Early-onset Scoliosis Patients Research Articles

A multicenter evaluation of the time and travel burden on families with children treated for early-onset scoliosis.

Patients who undergo growth-friendly (GF) treatment for early-onset scoliosis (EOS) undergo multiple clinical and surgical encounters. We sought to quantify the associated temporal and travel burden and estimate subsequent cost. Four centers in an international study group combined data on EOS patients who underwent surgical GF treatment from 2006 to 2021. Data collected included demographics, scoliosis etiology, GF implant, encounter type, and driving distance. We applied 2022 IRS and BLS data or $0.625/mile and $208.2/day off work to calculate a relative financial burden. A total of 300 patients were analyzed (55% female). Etiologies were: congenital (33.3%), idiopathic (18.7%), neuromuscular (30.7%), and syndromic (17.3%). The average age at the index procedure was 5.5years. For the 300 patients, 5899 encounters were recorded (average 18 encounters/patient). Aggregate encounter types were 2521 clinical office encounters (43%), 2045 surgical lengthening encounters (35%), 1157 magnetic lengthening encounters (20%), 149 spinal fusions (3%), and 27 spinal fusion revisions (0.5%). When comparing patients by scoliosis etiology or by GF implant type, no significant differences were noted in the total number of encounters or average travel distance. Patients traveled a median round trip distance of 158 miles/encounter between their homes and treating institutions (range 2.4-5654 miles), with a cumulative median distance of 2651 miles for the entirety of their treatment (range 29-90,552 miles), at an estimated median cost of $1656.63. The mean number of days off work was 18 (range 3-75), with an associated loss of $3643.50 in income. Patients with EOS averaged 18 encounters for GF surgical treatment. These patients and their families traveled a median distance of 158 miles/encounter, with an estimated combined mileage and loss of income of $5300.

How do implants overlying the spine influence "The Law of Diminishing Returns" in early-onset scoliosis patients?

The "law of diminishing returns" (LODR) in early-onset scoliosis (EOS) is well-known. We hypothesized that previously observed variations between constructs may be related to the lateral distance that each construct lies from the spine. We therefore sought to determine whether the curve magnitude improvement and spinal length gains for distraction-based constructs in EOS are positively correlated with the collinearity of the spine and the convex-sided implant on posteroanterior radiographs. A prospectively-collected, multicenter EOS registry was queried for all patients who underwent non-fusion, distraction-based instrumentation surgery. Post-index radiographs were graded from 1 to 5 based on amount of overlap between the convex-sided rod and the apical vertebra. Grade 1: convex rod is lateral to convex-sided pedicle; Grade 2: overlaps the convex-sided pedicle; Grade 3: lies between pedicles; Grade 4: overlaps concave-sided pedicle; Grade 5: medial to concave-sided pedicle. ANOVA assessed the correlations between post-index overlap grade and change in (a) curve magnitude and (b) T1-T12 height. Multivariable regression modeling further assessed these associations. 284 patients met all selection criteria and were included. On ANOVA, post-index grade was associated with curve magnitude (p <0.001) and T1-12 height (p = 0.028) change. Better curve correction and height change were associated with higher grade. On regression modeling, curve correction (R = 0.574) and T1-T12 height change (R = 0.339) remained significantly associated with grade when controlling for time, anchor locations, age, underlying diagnosis, and pre-index curve magnitude. More apical overlap by the convex rod was associated with better spinal deformity control and improved height gain. Therapeutic.

Safety and efficacy of waterproof casting for early onset scoliosis.

The efficacy of traditional Mehta casting in the treatment of early onset scoliosis (EOS) is well-established. However, waterproof casting has not been previously described. Inherent advantages of waterproof casting include clearance for bathing/swimming, avoiding cast holidays, and improved family satisfaction. The purpose of this study was to assess the safety and efficacy of waterproof serial casting at controlling curve progression in EOS. The current study is an IRB-approved Level IV retrospective consecutive cohort of EOS patients who underwent a serial 75% body weight traction-elongation-flexion Mehta cast protocol with waterproof cast padding. The addition of 3-point apical translation with stockinettes was utilized during casting. Bracing was initiated after correction < 15° or 1year of serial casting. Seventeen patients at mean age 21.6months, with pre-cast Cobb angle 52.3° (R: 35°-82°), underwent serial waterproof casting. In-cast correction index was 64%; for post-cast, Cobb angle was 18.6°. At mean 5.6years follow-up (R: 2.3-8.9years), 82% successfully avoided surgical intervention, 53% maintained correction < 25°, and 29% are considered "cured". 3/17 (18%) underwent a 2nd round of casting, and a total of 3/17 (18%) ultimately required surgery at 6.2years post-casting. No major cast-related complications, decubiti, or cast holidays were encountered. Serial waterproof casting is safe and efficacious in EOS when compared to published results of traditional Mehta casting. Of 17 patients with mean pre-cast Cobb 52.3°, 82% successfully avoided surgery and 53% maintained mild curves < 25° magnitude at 5.6years follow-up. No major complications or skin decubiti occurred, and advantages include clearance for bathing and avoidance of need for cast holidays during treatment. Level IV.

