Management Of Spinal Deformity Research Articles

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.

Consensus-Based Best Practice Guidelines for the Management of Spinal Deformity and Associated Tumors in Pediatric Neurofibromatosis Type 1: Screening and Surveillance, Surgical Intervention, and Medical Therapy.

Spinal conditions, such as scoliosis and spinal tumors, are prevalent in neurofibromatosis type 1 (NF1). Despite the recognized importance of their early detection and treatment, there remain knowledge gaps in how to approach these manifestations. The purpose of this study was to utilize the experience of a multidisciplinary committee of experts to establish consensus-based best practice guidelines (BPGs) for spinal screening and surveillance, surgical intervention, and medical therapy in pediatric patients with NF1. Using the results of a prior systematic review, 10 key questions that required further assessment were first identified. A committee of 20 experts across medical specialties was then chosen based on their clinical experience with spinal deformity and tumors in NF1. These were 9 orthopaedic surgeons, 4 neuro-oncologists/oncologists, 3 neurosurgeons, 2 neurologists, 1 pulmonologist, and 1 clinical geneticist. An initial online survey on current practices and opinions was conducted, followed by 2 additional surveys via a formal consensus-based modified Delphi method. The final survey involved voting on agreement or disagreement with 35 recommendations. Items reaching consensus (≥70% agreement or disagreement) were included in the final BPGs. Consensus was reached for 30 total recommendations on the management of spinal deformity and tumors in NF1. These were 11 recommendations on screening and surveillance, 16 on surgical intervention, and 3 on medical therapy. Five recommendations did not achieve consensus and were excluded from the BPGs. We present a set of consensus-based BPGs comprised of 30 recommendations for spinal screening and surveillance, surgical intervention, and medical therapy in pediatric NF1.

The relationship of the posterior iliac interval and the S1 screw trajectory

IntroductionSurgical fixation is widely practised in the management of spinal deformity. S1 screws are commonly incorporated in lumbosacral fusions and can be performed in both open and percutaneous techniques. However, their entry point is determined by the position of the pedicle as well as the posterior iliac interval (PII), as it creates an impedance for screw angulation. A wider angle screw has the potential to achieve a greater length and thus strength versus a narrow screw angle insertion due to risk of anterior breach. MethodsA retrospective analysis of 50 consecutive patients between July 2018 andDecember 2021 undergoing lumbo-sacral fusion with include S1 screw insertion from a single institution and surgeon. The age, screw angles, and the posterior iliac intervals were measured. ResultsThe patients ranged from age 27 to 83 years old (mean 64.7) with a posterior iliac interval (PII) ranging from 7.76 to 12.62 cm (mean 10.24) and the average S1 screw angle on the right was 76.01 degrees (range 59.37 to 88.48) and on the left 74.37 degrees (range 59.75 to 87.47 degrees). Applying the Pearson Correlation co-efficient, a wider PII correlated with a more angulated screw entry (P < 0.05). ConclusionAs expected, a wider PPI is significantly associated with a more angulated S1 screw trajectory and may have implication on patient biomechanics in lumbo-sacral fusion constructs.

RCC (reinforced criss-cross construct): an easy and effective multi-rod thoraco-lumbar posterior reconstruction technique.

Surgical technical note and literature review. To describe a technique that uses 4 rod constructs in cases of complex thoracolumbar spinal deformity correction or revision surgeries based on the hybrid use of two different types of purchase points by a staggered pedicle screw fixation. It utilizes two rods on either side of the spine using a lateral and medial entry point of pedicle screws in the vertebral body. Pedicle screws using extra-pedicular technique are more converging screws and are inserted alternately in the vertebral body and connected by rods. The left-out alternate vertebral bodies are fixed by a relatively straighter pedicle entry screw and connected to each other by a separate rod. So, two trajectories are independently used for a four-rod construct. This reconstruction has been named RCC (reinforced criss-cross construct). The screws in the index case were placed by free hand method, but we have increasingly utilized navigation guidance for placement of screws in recent times. We present a surgical technical note in a patient with human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV-AIDS). He was diagnosed to have multi-drug-resistant (MDR) tuberculous spondylodiscitis, complicated with Immune reconstitution inflammatory syndrome (IRIS) and implant failure resulting in kyphosis and thoracic myelopathy. RCC with pharmacological management achieved healing and union, which was maintained at 4years follow-up. Our method of four-rod construct provides a strong and lasting construct in the management of spinal deformities and three-column osteotomies. It provides good structural support to the spine till bony union is achieved. Hybrid multi-rod construct like RCC provides a rigid mechanical support to the instrumentation and reduces the chances of rod failure especially in complex thoraco-lumbar spinal deformity correction surgeries.

