgb z score as well as change in curve magnitude over time was assessed using piecewise linear mixed modeling for patients with elevated Hgb and those without., Results: Two hundred sixty-seven patients with EOS were treated surgically over the study period. Average age at initial implantation was 6.8 years. Forty-eight (18%; 95% confidence interval = 13.7%, 23.2%) subjects had an elevated Hgb (z score > 1) level before implantation procedure. Hgb levels decreased in subjects with elevated Hgb from implantation to 6 months (p < .001) with no change in Hgb from 6 to 12 months (p = .46) or from 12 to 18 months (p = .59), but an overall decrease from preoperative to 18 months (p < .001). There was no change in Hgb levels for subjects without elevated Hgb from implantation to 6 months (p = .94), from 6 to 12 months (p = .61), or from 12 to 18 months (p = .78)., Conclusions: In some patients with EOS and TIS, there appears to be significant positive impact on oxygenation from distraction instrumentation as evidenced by a meaningful proxy measurement: improvement in abnormal preoperative Hgb levels after surgery., Level of Evidence: III., (Copyright © 2018 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Placement of vancomycin powder into the surgical wound prior to closure has been shown to reduce postoperative infections in spine surgery. This study examines the effect of vancomycin powder on formation of epidural fibrosis (EF). Twenty-two rats underwent a two-level lumbar laminectomy. A control group, a low-dose and a high dose vancomycin powder (applied prior to closure) group was formed. Rats were sacrificed at 30 days and a blinded fellowshiptrained pathologist evaluated the laminectomy segments for EF. 50% of the samples in the high-dose vancomycin group were EF grade 3, compared to 20% of the low-dose and 16.7% of control samples. The average fibrosis grade for the high dose, low dose and control groups were 2.4, 1.4 and 1.8, respectively. There were more grade 3 EF specimens in the high dose vancomycin group. While the average EF grade was also higher in this group, there was not a statistical difference compared with the other groups., Competing Interests: Conflict of interest: the authors declare no conflict of interest.

179 patients with congenital rib fusions treated with rib-based or spine-based constructs and minimum 2-year follow-up were reviewed. 19 patients were treated with proximal spine-based and 160 with proximal rib-based devices. Patients treated with growing rods achieved equivalent SAL to those treated with rib-based devices, while also achieving greater improvement to their spine deformity, as measured by postoperative kyphosis, and Cobb angle.

Study Design: Retrospective review., Objectives: To describe clinical characteristics and infection rates in modern vertical expandable prosthetic titanium rib (VEPTR) surgery., Summary of Background Data: Prior studies have demonstrated infection rates from 10% to 30% with VEPTR surgery., Methods: A retrospective query was done on an institutional review board-approved, multicenter prospectively collected database for patients implanted with VEPTR from 2007 to 2013 at eight sites. This identified 213 patients with appropriate data for analysis. Average follow-up was 4.1 years (range 1.7-6.3). Data collected included a Classification of Early-Onset Scoliosis (C-EOS) diagnosis, American Society of Anesthesiologists Physical Status (ASA-PS), major Cobb angle, construct type, clinical symptoms, and microbiology. The distribution of infection rates across all the study sites was compared. The exact p value was estimated by Monte Carlo simulation., Results: Overall, 18% (38/213) of patients implanted with VEPTR developed infection requiring operative debridement. There were significantly different infection rates among the sites, ranging from 2.9% to 42.9% (p = .029). The average time to infection was 70 days (range 8-236) after the infecting procedure. The majority of infections were due to gram-positive bacteria (80%, 44/55), the most prevalent being methicillin-sensitive Staphylococcus aureus (45%, 25/55). There were 20 patients (53%, 20/38) with either partial or complete implant removal to resolve infection; however, only 3 of 38 (8%) of these resulted in abandonment of VEPTR treatment. There was no difference in infection rate across the primary C-EOS diagnosis categories (p = .21) or based on ASA score (p = .53). After controlling for study site, the odds ratio of an infection following an implant procedure versus an expansion was 2.8 (p = .002). There was no difference in the odds ratio of an infection between the other procedure types (implant, expansion, exchange/revision)., Conclusions: There were significant differences in infection rates between sites. The variability in infection rate indicates a need for guided efforts to standardize best practices for infection control in VEPTR surgery., Level of Evidence: III, therapeutic study., (Copyright © 2016 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the mid-term clinical and radiographic impact of pedicle screw fixation in patients with adolescent idiopathic scoliosis (AIS)., Methods: A multicenter AIS database was retrospectively queried to identify 99 consecutive patients who underwent posterior spinal fusion using an all pedicle screw construct with a minimum of 5-year follow-up. Radiographic and clinical parameters were reviewed at regular intervals up to 5 years., Results: The mean age was 14.4 ± 2.0 years with 79 % being female. The mean preoperative major curve was 51.7 ± 14.2° with a mean correction of 66 and 64 % at 2 and 5 years (p = 0.16). Pre-op thoracic kyphosis averaged 22.3 ± 12.9° and was 18.4 ± 10.6° at 5 years with no significant change from 2 years (p = 0.33). SRS total and domain scores demonstrated significant improvements at 2 years, which were slightly decreased at 5 years (p = 0.06). SRS scores of self-image (p = 0.99) and satisfaction (p = 0.18) were significantly improved after surgery with minimal change by 5 years. The change in SRS total scores from 2 to 5 years was attributed to differences in SRS scores of pain and mental health (p < 0.05)., Conclusions: Intermediate follow-up of patients with AIS treated with an all pedicle screw construct demonstrates maintenance of their coronal, and sagittal plane correction between 2- and 5-year follow-up. At 5 years, improvements in SRS scores were consistent with 2-year values, except for a decline in pain and mental health scores.