Autofusion in early-onset scoliosis growing constructs: occurrence, risk factors, and impacts.

Autofusion (AF) during growing rod (GR) instrumentation for early-onset scoliosis (EOS) has been reported, but AF incidence, causation, and clinical implications remain unknown. This article aims to (1) quantify frequency and severity of AF, (2) determine risk factors for AF, and (3) assess the influence of AF on final curve correction and spinal lengthening. EOS patients were prospectively enrolled (2016-2021). Patients underwent evaluation, GR implantation, lengthenings, and posterior spinal fusion (PSF). Cobb angle and spinal length measurements were collected. AF was assessed and graded, with grades I-II being low-grade and III-V being high-grade. Exposure analysis quantified risk factors' impact via odds ratios and Pearson regression correlates. Statistical significance was p ≤ 0.05 or ≥ 0.95. 28 patients, with variable EOS diagnoses, were included. On average, GR were implanted at 8.54-year-old and lengthened over 4.66years. 53.6% of patients received magnetically controlled GR (MCGR) and 46.4% traditional GR (TGR). The average construct bridged 13.4 levels. Over the lengthening period, for all indications, patients averaged 2.9 total open procedures. Curves corrected from 68.5º preoperatively to 35.3º after index GR to 35.6º after PSF. Spinal length increased from 30.0cm preoperatively to 33.9cm after index GR to 39.5cm after PSF. AF grading was: 28.6% Grade I, 25.0% Grade II, 17.9% Grade III, 25.0% Grade IV, and 3.6% Grade V. Idiopathic EOS tended to have lower AF grades (p = 0.37). AF risk factors included GR age < 8 (10.4×, p = 0.01), any interval open procedures (6.3×, p = 0.05), and residual curve > 30º after index GR (13.7×, p = 0.02). Protective factors included preoperative spinal length of > 30.0cm (0.11×,p = 0.01) and index MCGR (0.16×, p = 0.03). Maintenance of Cobb angles from index GR through PSF was relatively better in low-grade patients (p = 0.08). Spinal length gained was no different between low- and high-grade AF (p = 0.50). This largest-to-date evaluation found AF is nearly ubiquitous in GR constructs, but with variable severity. Both risk factors and protective factors coincide with AF. Ultimately, even in high-grade AF, curve correction was maintained, and spinal lengthening was achieved. Level II-prospective cohort study.

Validation of a patient-specific finite element analysis framework for identification of growing rod-failure regions in early onset scoliosis patients.

Growing rods are the gold-standard for treatment of early onset scoliosis (EOS). However, these implanted rods experience frequent fractures, requiring additional surgery. A recent study by the U.S. Food and Drug Administration (FDA) identified four common rod fracture locations. Leveraging this data, Agarwal et al. were able to correlate these fractures to high-stress regions using a novel finite element analysis (FEA) framework for one patient. The current study aims to further validate this framework through FEA modeling extended to multiple patients. Three patient-specific FEA models were developed to match the pre-operative patient data taken from both registry and biplanar radiographs. The surgical procedure was then simulated to match the post-operative deformity. Body weight and flexion bending (1Nm) loads were then applied and the output stress data on the rods were analyzed. Radiographic data showed fracture locations at the mid-construct, adjacent to the distal and tandem connector across the patients. Stress analysis from the FEA showed these failure locations matched local high-stress regions for all fractures observed. These results qualitatively validate the efficacy of the FEA framework by showing a decent correlation between localized high-stress regions and the actual fracture sites in the patients. This patient-specific, in-silico framework has huge potential to be used as a surgical tool to predict sites prone to fracture in growing rod implants. This prospective information would therefore be vital for surgical planning, besides helping optimize implant design for reducing rod failures.

Predicting early return to the operating room in early-onset scoliosis patients using machine learning techniques.