Guidelines for the conservative treatment of spinal deformities - Questionnaire for a Delphi consensus.

BackgroundSpinal deformity is the oldest disease known to humankind. Many types of treatment methods, including both conservative and surgical, are in use.ObjectiveWe aimed to validate a published guideline protocol based on the conservative treatment of spinal deformities.MethodA modified Delphi technique was used with a questionnaire sent out to professionals worldwide regarding the conservative treatment of spinal deformities.ResultsOur study was completed after two rounds. A strong level of agreement of 80% and more (consensus cut-off point) was achieved in most questions in the first round. Some statements were below this margin, and they were sent to the participants via email in the second round for re-evaluation. Consensus was achieved in almost all of the statements in the second round. Only two items did not reach the cut-off point but were close to this value.ConclusionThis proposed Guideline Protocol was approved by the participants using the Delphi method and can be used as a valid tool for the conservative treatment of spinal deformities.Clinical implicationsA conservative treatment guideline in spinal deformity management, will provide consistency in treatment and will facilitate comparability with surgery. It will be useful in determining the cost-effectiveness of treatment and in choosing the right patient for the right method of treatment. This guideline might help in this context, and may also create a systematic method for clinicians to use as a reference in both research and clinical practice.

Is Frailty Associated with Adverse Outcomes After Orthopaedic Surgery?: A Systematic Review and Assessment of Definitions.

There is increasing evidence supporting the association between frailty and adverse outcomes after surgery. There is, however, no consensus on how frailty should be assessed and used to inform treatment. In this review, we aimed to synthesize the current literature on the use of frailty as a predictor of adverse outcomes following orthopaedic surgery by (1) identifying the frailty instruments used and (2) evaluating the strength of the association between frailty and adverse outcomes after orthopaedic surgery. A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched to identify articles that reported on outcomes after orthopaedic surgery within frail populations. Only studies that defined frail patients using a frailty instrument were included. The methodological quality of studies was assessed using the Newcastle-Ottawa Scale (NOS). Study demographic information, frailty instrument information (e.g., number of items, domains included), and clinical outcome measures (including mortality, readmissions, and length of stay) were collected and reported. The initial search yielded 630 articles. Of these, 177 articles underwent full-text review; 82 articles were ultimately included and analyzed. The modified frailty index (mFI) was the most commonly used frailty instrument (38% of the studies used the mFI-11 [11-item mFI], and 24% of the studies used the mFI-5 [5-item mFI]), although a large variety of instruments were used (24 different instruments identified). Total joint arthroplasty (22%), hip fracture management (17%), and adult spinal deformity management (15%) were the most frequently studied procedures. Complications (71%) and mortality (51%) were the most frequently reported outcomes; 17% of studies reported on a functional outcome. There is no consensus on the best approach to defining frailty among orthopaedic surgery patients, although instruments based on the accumulation-of-deficits model (such as the mFI) were the most common. Frailty was highly associated with adverse outcomes, but the majority of the studies were retrospective and did not identify frailty prospectively in a prediction model. Although many outcomes were described (complications and mortality being the most common), there was a considerable amount of heterogeneity in measurement strategy and subsequent strength of association. Future investigations evaluating the association between frailty and orthopaedic surgical outcomes should focus on prospective study designs, long-term outcomes, and assessments of patient-reported outcomes and/or functional recovery scores. Preoperatively identifying high-risk orthopaedic surgery patients through frailty instruments has the potential to improve patient outcomes. Frailty screenings can create opportunities for targeted intervention efforts and guide patient-provider decision-making.

