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Background: Early-onset scoliosis is a heterogeneous condition, with highly variable manifestations and natural history. No standardized classification system exists to describe and group patients, to guide optimal care, or to prognosticate outcomes within this population. A classification system for early-onset scoliosis is thus a necessary prerequisite to the timely evolution of care of these patients.Methods: Fifteen experienced surgeons participated in a nominal group technique designed to achieve a consensus-based classification system for early-onset scoliosis. A comprehensive list of factors important in managing early-onset scoliosis was generated using a standardized literature review, semi-structured interviews, and open forum discussion. Three group meetings and two rounds of surveying guided the selection of classification components, subgroupings, and cut-points. Initial validation of the system was conducted using an interobserver reliability assessment based on the classification of a series of thirty cases.Results: Nominal group technique was used to identify three core variables (major curve angle, etiology, and kyphosis) with high group content validity scores. Age and curve progression ranked slightly lower. Participants evaluated the cases of thirty patients with early-onset scoliosis for reliability testing. The mean kappa value for etiology (0.64) was substantial, while the mean kappa values for major curve angle (0.95) and kyphosis (0.93) indicated almost perfect agreement. The final classification consisted of a continuous age prefix, etiology (congenital or structural, neuromuscular, syndromic, and idiopathic), major curve angle (1, 2, 3, or 4), and kyphosis (-, N, or +) variables, and an optional progression modifier (P0, P1, or P2).Conclusions: Utilizing formal consensus-building methods in a large group of surgeons experienced in treating early-onset scoliosis, a novel classification system for early-onset scoliosis was developed with all core components demonstrating substantial to excellent interobserver reliability. This classification system will serve as a foundation to guide ongoing research efforts and standardize communication in the clinical setting. [ABSTRACT FROM AUTHOR]

Background: Surgical site infection following correction of pediatric scoliosis is well described. However, we are aware of no recent multicenter study describing the rates of surgical site infection, and associated pathogens, among patients with different etiologies for scoliosis.Methods: A multicenter, retrospective review of surgical site infections among pediatric patients undergoing spinal instrumentation to correct scoliosis was performed at three children's hospitals in the United States. Study subjects included all patients undergoing posterior spinal instrumentation from January 2006 to December 2008. Surgical site infections were defined according to the Centers for Disease Control and Prevention's National Healthcare Safety Network case definition, with infections occurring within one year after surgery.Results: Following the analysis of 1347 procedures performed in 946 patients, surgical site infection rates varied among procedures performed in patients with different scoliosis etiologies. Procedures performed in patients with neuromuscular scoliosis had the highest surgical site infection rates (9.2%), followed by those performed in patients with syndromic scoliosis (8.8%), those performed in patients with other scoliosis (8.4%), those performed in patients with congenital scoliosis (3.9%), and those performed in patients with idiopathic scoliosis (2.6%). Surgical site infection rates varied among procedures in patients undergoing primary spinal arthrodesis based on etiology, ranging from 1.2% (95% confidence interval, 0.1% to 1.3%) in patients with idiopathic scoliosis to 13.1% (95% confidence interval, 8.4% to 17.8%) in patients with neuromuscular scoliosis. Surgical site infection rates following primary and revision procedures were similar among patients with different etiologies. In distraction-based growing constructs, rates were significantly lower for lengthening procedures than for revision procedures (p = 0.012). Multivariate analysis demonstrated that non-idiopathic scoliosis and extension of instrumentation to the pelvis were risk factors for surgical site infections. The three most common pathogens were Staphylococcus aureus (25.0% [95% confidence interval, 17.8% to 32.2%]), coagulase-negative staphylococci (17.1% [95% confidence interval, 10.9% to 23.3%]), and Pseudomonas aeruginosa (10.7% [95% confidence interval, 5.6% to 15.8%]). Overall, 46.5% (95% confidence interval, 35.5% to 57.5%) of surgical site infections contained at least one gram-negative organism; 97.0% (95% confidence interval, 90.8% to 100.0%) of these infections were in patients with non-idiopathic scoliosis.Conclusions: Surgical site infection rates were significantly higher following procedures in patients with non-idiopathic scoliosis (p < 0.001). Lengthening procedures had the lowest rate of surgical site infection among patients with early onset scoliosis who had undergone instrumentation with growing constructs. Gram-negative pathogens were common and were most common following procedures in patients with non-idiopathic scoliosis. These findings suggest a role for targeted perioperative antibiotic prophylaxis to prevent surgical site infection following pediatric scoliosis instrumentation procedures. [ABSTRACT FROM AUTHOR]