Surgical treatment of early-onset scoliosis (EOS) is associated with high rates of complications, often requiring unplanned return to the operating room (UPROR). The aim of this study was to create and validate a machine learning model to predict which EOS patients will go on to require an UPROR during their treatment course. A retrospective review was performed of all surgical EOS patients with at least 2 years follow-up. Patients were stratified based on whether they had experienced an UPROR. Ten machine learning algorithms were trained using tenfold cross-validation on an independent training set of patients. Model performance was evaluated on a separate testing set via their area under the receiver operating characteristic curve (AUC). Relative feature importance was calculated for the top-performing model. 257 patients were included in the study. 146 patients experienced at least one UPROR (57%). Five factors were identified as significant and included in model training: age at initial surgery, EOS etiology, initial construct type, and weight and height at initial surgery. The Gaussian naïve Bayes model demonstrated the best performance on the testing set (AUC: 0.79). Significant protective factors against experiencing an UPROR were weight at initial surgery, idiopathic etiology, initial definitive fusion construct, and height at initial surgery. The Gaussian naïve Bayes machine learning algorithm demonstrated the best performance for predicting UPROR in EOS patients. Heavier, taller, idiopathic patients with initial definitive fusion constructs experienced UPROR less frequently. This model can be used to better quantify risk, optimize patient factors, and choose surgical constructs. Prognostic: III.

Radiological Outcomes of Magnetically Controlled Growing Rods for the Treatment of Children with Various Etiologies of Early-Onset Scoliosis-A Multicenter Study.

Background: The management of spinal deformities diagnosed before the age of 10 is critical due to the child's development, skeletal system, and growth mechanism. Magnetically controlled growing rods (MCGRs) are a surgical treatment option for the growing spine. The aim of this study was to analyze the radiological findings of patients treated with MCGRs for early-onset scoliosis (EOS) of various etiologies. We hypothesized that the MCGRs could provide acceptable long-term radiographic results, such as an increase in the T1-T12 and T1-S1 height and significant overall deformity correction. Methods: We retrospectively reviewed 161 EOS patients with a combined total of 302 MCGRs inserted at five institutions between 2016 and 2022 with a mean follow-up of at least two years. The Cobb angle of the major curve (MC), thoracic kyphosis (TK), lumbar lordosis (LL), and T1-T12 and T1-S1 height measurements were assessed before, after, and during the follow-up. Results: Among the 90 female and 71 male patients, there were 51 neurological, 42 syndromic, 58 idiopathic, and ten congenital scoliosis etiologies. Of the patients, 73 were aged under six years old. The mean follow-up time was 32.8 months. The mean age at placement of the MCGRs was 7 years and that at the last follow-up after fusion surgery was 14.5 years. The mean MC before the initial surgery was 86.2°; following rod implantation, it was 46.9°, and at the last follow-up visit, it was 45.8°. The mean correction rate among the etiology subgroups was from 43% to 50% at follow-up. The mean TK was noted as 47.2° before MCGR implantation, 47.1° after MCGR placement, and 44.5° at the last follow-up visit. The mean T1-T12 height increased by 5.95 mm per year, with a mean T1-S1 height of 10.1 mm per year. Conclusions: MCGR treatment allowed for an average correction of the curvature by 50% during the period of lengthening, while controlling any deformity and growth of the spine, with a significant increase in the T1-T12 and T1-S1 values during the observation period. MCGR treatment in EOS carries a risk of complications. While congenital and syndromic EOS often have short and less flexible curves in those groups of patients, single rods can be as effective and safe. Definitive fusion results in the mean final coronal correction between the start of MCGR treatment and after undergoing PSF of approximately 70%. The mean T1-T12 spinal height increased by 75 mm, while the T1-S1 spinal height gained a mean of 97 mm.

A Prospective Multicenter ≥2 Years Clinical Study of the Active Apex Correction (APC) Technique in Early Onset Scoliosis (EOS) Patients.

prospective multicenter study. Active apex correction (APC) is posterior tethering technique for correction of early onset scoliosis (EOS) via reverse modulation at the apex. Active apex correction has been increasingly used worldwide. This study aimed to assess short-term outcomes of multicenter study with ≥2years of APC on spine length, curve correction, complications, unplanned surgeries, and proposed low crankshaft phenomena incidence. Prospective multicenter study including 24 EOS patients treated by APC; involves inserting and compressing pedicle screws on convex side of apex proximal and distal to most wedged vertebra allowing apex modulation according to Hueter-Volkmann law. Excluded patients with <2years follow-up whom APC was not primary surgery. Mean age 85.97 ± 32.43months, 71% congenital scoliosis, mean follow-up 35.54 ± 12.36months. At final follow-up, statistically significant improvement in Cobbs angle (∆ = 23.96%, P < .0001), spinal length T1-T12 (∆ = 12.83%, P < .0001), T1-L5 (∆ = 13.41%, P < .0001) but not in apical vertebral translation (AVT) albeit clinical improvement (∆ = 7.9%, P = .36) compared to preoperative measurements. Comparing immediate postoperative measurements to >2 years follow-up, statistically significant improvement in spinal length T1-T12 (∆ = 6.03%, P = .0002) and T1-L5 (∆ = 6.26%, P < .0001) but not in Cobbs angle (∆ = 4.93%, P = .3) or AVT (∆ = 14.77%, P = .25). 9 complications requiring 3 unplanned surgeries recorded in all patients including 2 broken rods, 2 adding-on and 4 screw dislodgement. Active apex correction is a novel technique that has been incorporated in several countries as treatment modality for EOS. Short-term outcomes are promising in terms of clinical improvement, complication rates and decreased need for multiple operations or unplanned surgeries.