P95. Geographic variation in the philosophy of adult spinal deformity management and patient outcomes: A propensity score matching analysis from the Prospective Evaluation Deformity Surgery (PEEDS) Study

<h3>BACKGROUND CONTEXT</h3> Severity of deformity, preoperative disability, and surgical strategies are variable between, and within, centers performing reconstructive surgery for spinal deformity. However, geographic variation in how surgeons manage ASD patients worldwide is unknown. <h3>PURPOSE</h3> The purpose of this study was to compare the surgical approach and clinical outcomes of elderly patients treated with fusion for spinal deformity in North America and Asia. <h3>STUDY DESIGN/SETTING</h3> Retrospective review of the prospectively collected data. <h3>PATIENT SAMPLE</h3> All patients enrolled in the database were eligible and were propensity score matched according to their region (North America and Asia) <h3>OUTCOME MEASURES</h3> Surgical details, postoperative radiological parameter and health-related quality of life (HRQoL) scores at preoperative and 2 years, and occurrence of adverse events within the study period were compared in the matched pairs with dependent statistical tests. <h3>METHODS</h3> The two largest regions (North America and Asia) from the Prospective Evaluation Deformity Surgery (PEEDS) database, consisting of ASD patients over aged 60 with primary spinal fusion of at least 5 segments with a minimum of 2 year follow-up, were compared. Patients were 1:1 propensity score-matched using age, gender, Charlson Comorbidity Index, lumbar lordosis (LL), pelvic incidence (PI)-LL mismatch, sagittal vertical axis (SVA), absolute lumbar cobb angle, and sacral slope for calculation of propensity score and applying greedy algorithm to identify the best matches between the 2 regions with maximal absolute distance of 0.25 in propensity score to each other. <h3>RESULTS</h3> Out of the 219 patients enrolled in the database, 82 propensity score-matched patients were identified (n=41 in each region), with a median age of 68.0 (range 64-72) years (NA) and 68.0 (range 63-73) years (A). Both cohorts had comparable distributions of all preoperative radiological parameters and HRQoL scores. Out of the 219 patients enrolled in the database, 82 propensity score-matched patients were identified (n=41 in each region), with a median age of 68.0 (range 64-72) years (NA) and 68.0 (range 63-73) years (A). Both cohorts had comparable distributions of all preoperative radiological parameters and HRQoL scores. Patients treated in NA had higher proportion of single stage surgery (88% vs 44%, p<0.001), more levels fused throughout all stages (11.5±3.7 vs 9.1±2.3, p<0.001), and higher cumulative median blood loss (1500ml vs 1200ml, p=0.010) compared with those treated in A. Surgical procedures differed between the two groups: posterior instrumentation with TLIF were predominant in NA (83%), whereas a combined lateral and posterior approach (49% vs 5%) was more common in A. The occurrence of having any adverse events was higher in the NA group (82% vs 35%, p=0.002), due to a difference in the incidence of deep vein thrombosis (21% vs 0%, p=0.016) and other AEs (44% vs 15%, p=0.013). At 2-year follow-up, there was no difference in the correction of radiological parameters between the two groups. In terms of HRQoL, at 2 year follow-up patients in NA had a more favourable SRS-22r total score, EQ-5D VAS and leg pain NRS compared with the matched pairs in A, but similar EQ-5D index, ODI and back pain scores. <h3>CONCLUSIONS</h3> In this propensity score matched analysis, we demonstrated marked geographic variation in surgical practice toward surgeries for adult spinal deformity despite similar baseline patient characteristics and radiological parameters between North America and Asia. However, the 2 year radiological and clinical outcomes were similar. Further study is necessary to understand the drivers of this variation. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

The Relationship Between the Amount of Time for Brace Wear and Its Psychological Effects and the Level of Social Participation of Adolescents With Spinal Deformity

Background and Objectives: Braces are common non-surgical treatments for the management of spinal deformities in adolescents. There are factors that may determine the success of non-surgical treatments of spinal deformities. Hence the aim of current study was to investigate the relationship between the amount of time for brace wear and its psychological effects and the level of social participation of adolescents with spinal deformity. Subjects and Methods we examined adolescents undergoing brace treatment for spinal deformity attending to Ahvaz Technical Orthopedic Centers. Among them, 30 adolescents including 3 males and 27 females (mean age: 14.7 (1.92) years) were included in the study. Sampling method was simple non-probability sampling. Data were collected using Fear of Negative Evaluation questionnaire, Participation Scale questionnaire, Bad Sobernheimer stress (Deformity) and Bad Sobernheimer (brace) questionnaire. The duration (hours and months) of brace treatment was also recorded. Statistical analysis was performed using Spearman correlation coefficient calculation and correlational analysis. Results The results demonstrated that the participation scale had a negative correlation with Bad Sobernheimer (brace) score (r= 0.49, p=0.006). Participation scale also had a positive correlation with fear of negative evaluation score (r= 0.42, p=0.019). There were no significant correlation between other variables. Conclusion Psycho-social factors can affect adolescents’ participation score undergoing brace treatment. People with scoliosis and hyper kyphosis undergoing brace treatment are young, so, it is important to consider psychological and social factors during brace treatment, to minimize negative consequences of brace treatment.