Background: Surgical site infection following correction of pediatric scoliosis is well described. However, we are aware of no recent multicenter study describing the rates of surgical site infection, and associated pathogens, among patients with different etiologies for scoliosis. Methods: A multicenter, retrospective review of surgical site infections among pediatric patients undergoing spinal instrumentation to correct scoliosis was performed at three children's hospitals in the United States. Study subjects included all patients undergoing posterior spinal instrumentation from January 2006 to December 2008. Surgical site infections were defined according to the Centers for Disease Control and Prevention's National Healthcare Safety Network case definition, with infections occurring within one year after surgery. Results: Following the analysis of 1347 procedures performed in 946 patients, surgical site infection rates varied among procedures performed in patients with different scoliosis etiologies. Procedures performed in patients with neuromuscular scoliosis had the highest surgical site infection rates (9.2%), followed by those performed in patients with syndromic scoliosis (8.8%), those performed in patients with other scoliosis (8.4%), those performed in patients with congenital scoliosis (3.9%), and those performed in patients with idiopathic scoliosis (2.6%). Surgical site infection rates varied among procedures in patients undergoing primary spinal arthrodesis based on etiology, ranging from 1.2% (95% confidence interval, 0.1% to 1.3%) in patients with idiopathic scoliosis to 13.1% (95% confidence interval, 8.4% to 17.8%) in patients with neuromuscular scoliosis. Surgical site infection rates following primary and revision procedures were similar among patients with different etiologies. In distraction-based growing constructs, rates were significantly lower for lengthening procedures than for revision procedures (p = 0.012). Multivariate analysis demonstrated that non-idiopathic scoliosis and extension of instrumentation to the pelvis were risk factors for surgical site infections. The three most common pathogens were Staphylococcus aureus (25.0% [95% confidence interval, 17.8% to 32.2%]), coagulase-negative staphylococci (17.1% [95% confidence interval, 10.9% to 23.3%]), and Pseudomonas aeruginosa (10.7% [95% confidence interval, 5.6% to 15.8%]). Overall, 46.5% (95% confidence interval, 35.5% to 57.5%) of surgical site infections contained at least one gram-negative organism; 97.0% (95% confidence interval, 90.8% to 100.0%) of these infections were in patients with non-idiopathic scoliosis. Conclusions: Surgical site infection rates were significantly higher following procedures in patients with non-idiopathic scoliosis (p < 0.001). Lengthening procedures had the lowest rate of surgical site infection among patients with early onset scoliosis who had undergone instrumentation with growing constructs. Gram-negative pathogens were common and were most common following procedures in patients with non-idiopathic scoliosis. These findings suggest a role for targeted perioperative antibiotic prophylaxis to prevent surgical site infection following pediatric scoliosis instrumentation procedures. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Introduction: Decompensation of un-fused vertebrae is a potential complication of spinal instrumentation performed for adolescent idiopathic scoliosis (AIS). This can result in problems requiring revision surgery. The purpose of this study was to compare patients who decompensated in the sagittal/coronal plane and those who do not and to identify risk factors. Methods: The Spinal Deformity Study Group data-base for AIS identified 908 patients at 2 years post-op. Coronal measures analyzed included coronal balance (CB), coronal position of the lower instrumented vertebra (CPL) and LIV tilt angle (LTA). Sagittal measures included sagittal balance (SB) and distal-junctional kyphosis (DJK). The incidence of decompensation at 2 years was: CB-16.83%, LTA-37.53%, CPL-21.17%, negative SB-51.88%, positive SB-7.62%, DJK-6.8%. Decompensated patients were compared to those who were not using preoperative, and 4-16 weeks post-op values. Results: Numerous significant differences were found between patients who decompensated at 2 years and those who did not. CB was significantly influenced by larger height/weight, increased Cobb, preexisting CB and a thoracic LIV. In addition to other factors LTA decompensation was more likely to occur in JIS. CPL was associated with pelvic-obliquity and thoracic LIV. Post-operative sagittal balance could be predicted by pre-operative sagittal balance. DJK was also associated with larger weight and preoperative sagittal measures. Discussion and Conclusion: Less correction in sagittal/coronal planes is a risk factor for decompensation. Curve correction was significant in predicting coronal decompensation. Failure to control sagittal alignment was a risk factor in sagittal decompensation. [ABSTRACT FROM AUTHOR]