Health-related quality of life and clinical outcomes for magnetically controlled growing rod patients after treatment termination.

To determine the health-related quality of life (HRQoL) and clinical outcomes of children with early onset scoliosis (EOS) treated with magnetically controlled growing rods (MCGR) followed to definitive fusion (DF). A retrospective review of EOS patients treated with MCGR and followed to DF was performed. Outcomes included HRQoL scores, radiographic, clinical, and unplanned returns to the operating room (UPROR) data collected at pre-MCGR implantation, immediately post-MCGR implantation, pre-DF, and post-DF. HRQoL scores were collected at least 6months post-DF. Twenty-eight patients (57.1% females, mean age at MCGR insertion 7.19 ± 1.5years, mean pre-MCGR Cobb 64.7° ± 17.6) met inclusion criteria. MCGR treatment resulted in an overall 30.2% improvement in coronal plane deformity following DF. The mean growth rates between MCGR implantation and pre-DF for T1-T12 height and T1-S1 length were 0.33 ± 0.23mm/month and 0.49 ± 0.28mm/month, respectively. Of the 28 included patients, 26 (92.9%) experienced at least one UPROR, with a total of 52 surgical complications occurring in the total cohort, representing 1.9 UPROR/patient. Interestingly, there was a decline in scores reported between post-MCGR implantation and the pre-DF time-point (N = 16, 78.2 ± 14.9 vs 69.7 ± 17.8, p = 0.02). These scores recovered post-DF, resulting in an overall unchanged HRQoL when comparing pre-MCGR to post-DF (N = 11, 79.9 ± 15.1 vs 76.7 ± 17.9, p = 0.44). While MCGR treatment achieves coronal plane deformity control and facilitates spinal growth, only 7.1% of children experienced a complication-free treatment course when followed to definitive fusion. Patients achieved modest curve correction and spinal growth, while maintaining stable HRQoL outcomes between pre-MCGR and post-DF.

Does radiographic calibration affect linear radiographic measurements in a large pediatric spine registry?

Large registries are increasingly at the forefront of modern pediatric spine research, with manual, centralized, trained radiographic measurement serving as the gold standard for spine research. However, there is limited data regarding the reliability of registry measurements which may be subject to differences in radiographic calibration.We undertook this study to evaluate reliability of T1-T12 height, L1-S1 height, and coronal balance measurements for a large registry of early onset scoliosis patients. Three trained technicians from the Pediatric Spine Study Group measured 43 radiographs for T1-T12, L1-S1, and coronal balance using 3 different calibration techniques. All radiographs were AP views of patients with magnetically controlled growing rods with known diameters. The calibration techniques used a pre-export manually drawn line, a digital automatically generated computerized marker, and the diameter of a magnetically controlled growing rod.The intraclass correlation coefficient (ICC) was calculated to determine reliability. 1161 measurements were performed.For each of the three raters, coronal balance, T1-T12 height and L1-S1 height had excellent agreement regardless of the calibration technique (alpha 0.93-1.0).Among the parameters, coronal balance had the worst inter-rater reliability, whereas there was excellent interrater reliability regarding T1-T12 height and L1-S1 height (alpha 0.91-0.99). There was excellent agreement among reviewers and between the 3 different calibration techniques. While calibration using rod diameter served as the gold standard, this data shows that other standard calibration methods were adequate and achieved excellent reliability for registry radiographs.

Ultrasonographic assessment of magnetic growing rods overestimates the lengthening of the thoracic spine compared to radiographs in early-onset scoliotic patients.