Management of spinal deformities and tibial pseudarthrosis in children with neurofibromatosis type 1 (NF-1)

Summary of background dataThe skeletal system is affected in up to 60% of patients with neurofibromatosis type 1. The most commonly observed entities are spinal deformities and tibial dysplasia. Early recognition of radiologic osseous dystrophy signs is of utmost importance because worsening of the deformities without treatment is commonly observed and surgical intervention is often necessary. Due to the relative rarity and the heterogenic presentation of the disease, evidence regarding the best surgical strategy is still lacking.PurposeTo report our experience with the treatment of skeletal manifestations in pediatric patients with (neurofibromatosis type 1) NF-1 and to present the results with our treatment protocols.Materials and methodsThis is a retrospective, single expert center study on children with spinal deformities and tibial dysplasia associated with NF-1 treated between 2006 and 2020 in a tertiary referral institution.ResultsSpinal deformity: Thirty-three patients (n = 33) were included. Mean age at index surgery was 9.8 years. In 30 patients (91%), the deformity was localized in the thoracic and/or lumbar spine, and in 3 patients (9%), there was isolated involvement of the cervical spine. Eleven patients (33%) received definitive spinal fusion as an index procedure and 22 (67%) were treated by means of “growth-preserving” spinal surgery. Halo-gravity traction before index surgery was applied in 11 patients (33%). Progression of deformity was stopped in all patients and a mean curve correction of 60% (range 23–98%) was achieved. Mechanical problems with instrumentation requiring revision surgery were observed in 55% of the patients treated by growth-preserving techniques and in none of the patients treated by definitive fusion. One patient (3%) developed a late incomplete paraplegia due to a progressive kyphotic deformity.Tibial dysplasia: The study group comprised of 14 patients. In 5 of them (36%) pathological fractures were present on initial presentation. In the remaining 9 patients (64%), anterior tibial bowing without fracture was observed initially. Four of them (n = 4, 28%) subsequently developed a pathologic fracture despite brace treatment. Surgical treatment was indicated in 89% of the children with pathological fractures. This involved resection of the pseudarthrosis, autologous bone grafting, and intramedullary nailing combined with external fixation in some of the cases. In 50% of the patients, bone morphogenic protein was used “off-label” in order to promote union. Healing of the pseudarthrosis was achieved in all of the cases and occurred between 5 to 13 months after the index surgical intervention. Four of the patients treated surgically needed more than one surgical intervention in order to achieve union; one patient had a re-fracture. All patients had a good functional result at last follow-up.ConclusionEarly surgical intervention is recommended for the treatment dystrophic spinal deformity in children with NF-1. Good and sustainable curve correction without relevant thoracic growth inhibition can be achieved with growth-preserving techniques alone or in combination with short spinal fusion at the apex of the curve. Preoperative halo-gravity traction is a safe and very effective tool for the correction of severe and rigid deformity in order to avoid neurologic injury. Fracture union in tibial dysplasia with satisfactory functional results can be obtained in over 80% of the children by means of surgical resection of the pseudarthrosis, intramedullary nailing, and bone grafting. Wearing a brace until skeletal maturity is achieved is mandatory in order to minimize the risk of re-fracture.

Spinal Deformity in Sotos Syndrome: First Results of Growth-friendly Spine Surgery.