Background: Spinal cord monitoring is now considered standard care during surgery for spinal deformity. Combined somatosensory and motor evoked potential monitoring allows the detection of early spinal cord dysfunction in most patients. The purpose of the current study was to identify clinical factors that increase the risk of intraoperative electrophysical changes and to provide management recommendations. Methods: The records of 162 consecutive patients who underwent surgery for the treatment of spinal deformity at a tertiary referral center were reviewed. Electrophysical monitoring of these patients was considered to have been successful if reproducible signals had been obtained. Relevant electrophysical changes included a reduction, as compared with baseline, of >50% in the amplitude of the somatosensory evoked potentials; an increase, as compared with baseline, of >10% in the latency of the somatosensory evoked potentials; a loss of motor evoked potentials; and an abrupt decrease of >75% in the motor evoked potentials. Results: One hundred and fifty-one (93%) of the 162 patients were monitored successfully. Four of the eleven patients with unsuccessful monitoring had neuromuscular scoliosis. Twelve of the 151 successfully monitored patients had a true electrophysical event, and two of them were found to have new postoperative neurologic deficits that represented a change from the findings of their preoperative neurologic examination. The determined causes of these electrophysical events included curve correction in eight patients, hypotension in two, direct cord trauma in one, and malposition of a pedicle screw in one. The patients with a true electrophysical event had a significantly higher rate of neurologic events than did the patients who did not have a true electrophysical event (p < 0.001). The rate of true electrophysical events was significantly higher in the patients with cardiopulmonary comorbidities than it was in the patients with no comorbidities (p = 0.011). Conclusions: Combined somatosensory and motor evoked potential monitoring effectively prevents neurologic injury in most children undergoing surgery for spinal deformity. Despite the potential for false-positive results, we recommend setting a low threshold for defining relevant electrophysical changes. Rapid intervention can reverse these changes and avoid potentially serious neurologic complications. Patients with cardiopulmonary comorbidities may be at a higher risk for having relevant electrophysical events. Level of Evidence: Diagnostic Level Ill. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The article presents a study on the clinical efficacy and safety of the use of recombinant human bone morphogenetic protein-7 (rhBMP-7) for the treatment of congenital pseudarthrosis of the tibia in skeletally immature patients. The subjects used in the study were five consecutive patients with congenital pseudarthrosis of the tibia. It offers information on the surgical treatment, clinical and radiographic evaluation and the case reports of each subject. The result of the study was discussed.

Background: Controversy exists regarding the optimal fellowship training experience for surgeons who perform scoliosis surgery in pediatric patients. While many studies have demonstrated that higher surgical volumes are associated with superior outcomes, the volume of scoliosis procedures performed by pediatric orthopaedic-trained surgeons as opposed to spine surgery-trained surgeons has not been reported. Methods: Validated, statewide hospital discharge databases from the states of New York and California were utilized to examine the volume of spinal fusion procedures performed for the treatment of scoliosis in patients who were eighteen years of age or less. Fellowship training of surgeons in New York who had performed more than fifty procedures from 1992 to 2001 (that is, more than five procedures per year) was determined, and the operative volumes of surgeons who had received pediatric orthopaedic as opposed to spine fellowship training were compared. Hospitals in California with either type of fellowship program were identified, and the operative volumes of hospitals and fellows with pediatric orthopaedic or spine fellowship training from 1995 to 1999 were compared. Results: Among the 228 surgeons in New York who had performed one or more spinal fusion procedures in patients eighteen years of age or less from 1992 to 2001, only 13% (thirty) had performed more than five procedures per year. However, these thirty surgeons accounted for 75% (3858) of all 5136 procedures in this age-group. Surgeons who had completed a pediatric orthopaedic fellowship had performed a mean of 14.5 procedures per physician per year, whereas those who had completed a spine fellowship had performed a mean of 10.5 procedures per physician per year. Surgeons who had not completed either type of fellowship had performed a mean of 14.4 procedures per physician per year. In California, the mean annual volume of scoliosis procedures from 1995 to 1999 was 59.0 procedures per year at hospitals with pediatric orthopaedic fellowship programs and 15.7 procedures per year at those with spine surgery programs. The mean number of procedures per fellow at hospitals with pediatric orthopaedic fellowship programs was 31.6 procedures per fellow per year, and the mean number at hospitals with spine surgery pro- grams was 12.7 procedures per fellow per year. Over time, there was a significant increase in the number of procedures per year at hospitals with both types of fellowship programs, but the percentage increase was greater for hospitals with pediatric orthopaedic fellowship programs than for hospitals with spine surgery fellowship programs (45.2% compared with 13.5%). Conclusions: These data indicate that, on the average, a large number of surgeons in New York performed five scoliosis procedures per year or fewer. Among higher-volume surgeons in New York, those with pediatric orthopaedic fellowship training performed more scoliosis procedures on children and adolescents than those with orthopaedic spine training did. In California, the volume of scoliosis procedures at hospitals with pediatric orthopaedic fellowship programs was nearly four times greater than that at hospitals with spine fellowship programs and the volume of procedures per fellow was more than two times greater, and this disparity is widening over time. These data are an important element in establishing what type of fellowship best prepares surgeons for scoliosis surgery. [ABSTRACT FROM AUTHOR]