Magnetic growing rods (MGRs) are one of the most common procedures to treat early-onset scoliosis (EOS). Radiographic examinations (X-ray) or ultrasonographic (US) assessments are used to evaluate the lengthening of the rods. X-ray exposes patients to radiation, while the US has not been validated and may be affected by the radiologist's ability to assess elongation. The research question of the present study is to compare the difference between US and X-ray growth assessments in EOS patients treated with MGRs. The study enrolled 65 patients consecutively from July 2011 to July 2022. Noninvasive lengthening was performed every fourmonths, and X-ray follow-up was performed at different intervals. An experienced radiologist assessed the mean US rod elongation per session. The mean elongation/session of T2-T12 and T2-S1 was calculated, and the results were compared using an independent t-test. The mean age at operation was 8.8 ± 2years, and the mean follow-up was four± twoyears. The average rod elongation assessed by the US was 3.1 ± 0.1mm. The average rod elongation evaluated by X-ray was 1.2 ± 2.9mm (T2-T12) and 1.8 ± 1.9mm (T2-S1). The difference between the values measured by US and X-ray was statistically significant in the T2-T12 group (p < 0.05) and not significant in the T2-S1 group (p = 0.34). This is the most extensive single-center study comparing US and X-ray data for MGRs in EOS patients. US overestimates thoracic spine elongation compared to X-ray. US elongation analysis could be appropriate in long thoracolumbar curves.

Health-related quality of life in early onset scoliosis patients treated with the spring distraction system: what to expect in the first 2 years after surgery

PurposeThe Spring Distraction System (SDS) is a novel “growth-friendly” implant for the treatment of Early-Onset Scoliosis (EOS). This prospective study aims to determine the evolution of the “24-Item Early-Onset Scoliosis Questionnaire” (EOSQ-24) scores during 2-year follow-up after SDS surgery. Secondary aims include investigating the relation between EOSQ-24 scores and EOS etiology, and evaluating the impact of an unplanned return to the operating room (UPROR) on HRQoL.MethodsAll SDS patients with at least 2-year follow-up were included. Caregivers completed the EOSQ-24 pre-operatively, post-operatively, and at 6, 12, and 24 month follow-up. Mean total and -domain scores were graphed over time. Repeated-measures ANOVA analyzed the influence of etiology on EOSQ-24 scores. Multiple regression analyzed associations between UPRORs and EOSQ-24 scores.ResultsForty-nine patients were included. Mean total EOSQ-24 scores decreased from 70 pre-operatively to 66 post-operatively, then gradually increased to 75 (24 months). Most domains exhibited changes over time, with initial declines, but eventually surpassing pre-operative levels after 2-year follow-up. Neuromuscular/Syndromic patients had lower scores, but showed similar improvements over time compared with other etiologies. Multiple regression showed lower Parental Burden domain score (− 14 points) in patients with UPRORs, although no significant reductions were found in total score, or in other domains.ConclusionHRQoL decreases immediately following SDS surgery but quickly recovers and exceeds pre-operative levels at 2-year follow-up in all domains. Neuromuscular/Syndromic patients have lower initial scores, but progress similarly over time. UPRORs do not influence EOSQ-24 scores, except for a negative impact on the Parental Burden domain in the short term.Level of EvidenceIII.

Magnetically Controlled Growing Rods Graduation: Lessons From a Single-center Series of 48 Patients.

Magnetically controlled growing rod (MCGR) treatment for early-onset scoliosis (EOS) has become a widely utilized method of deformity control, but long-term follow-up reports are sparse. We evaluated the outcomes of a large group of consecutive pediatric patients diagnosed with EOS who were treated by MCGR to the endpoint of definitive spinal fusion in a single center. We hypothesized that lessons learned from treating a large volume of MCGR patients would lower the complication rate in comparison to what was previously reported by other studies. The records of 48 EOS patients with varied etiologies who were treated by MCGR between 2012 and 2022 and reached the end of treatment were analyzed retrospectively for baseline and final radiographic measurements and surgery-related complications. The mean percent of improvement in the major coronal deformity was 51.7±25.0% and the mean T1 to T12 total growth was 52.9±21.9mm. The total complication rate was 22.9% of which 12.5% required a single unplanned surgery, 6.3% required multiple unplanned surgeries, and 4% did not require any unplanned surgery. MCGR treatment provides adequate control of EOS, enabling satisfactory growth of the thoracic spine. The complication rate in a single large volume center is moderate. IV.