Sotos syndrome (SS), or cerebral gigantism, describes children with macrocephaly, craniofacial abnormalities, general overgrowth, ligamentous laxity, developmental delay, and neurological disabilities. Fewer than 500 cases have been reported since Sotos and colleagues described the condition in 1964 and no literature exists on the management of spinal deformity in children under 10 years old.The aims of this study were: (1) to characterize the presentation of spinal deformities in patients with SS; and (2) to provide preliminary results of growth-friendly instrumentation (GFI) in these children. Thirteen children (9 boys) with SS and minimum of 2-year follow-up were identified from 2 multicenter early-onset scoliosis (EOS) databases (1997-2017). Mean age at index surgery and follow-up duration were 5.0 years (range, 1.8 to 10 y) and 7.2 years (range, 2.1 to 14.9 y), respectively. Patients underwent GFI for a mean of 5.7 years (range, 2 to 10.2 y), with an average of 9 lengthenings (range, 2 to 18). Definitive spinal fusion was performed in 4 patients (31%). Major curve magnitude, T1-T12 and T1-S1 lengths, thoracic kyphosis, and lumbar lordosis were evaluated preindex, postindex, latest GFI, and postfusion, when possible. Five thoracolumbar (38%), 4 double major (31%), 2 main thoracic (15%), and 2 double thoracic curves (15%) were seen that spanned a mean of 6.8 levels (5 to 9). Major curves improved 36% (range, 5% to 71%), from a mean of 71 degrees (range, 48 to 90 degrees) to 46 degrees (range, 20 to 73 degrees) postindex surgery (P<0.001). Major curves remained stable at a mean of 52 degrees (range, 20 to 87 degrees) at latest GFI (P=0.36). True T1-T12 and T1-S1 growth velocities during GFI were 0.5 mm/mo (range, 0.4 to 0.8 mm/mo) and 0.8 mm/mo (range, 0.1 to 2.1 mm/mo), respectively. Twenty-six complications occurred in 9 patients (69%) averaging 2 complications per patient (range, 0 to 7). This is the first study to evaluate the outcomes of GFI in children with SS and EOS. Compared with published data for outcomes of GFI in EOS, children with SS may have less major curve correction. Growth-friendly surgery remains an effective treatment method for EOS in patients with SS. Level IV-retrospective case-series.

Mechanical Analysis of Notch-Free Pre-Bent Rods for Spinal Deformity Surgery.

Experimental study of spinal rod as per the American Society for Testing Materials (ASTM) F2193 methodology for static and dynamic four-point bending. The hypotheses underlying this study were that the notch-free, curved rod would have a significantly higher ultimate load and fatigue strength compared with conventional notched curved rods. This study aimed to analyze the mechanical properties of notch-free curved rods compared with conventional notched rods. The goal of instrumented spinal fusion in the management of spinal deformities is to realign the spine and maintain the correction and stability in order to obtain arthrodesis. Although rod curvature could play an important role, intraoperative contouring of the straight rod induces notches into the rod, leading to decreased fatigue strength. Commercially produced titanium alloy (ϕ6.0 mm) and cobalt chromium alloy (ϕ5.5 mm) spinal rods were assessed by four-point bending tests in accordance with the ASTM F2193. Static four-point bending tests for the curved spinal rods showed that cobalt chromium alloy rods had significantly higher stiffness compared with titanium alloy rods. Notch-free cobalt chromium alloy rods had a significantly higher ultimate load than the conventional notched cobalt chromium alloy and titanium alloy rods. The dynamic four-point bending test showed that force/displacement at a minimum force at 2,500,000 cycles was larger in the notch-free cobalt chromium alloy rod than in the notched cobalt chromium alloy rod. The notch-free curved cobalt chromium alloy rod is likely to maintain its curvature after spinal deformity surgery with a decreased risk of breakage and could overcome the problems of the conventional notched rod such as breakage and spring-back. N/A.

Treatment of Spinal Deformities - The Appearance of a Conflict of Interest

The majority of patients with spinal deformities need some type of treatment. Typically, physiotherapy and bracing are sufficient and a minority of cases require surgical treatment. However, in many international papers on spinal deformities surgical issues are investigated while conservative management of spinal deformities is definitively underrepresented. The purpose of this survey is to look more deeply into the implications of the surgical societies and spine surgeons lobbyism on the payroll of industry and how these groups influence payments (reimbursement) made by national health services or health insurance systems worldwide for the treatments of patients with spinal deformities. Materials and methods: An international network of specialists for the conservative treatment of spinal deformities have performed a survey analyzing the cost of spinal surgery for spinal deformities (scoliosis), the cost of a brace and whether insurance/the NHS reimbursement applies with surgery or bracing. Results: In most countries surgery is paid without co-payments by the patient. In Japan, China and Ukraine co-payments are necessary for surgery. There are more restrictions when looking at payments for braces. In some countries, braces are not covered by the health care systems or insurance companies at all (China, Indonesia) in others the amount covered is only minimal (Turkey, Ukraine). Conclusions: Evidence in scientific literature is not reflected in the political decision making in parliaments. Evidence based treatment approaches for patients with spinal deformities are not necessarily reimbursed by local health care systems while surgery without scientific evidence is reimbursed more easily although it is more expensive. The most economic approach would be to pay for high quality conservative treatment in order to largely prevent the need for surgery. Surgical indications should be approved by an independent non-surgical specialist for spinal deformites.