An abstract of the article "Evaluating the Extent of Clinical Uncertainty Among Treatment Options for Patients with Early-Onset Scoliosis," by Jacqueline Corona and colleagues is presented.

Introduction: Pedicle screw misplacement in scoliosis surgery is well documented in adolescent idiopathic scoliosis (IS), but not in the non-idiopathic and skeletally immature population. Objective: To evaluate the pedicle screw misplacement rate in children undergoing surgical treatment for all scoliosis etiologies. Materials and Methods: 1042 pedicle screws were prospectively evaluated for misplacement by CT-scan in 54 children(mean:14.0y, range:4-20) undergoing PSI(mean Cobb: 63.2o, range: 30–112). Misplacement was defined as: >2mm for the medial cortex, >4mm for the lateral/anterior cortices. Scoliosis etiologies included:52% idiopathic, 22% congenital(CS), 26% neuromuscular scoliosis(NMS). Results: 8.4% of screws were misplaced: 4.5% medially, 3.1% laterally, 0.08% anteriorly. Misplacement rates between IS(7.1%) and CS(11.5%,p=.066) trended towards significant difference. The misplacement rate for NMS(8.7%) was not higher when compared with IS(p=.413). Univariate analysis demonstrated no difference in misplacement rates in children . or .10 years of age(p=0.599). Differences in misplacement rates were found in: proximal(12.5%) vs. periapical(5.0%,p=.001) vs. distal screws(5.5%,p=.003); and T1(40%,p=.008) and T2(19%,p=.024) pedicle screws vs. average misplacement at other levels(8.4%). Multivarite analysis demonstrated no difference in misplacement rates between scoliosis etiology groups. T1 and T2 pedicle screws were 7.9 and 2.8 times more at risk of being misplaced than those at all other levels, respectively. No screws required removal or caused complications. Conclusion: Only a consistent relationship between pedicle screw placement at T1 and T2 and higher misplacement rate was found. Significance: Although there was a trend toward higher pedicle screw misplacement rate in CS after controlling for confounders, the misplacement rate in this heterogeneous population was the same or lower than reported in the AIS literature. [ABSTRACT FROM AUTHOR]

: Background contextThere is considerable controversy regarding the effectiveness of bracing for patients with adolescent idiopathic scoliosis (AIS). Furthermore, little work has focused on the effect of formal bracing on the health-related quality of life (QOL) of affected adolescents.: PurposeThis study is an attempt to assess the QOL of adolescents with AIS who were treated with a brace in comparison to those who were not.: Study design/settingThis is a questionnaire-based study of patients presenting to our institution for evaluation and treatment of AIS. The study was conducted at Columbia University and the New York Presbyterian Medical Center, New York, NY.: Patient sampleA total of 136 patients with AIS who were being observed and 78 patients who were braced were included in this study.: Outcome measuresThe Child Health Questionnaire (CHQ) and the American Academy of Orthopaedic Surgeons Pediatric Outcomes Data Collection Instrument (PODCI) were administered to 214 parents of adolescents undergoing evaluation for AIS.: MethodsParents of AIS patients were administered the CHQ and PODCI to assess their child''s QOL. Independent samples t tests were conducted to compare the QOL among braced versus observed patients. Univariate and multivariate analyses were conducted to determine the effect of gender, age, curvature and treatment type on QOL.: ResultsThere were few differences in QOL between braced versus observed patients, but boys tended to outscore the girls across most domains. Surprisingly, the QOL of adolescents undergoing bracing in this study was not significantly lower than age-adjusted norms.: ConclusionsBrace wearing did not decrease the QOL of adolescents, compared with their observed counterparts, in our study population. [Copyright &y& Elsevier]