Growth-preserving instrumentation for early onset scoliosis

Early onset scoliosis is defined as aspinal deformity originating in the first 10years of life. Growth-preserving spinal instrumentation has therefore been designed to preserve growth of spine and chest wall and lungs to avoid serious pulmonary complications after early spine fusion. Indications, surgical technique and results of the vertical expandable prosthetic titanium rib (VEPTR) technique, traditional growing rods (TGR), and magnetically controlled growing rods (MCGR) will be described. Indications for VEPTR are so-called mixed congenital deformities (type3) associated with vertebral malformations in association with chest wall deformities, especially fused ribs. There are also indications for neuromuscular or syndromic early onset scoliosis with bilateral rib-to-ilium constructs. However, most of those deformities are currently treated with either GR or MCGR in most centers. GR and MCGR are currently the treatment of choice for the majority of early onset scoliosis. There is no indication for growth-preserving strategies if the patients are mature or there is only little growth remaining. In these cases, final fusion should be performed. While the VEPTR technique involves an extensive approach with muscular dissections to the thoracic cage including rib osteotomies and thoracotomies, treatment with TGR or MCGR is minimally invasive, only exposing proximal and distal anchor points, leaving most of the spine including the apex undisturbed. Early mobilization is usually possible after 24-48 h. Braces may have to be prescribed for patients with osteopenia, noncompliance, or arisk to fall. Since 2005, more than 200patients were treated with the VEPTR technique, more than 200 patients with the MCGR technique, and about 30patients with the TGR technique in our department. Complication rates are high with all techniques including the law of diminishing returns, autofusion, bone anchor-related complications like loosening or migration of implants, failure to distract and proximal junctional kyphosis. In our own series of 13patients below age 3years, VEPTR proved to be effective for mixed deformities. In other studies, we were able to show that physiological growth with MCGR can be maintained for 2-3years but spinal growth declines after that period with acceptable complications. Complication rates in most studies are lower with MCGR compared to TGR and VEPTR. Therefore, it is currently the treatment of choice for most early onset scoliosis patients.

Traditional Dual Growing Rods With 2 Different Apical Control Techniques in the Treatment of Early-Onset Scoliosis.

Based on traditional dual growing rods (TDGR), apical control techniques (ACTs) were introduced as adjuvant procedures to improve deformity correction at the apex segment in the treatment of early-onset scoliosis (EOS). We aimed to explore whether TDGR+ ACTs have different indications, attain more deformity correction, have negative effects on spinal growth, and have different complications. Between 2004 and 2019, a retrospective study of EOS patients treated with TDGR with or without ACTs was conducted and divided into 3 groups: TDGR group; hybrid technique (HT) group: Vertebrectomy/hemivertebrectomy with short fusion and TDGR; ACPS group: apical convex control pedicle screws (ACPS) and TDGR. Demographic, radiographic parameters, clinical outcomes, complications, and revisions were analyzed and compared. Seventy-eight EOS patients were enrolled. The preoperative main curve was the largest in the HT group. ACPS group had the smallest residual curve (19° ± 8.9°) and apical vertebral translation (12.0 ± 9.0 mm) at the latest follow-up, followed by the HT group (30° ± 17.4°, 22.1 ± 13.4 mm) and TDGR group (30° ± 13.2°, 32.8 ± 17.1 mm). ACPS group had the largest T1-12 height and T1-S1 height after index surgery. Complications and revisions in the ACTs groups was lower than the TDGR group. Scoliosis Research Society-22 self-image questionnaire was superior in the ACPS group. According to our intermediate results, TDGR+ACTs could improve correction ability of apex deformity. ACTs had little deleterious effects on spinal height during the lengthening procedures, with a lower complication rate than TDGR. TDGR+ACTs might be a supplemental option for suitable EOS patients.

Growth friendly surgeries increase 3D true spine length at two-years post-operative.

Traditional coronal-plane vertical spine height measurements, such as T1-T12 and T1-S1 spine height, are influenced by 3-dimensional spinal deformity. Therefore, they are unreliable indicators of true spine growth. The novel 3D true spine length (3D-TSL) technique assesses spine growth regardless of the presence of 3D spinal deformity. This study evaluates the effect of growth friendly surgery on spine growth using the 3D-TSL technique at two years follow-up. Radiographs of early onset scoliosis (EOS) participants undergoing growth friendly surgery at a single institution were evaluated at pre-index, post-index, and at 2-year follow-up. Scoliosis, kyphosis, traditional coronal height and 3D-TSL were measured. Twenty-four EOS patients (14 female) with a mean age of 6.3years were included. Scoliosis improved from 77.8 ± 18.7° pre-index to 56.0 ± 17.8° post-index (p < 0.001); but increased at 2years to 65.9 ± 20.1° (p < 0.05). Kyphosis improved from 56.0 ± 20.7° pre-index to 39.3 ± 13.8° post-index (p < 0.001); and increased again at 2years to 48.6 ± 16.4° (p < 0.05). Traditional T1-S1 height increased from pre-index to post-index, to 2-year follow-up (245.5 ± 37.2mm to 275.8 ± 42.7mm; p < 0.001, to 288.0 ± 41.7mm; p = 0.005). As expected, T1-S1 3D-TSL did not change from pre to immediately post-index (305.6 ± 43.9mm vs 306.5 ± 44.0mm); there was a significant change from post-index to 2-year follow-up (334.1 ± 48.0mm; p < 0.001). Out of plane changes in scoliosis and kyphosis over time justify the use of the 3D-TSL for this cohort of patients. There was no significant change in 3D-TSL from pre-index to post-operatively; however, during the growth phase of treatment 3D-TSL increased significantly by 27.6mm.