Purpose: Previous studies have demonstrated good ability to improve the sagittal profile with the use of segmental instrumentation for adolescent idiopathic scoliosis (AIS) by analysing the sagittal vertical axis (SVA). However, several authors recommend analysing the spinopelvic relation in addition to the SVA. While compensatory mechanisms may neutralise a positive SVA, these mechanisms are energy consuming and may lead to unphysiological biomechanics, which can negatively influence the quality of life. The purpose of this radiographic analysis was to analyse global sagittal balance and to identify potential compensatory mechanisms after segmental instrumentation for AIS., Methods: From a prospectively collected multicentre database, patients with segmental instrumentation for AIS and a minimum follow-up of 2 years were identified. An additional inclusion criterion was the ability to measure lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence (PI), and SVA on each X-ray (preoperative, 1st erect, and the 2-year follow-up visits). LL was analysed in relation to PI in order to identify iatrogenic changes. Changes in LL were correlated to changes in PT and SVA., Results: 91 patients were included. On the 1st erect X-ray, LL significantly decreased from pre-op but the SVA remained stable due to a significant increase of PT. At two years follow-up, PT recurred to preoperative values, accompanied by a significant increase of SVA despite a compensatory hyperlordosis below the instrumentation. The temporary increase of PT on the 1st erect was significantly correlated to an iatrogenic decrease of LL. An iatrogenic decrease of LL was significantly correlated to an increase of SVA on the 1st erect and at 2 years follow-up., Conclusion: An iatrogenic decrease of LL after segmental instrumentation for AIS is initially compensated for by pelvic retroversion and later by a hyperlordosis below the instrumentation., (Georg Thieme Verlag KG Stuttgart · New York.)

Object: There are few data on treatment results for patients with idiopathic infantile scoliosis (IIS). Thus, the authors have performed a retrospective review of their experience with treating these patients, particularly as newer technologies, such as the vertical expandable prosthetic titanium rib (VEPTR), emerge., Methods: This retrospective study was conducted to evaluate the methods of treatment used to manage IIS at a single institution. The authors reviewed 31 consecutive patients with a primary diagnosis of IIS. Patients were screened to ensure that there were no confounding congenital anomalies or comorbidities that may have contributed to the spinal deformity. The average age at the time of initial treatment was 25 months. Treatment modalities included bracing, serial body casting, and VEPTR. Pretreatment, posttreatment, and most recent Cobb angles were compared to assess the overall curve correction, and patient charts were reviewed for the occurrence of complications., Results: Of the 31 patients, 17 were treated with a brace, 9 of whom had curve progression and went on to other forms of treatment. Of the 8 who did respond, there was an overall improvement of 51.2%. The 10 patients who received body casts, who had a mean preoperative Cobb angle of 50.4 degrees, demonstrated an average correction of 59.0%, with only a few skin irritations reported. The 10 patients treated with VEPTR devices demonstrated a mean preoperative Cobb angle of 90.0 degrees, and an average correction of 33.8% was attained. Three of the VEPTR-treated patients (33%) experienced minor problems., Conclusions: The authors' results suggest that body casting has utility for appropriately selected patients; that is, those with smaller, flexible spinal curves. Bracing had limited utility, with high levels of progression and the need for secondary treatments. The VEPTR device appears to be a viable alternative for large-magnitude curves.

The authors review their experience with four patients with congenital deficiency of the anterior cruciate ligament (ACL) who underwent surgical treatment of symptomatic knee instability at a mean age of 15.8 years (range 14-17 years). Associated syndromes included fibular hemimelia, congenital short femur, and an unspecified skeletal dysplasia. All patients had undergone multiple previous realignment and leg lengthening procedures and were skeletally mature at the time of the reconstruction. All four patients underwent ACL reconstruction, and one patient underwent concomitant posterolateral corner reconstruction. One patient required an osteochondral autograft transplant procedure in addition to ACL reconstruction. Hypertrophy of the meniscofemoral ligament of Humphrey was a consistent anatomic finding at surgery. The patients were followed for a mean of 38 months (range 26-58 months) after the reconstruction. The mean preoperative Lysholm II score was 38 (range 28-56); the score had improved to a mean of 81 (range 78-93) at the latest follow-up. The authors conclude that reconstructive surgery is a viable option for restoration of knee stability and function in appropriately selected patients with congenital ACL deficiency.

Recent studies have demonstrated imprinting of the human neuronatin (NNAT) gene. NNAT maps to 20q11.2-q12, a region exhibiting loss of heterozygosity in acute myeloid leukemia and myelodysplastic/myeloproliferative disease. To investigate possible epigenetic dysregulation of genes in this region relevant to leukemogenesis, we analyzed methylation of the NNAT gene in normal tissues and in leukemias. We found a differential methylation pattern, typical of imprinted genes, at sites in the CpG island containing NNAT exon 1 in normal pituitary, peripheral blood cells and bone marrow-derived CD34-positive hematopoietic progenitor cells. Substantial or complete loss of the unmethylated NNAT allele was observed in leukemia cell lines and in 20 of 29 (69%) acute myeloid or lymphoid leukemia samples. While most highly expressed in brain, NNAT mRNA was also detected in normal hematopoietic progenitor cells and in leukemia cells exhibiting the normal methylation pattern, although not in hypermethylated leukemia cells. Demethylation by treatment of hypermethylated leukemia cells with 5-aza-2'-deoxycytidine resulted in reactivation of NNAT expression, concomitant with a reversion to the normal methylation pattern. The data demonstrate that hypermethylation of the NNAT locus is a frequent event in both myeloid and lymphoid acute leukemias of childhood. Aberrant hypermethylation of the NNAT locus suggests that the dysregulation of genes at 20q11.2-q12 in leukemia may be the result of epigenetic as well as genetic events.