Peri-operative management of children with spinal muscular atrophy

Background and Aims:Current multi-disciplinary management of children with spinal muscular atrophy (SMA) often requires the surgical management of spinal deformities. We present the outcomes of our peri-operative experience around the time of their spinal surgery and share our neuromuscular perioperative protocol.Methods:A single-centre retrospective chart review was performed to evaluate all children with SMA types I and II that underwent thoracolumbar spinal deformity correction (posterior spinal fusion or growing rod insertion) from 1990 to 2015. Electronic medical records were reviewed to assess pre-operative, intraoperative, and postoperative variables. T-tests, Wilcoxon Rank Sum, Fisher's Exact tests were performed as appropriate.Results:Twelve SMA I and twenty-two SMA II patients were included. Type I patients tended to be smaller and had a higher percentage (36.4% vs 4.5%) of American Society of Anesthesiologists (ASA) class 4 patients. Preoperative total parenteral nutrition (TPN) was utilised in 75.0% of type I and 18.2% type II patients. A difficult intubation was experienced in around 25% of the patients (20.0% SMA I, 27.3% SMA II). Approximately two hours of anaesthetic time was required in addition to the actual surgical time in both types. The intensive care unit (ICU) length of stay averaged 6 (4.0-7.5) days for type I and 3 (3-5) days for type II (p = 0.144). Average post-operative length of stay was (8 (7-9) vs. 7 (6-8)) P = 1.0.Conclusion:Children with type I and II SMA have similar hospital courses. The surgical and anaesthesia team should consider perioperative TPN and NIPPV (non-invasive positive-pressure ventilation), anticipate difficult intubations, longer than usual anaesthetic times, and potentially longer ICU stays in both SMA type I and II.

Point of View

Commentary on this issue's Current Concepts Review article on the "Management of Spinal Deformity in Cerebral Palsy"

156. Forecasting spinal deformity health care burden and operative utilization in the United States from 2015 to 2040: an epidemiological-based autoregressive integrated moving average (ARIMA) computation modeling

BACKGROUND CONTEXT Spinal deformity constitutes a spectrum of disorders affecting the spinal curvature. Management of spinal deformities often involves multidisciplinary teams and can be resource intense in patients requiring a prompt surgical correction for axial stability. Operative management warrants adequate subspecialty (fellowship) training and expertise for optimized health care delivery. With recent advances in diagnostic modalities and operative techniques in conjunction with an aging population, assessing the current and forecasting the future impact of spinal deformity spectrums on health care can be beneficial for meticulous planning and resource allocation to meet rising demands, ensuring the future economic viability of these procedures in the setting of cost-containment reforms. PURPOSE To forecast the health care burden and socioeconomics of spinal deformity disorders in the United States from 2015 to 2040. STUDY DESIGN/SETTING Epidemiological-based, time-series forecasting. PATIENT SAMPLE A total of 2,424,941 patients with underlying spinal deformity (based on extrapolated, weighted sampling across non-federal inpatient admissions). OUTCOME MEASURES Forecasting crude estimates of hospitalization burden and socioeconomics [operative utilization, costs, length of stay (LOS)] related to spinal deformities in the US from 2015 to 2040. METHODS A time-series, computation modeling using autoregressive integrated moving average (ARIMA) and seasonal ARIMA algorithms were constructed to forecast the impact of spinal deformities on health care delivery and resource utilization until 2040. Modeling of annual estimates for forecasting analysis relied upon the epidemiological data obtained from the Healthcare Cost and Utilization (HCUP) national datasets [National Inpatient Sample 2001-2014]. All forecast estimates were compared to the baseline 2014 year and evaluated as a percent change in primary endpoints. Diagnostics for forecasting models were assessed prior to model selection. RESULTS In 2030 and 2040, hospital admissions from spine deformities will increase by approximately 75% and 122% from their baseline 2014 crude admission rates. From 2014-2030, crude annual admissions related to scoliotic disorders will witness highest increment (+80.9%), followed by lordotic (+77%) and kyphotic (73.8%) disorders, respectively. Between 2030 and 2040, the crude annual admissions from lordotic disorders of the spine will surpass scoliosis by a 10-year cumulative net marginal increase of 3.72% (change in lordosis and scoliosis in 2040 from 2014: 131.34% and 131.54% respectively). The rate of surgical correction of deformity will outpace conservative management techniques and likely to see increases of 87.9% (in 2030) and 143% (in 2040) above 2014 rates. The cost of care will increase by 48% (2030) and 76% (2040) compared to 2014 estimates ($23,031) despite the decrease in LOS (−11.6% in 2030 and −18.1% in 2040 vs 5.54 days in 2040). CONCLUSIONS The current investigation provides projection forecasting for various spectrums of spinal deformities and for operative spinal correction. The study notes that operative utilization for deformity surgery will outpace conservative strategies. From a policymaking perspective, the data call for preparedness in establishing focused fellowship curriculae for training the adequate number of orthopedic or neurosurgeons specializing in spine deformity surgery to meet the increasing demand, reducing access disparities, and appropriately allocating resources for optimized care. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