Reliability and validity of the Chinese version of the Early-Onset Scoliosis Self-Report Questionnaire in children aged 8 to 18 years with early-onset scoliosis.

The Early-Onset Scoliosis Self-Report Questionnaire (EOSQ-SELF) is a novel self-report instrument to evaluate the health-related quality of life (HRQoL) of early onset scoliosis (EOS) patients, as a complementary HRQoL assessment tool for the proxy-repot 24-item Early-Onset Scoliosis Questionnaire (EOSQ-24). This study aimed to translate and adapt the EOSQ-SELF into a Chinese version and evaluate its reliability and validity in EOS patients. A cross-sectional study was performed from July 2022 to September 2022. Patients aged 8 to 18 years with EOS were recruited. Forwards-backwards translation and cross-cultural adaptation of the original EOSQ-SELF were performed. The Chinese EOSQ-SELF was administered and collected twice through social media, with a 2 weeks interval. Reliability was evaluated by using internal consistency, and test-retest reliability was assessed by the intraclass correlation coefficient (ICC) of data between the two time points. A Delphi survey in the expert committee was used to investigate the content validity. SRS-22r, PedsQL4.0, and EQ-5D-Y scales were used to assess the criterion-related validity. Nonparametric tests and multiple linear regression were performed to evaluate the discriminative ability. A total of 101 valid responses from EOS patients were received. The mean age was 12.08±2.19 years, and 53.47% were female. The mean Cobb angle was 60.56°±19.48°. Floor effects of 0.00% to 7.92% and ceiling effects of 0.00% to 52.48% were observed. Excellent internal consistency and test-retest reliability of the Chinese EOSQ-SELF was observed, with a Cronbach's α coefficient of 0.942, McDonald's ω coefficient of 0.940, and ICC of 0.930. All domains of the Chinese EOSQ-SELF were significantly correlated with SRS-22r (0.709 to 0.878), PedsQL4.0 (0.568 to 0.718), and EQ-5D-Y (-0.598 to -0.625), depicting excellent criterion-related validity. Discriminative ability was validated in aetiology (P<0.001), severity of spinal deformity (P<0.001), treatment status (P<0.001), and ambulatory ability (P<0.001). The Chinese EOSQ-SELF is a reliable and valid tool for the assessment of self-report HRQoL in patients aged 8 to 18 years with EOS. It can be easily applied in clinical settings and for research purposes, as a complementary tool for the proxy-report EOSQ-24.

Weight Gain and Nutritional Improvement After Magnetically Controlled Growing Rod Surgery in Early-Onset Scoliosis: A Single Centre Analysis of 68 Patients.

Early-onset scoliosis (EOS) is frequently associated with complex spine and chest wall deformities that may lead to severe cardiopulmonary impairment and malnutrition. The aim of this study is to evaluate the change in the nutritional status of EOS patients after treatment with magnetically controlled growing rod instrumentation (MCGR) in a single center. We prospectively collected data of patients treated with MCGR for EOS in a single center. Exclusion criteria were <2 years' follow-up and incomplete weight-for-age Z-scores (WAZ) data. Preoperative and postoperative WAZ, radiographic parameters, including major coronal curve, kyphosis angle, space available for lung ratios, thoracic height, and unplanned returns to the operating room (UPROR), were analyzed. SD and 95% Confidence intervals (CI) are presented with means. Sixty-eight patients (37 males/31 females) were included. The mean age at surgery was 8.2 years (SD 2.8, range 1.8-14.2), and the mean follow-up time was 3.8 years (SD 1.0, range 2.1-6.8). The study population was categorized by the primary diagnosis as follows: 23 neuromuscular, 18 idiopathic, 15 congenital, and 12 syndromic patients. The major coronal curve improved between the preoperative and latest visits by 40% ( P <0.005, SD 27, CI 33-47), while the space available for lung ratios improved by 8% ( P <0.005, SD 13, CI 5-12). Thoracic height increased by 25% ( P <0.005, SD 13, CI 22-28), and kyphosis angle decreased by 25% ( P <0.005, SD 26, CI 9-39). Eighteen patients (27%) required a total of 53 UPRORs. WAZ improved significantly between the preoperative and the latest follow-up ( P =0.005). Regression analysis showed WAZ improvements were most significant in the underweight patients and the Idiopathic or Syndromic EOS patients. UPROR was not associated with deterioration in WAZ. Treatment of EOS patients with MCGR resulted in an improvement in nutritional status, as evidenced by the significant increase in WAZ. Underweight, Idiopathic and Syndromic EOS patients, and those who required UPROR all had significant improvement in their WAZ with MCGR treatment. Therapeutic Study-Level II.