Background context: Ketorolac Tromethamine (ketorolac) is a nonsteroidal anti-inflammatory drug (NSAID) with proven efficacy in decreasing postoperative pain in various surgical settings, including the treatment of spine deformities. However, some studies have raised questions regarding the potential side effects of this agent, such as increased bleeding and inhibition of bony fusion.Purpose: This study was conducted to determine whether there is any association between the use of ketorolac and postoperative complications in a group of children who underwent scoliosis surgery.Study design/setting: This is a retrospective review of a group of children who underwent spinal fusion between 1989 to 1999 at our institution.Patient sample: Data on a total of 208 children were analyzed in this study. Sixty received ketorolac and 148 did not.Outcome measures: Postoperative transfusion and reoperation rates were the two main outcome measures of interest.Methods: A retrospective review of 208 children who underwent scoliosis surgery was conducted, with a focus on ketorolac use. Univariate analysis and logistic regression were used to quantify the determinants of postoperative complications.Results: Our analyses detected no significant differences in a broad range of socioclinical variables between the two patient groups, including age at surgery, gender, type of scoliosis, surgical approach, use of erythropoietin, levels of curvature and degree of curvature. Analysis of complication rates focusing on postoperative transfusion and revision surgery showed that there were no significant differences between the two groups.Conclusions: In this retrospective study of 208 children undergoing spine surgery, postoperative use of ketorolac did not significantly increase complications, including transfusion and reoperation. [Copyright &y& Elsevier]

Background context: The risks and costs of transfusion are a great concern in the area of pediatric spine surgery, because it is a blood-intensive procedure with a high risk for transfusion. Therefore, determining the predictors of transfusion in this patient population is an important first step and has the potential to improve upon the current approaches to reducing transfusion rates. In this study, we reveal several predictors of transfusion in a pediatric patient population undergoing spine surgery. In turn, we present a general rule of thumb (“rule of two''s”) for gauging transfusion risk, thus enhancing the surgeon''s approach to avoiding transfusion in certain clinical scenarios.Purpose: This study was conducted to determine the main factors of transfusion in a population of pediatric patients undergoing scoliosis surgery. The goal was to present an algorithm for quantifying the true risk of transfusion for various patient groups that would highlight patients “at high risk” for transfusion. This is especially important in light of the various risks associated with undergoing a transfusion, as well as the costs involved in maintaining and disposing of exogenous blood materials. Study design/setting: This is a retrospective review of a group of children who underwent scoliosis surgery between 1988 and 1995 at an academic institution. Patient sample: A total of 290 patients were analyzed in this study, of which 63 were transfused and 227 were not.Outcome measures: No outcomes measures were used in this study. Methods: A retrospective review of 290 patients presenting to our institution for scoliosis surgery was conducted, with a focus on socioclinical data related to transfusion risk. Univariate analysis and logistic regression were used to quantify the determinants of transfusion risk. Results: Univariate analysis identified many factors that were associated with the risk of transfusion. However, it is clear that several of these factors are dependent on each other, obscuring the true issues driving transfusion need. We used multivariate analysis to control for the various univariate predictors of transfusion. Our logistic regression model suggested that the type of scoliosis (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.07 to 3.82), degree of curvature (OR, 1.012/degree curve; 95% CI, 1.01 to 1.03), and use of erythropoietin (OR, 0.29; 95% CI, 0.14 to 0.62) were the main determinants of transfusion risk for our population. Conclusions: The main risk factors of transfusion were used to formulate a simple algorithm, which can be used to quantify transfusion risk and to guide efforts to avoid transfusion in children undergoing spinal surgery. Given a 10% baseline risk for transfusion, our “rule of two''s” indicates that each risk factor approximately doubles the chance of transfusion, whereas the administration of recombinant human erythropoietin roughly halves the risk of transfusion. [Copyright &y& Elsevier]