Clinical outcomes of the traditional dual growing rod technique combined with apical pedicle screws in the treatment of early-onset scoliosis: preliminary results from a single center.

Limited control of an apical deformity is a major disadvantage in the traditional dual growing rod (TDGR) technique. Previous literature has reported the results of apical pedicle screw placement (APS) as an apical control technique in patients with early-onset scoliosis (EOS). However, the clinical outcomes, indications, and complications of the TDGR technique combined with APSs have not been well described. The purpose of this study was to evaluate the preliminary clinical outcomes of the TDGR technique combined with APSs in EOS patients. Clinical data of 12 patients with EOS who were treated with the TDGR technique combined with APSs at the index surgery at the authors' center from January 2010 to January 2020, with a minimum 2-year follow-up, were retrospectively reviewed. Indications for the use of APSs included 1) no vertebral segmentation failure, fused ribs, or multiple hemivertebrae at the apex; 2) at least 2 normal discs around the apex; and 3) proper development of apical pedicles on the convex side. Etiology, age at index surgery, number of lengthening procedures, follow-up duration, and complications were recorded. Radiographic measurements included Cobb angle, apical vertebral translation (AVT), apical vertebral rotation (AVR), thoracic kyphosis, lumbar lordosis, spine height, and space available for the lung (SAL). The mean follow-up period was 4.0 ± 1.4 years, with a mean of 4.8 lengthening procedures per patient. The mean Cobb angle improved from 61.7° ± 10.4° to 19.9° ± 9.0° after the index surgery (19.6° ± 9.4° at the latest follow-up). The mean postindex AVT decreased to 16.8 ± 8.9 mm from a preindex AVT of 56.3 ± 9.7 mm and further improved to 13.6 ± 10.0 mm at the latest follow-up. The mean annual increases in T1-12 and T1-S1 height were 9.0 ± 4.7 mm and 13.9 ± 6.5 mm, respectively. The SAL improved from 0.91 to 1.04 at the latest follow-up. AVR improved significantly after the index surgery (p = 0.013), while minor deterioration was observed after repeat lengthening procedures. Five complications (2 implant related and 3 alignment related) occurred in 4 patients. For EOS patients with good flexibility (without segmentation failure or multiple hemivertebrae at the apex), the TDGR technique combined with APSs can improve primary curve correction, maintain good correction results, and allow continuous spine growth, which may reduce the risks of complications during lengthening treatment. More multicenter prospective studies with larger samples are needed to further validate the findings of this study.

Intraoperative Antibiotic Use in Patients With Early-onset Scoliosis: Current Practices and Trends.

Best Practice Guidelines (BPGs) regarding antibiotic prophylaxis in early-onset scoliosis (EOS) patients were published in September 2019. Recommendations included using intravenous cefazolin and topical vancomycin for all index procedures, plus gram-negative coverage for neuromuscular patients. Guideline adherence is unknown. This study aimed to characterize antibiotic prophylaxis at the time of index growth-friendly procedures and assess changes in practice patterns over time. This retrospective review of data collected through a multicenter study group included EOS patients undergoing index growth-friendly procedures between January 2018 and March 2021, excluding revisions, lengthenings, and tetherings. Demographics, clinical measurements, intraoperative antibiotics, and 90-day complications were recorded. Descriptive and univariate statistics were utilized. Antibiotic prophylaxis from April 2018 through September 2019 and October 2019 through March 2021 were compared with evaluate change after BPG publication. A total of 562 patients undergoing growth-friendly procedures were included. The most common scoliosis types included neuromuscular (167, 29.7%), syndromic (134, 23.8%), and congenital (97, 17.3%). Most index procedures involved magnetically controlled growing rods (417, 74%) followed by vertical expandable prosthetic titanium rib or traditional growing rods (105, 19%). Most patients received cefazolin alone at index procedure (310, 55.2%) or cefazolin with an aminoglycoside (113, 20.1%). Topical antibiotics were used in 327 patients (58.2%), with most receiving vancomycin powder. There was increased use of cefazolin with an aminoglycoside after BPG publication (16% vs. 25%) (P=0.01). Surgical site infections occurred in 12 patients (2.1%) within 90 days of index procedure, 10 pre-BPGs (3%), and 2 post-BPGs (0.9%), with no significant difference in surgical site infection rate by type of antibiotic administered (P>0.05). Historical variability exists regarding antibiotic prophylaxis during index growth-friendly procedures for EOS. There continues to be variability following BPG publication; however, this study found a significant increase in antibiotic prophylaxis against gram-negative bacteria after BPG publication. Overall, greater emphasis is needed to decrease variability in practice, improve compliance with consensus guidelines, and evaluate BPG efficacy. Level III-retrospective.