What Should an Ideal Adult Spinal Deformity Classification System Consist of?: Review of the Factors Affecting Outcomes of Adult Spinal Deformity Management.

This literature review aims to determine potential clinical factors or comorbidities besides radiological parameters that affect the outcome of adult spinal deformity (ASD) management and review existing classifications associated with ASD. ASD is a multifactorial disease that comprises pathologies like radiological spine deformity, coexistence of spinal canal stenosis, radiculopathy, and multiple comorbidities. The available classification systems of ASD are predominantly based on radiological parameters and do not consider related clinical conditions. ASD patients with different combinations of these parameters behave differently and need different management strategies. We conducted a narrative literature review with search limited to English language of PubMed/MEDLINE using Medical Subject Heading (MeSH) terms. The terms specific to the review were ASD and several other related terminologies. We analyzed the information of the selected papers including factors affecting surgical outcomes for degenerative scoliosis. We reviewed 614 citations. Based on the inclusion criteria, 39 citations were selected for full-text retrieval; of these, 28 were excluded because of not fulfilling the inclusion criteria. Thus, 11 studies were selected and included for the final analysis. The presence of leg pain, spinal stenosis, obesity, osteoporosis, smoking, and age of patients were major influencing factors. Furthermore, the factors included in the available classifications, such as the Scoliosis Research Society–Schwab classifications, were reviewed and results were tabulated. This review highlights the significance of neurological symptoms, spinal stenosis, osteoporosis, obesity, age, and smoking, which markedly affect the management of ASD. With increasing number of patients being diagnosed and treated with ASD, there has been a growing need to comprehensively classify these patients into clinicoradiological subgroups.

Current concepts in neuromuscular scoliosis.

Spinal deformity is a common issue in pediatric patients with an underlying neurological diagnosis or syndrome. Management of neuromuscular scoliosis (NMS) is a major part of the orthopedic care of such patients, as the deformity is often progressive, and may affect gait, seating and positioning. In addition, untreated large spinal deformities may be associated with pain and/or cardiopulmonary issues over time. Recent changes in medical management of the underlying disease process appears to alter the natural history of certain neuromuscular conditions, and in the case of patients with Duchenne's muscular dystrophy significantly diminish the incidence of spinal deformity. In the most common diagnosis associated with NMS, cerebral palsy, there is evidence that despite a high complication rate, surgical management of spinal deformity is associated with measurable improvements in validated health-related quality-of-life measures. Spinal deformity is a common finding in patients with neurological diagnoses. It is important for those involved in the care of these patients to understand the natural history of NMS, as well as the potential risks and benefits to the patient and caregivers, of surgical and non-surgical interventions.

Book Review: Modern Management of Spinal Deformities: A Theoretical, Practical, and Evidence-Based Text

Book Review: Modern Management of Spinal Deformities: A Theoretical, Practical, and Evidence-Based Text

Robert Dickson, Juergen Harms (eds): Modern management of spinal deformities: a theoretical, practical, and evidence-based text

Robert Dickson, Juergen Harms (eds): Modern management of spinal deformities: a theoretical, practical, and evidence-based text

Type V osteogenesis imperfecta undergoing surgical correction for scoliosis.

The objective of this article is to report a case of type V osteogenesis imperfecta (OI) undergoing posterior instrumented fusion for scoliosis. Type V OI is a moderately severe dysplasia causing primary defects in endochondral bone ossification or mineralisation. It is characterised by hyperplastic callus (HPC) formation, interosseous membrane calcifications, poor bone quality and spinal deformities including scoliosis. Data on the surgical management of spinal deformities in this patient group are lacking. A 16-year-old patient with a confirmed diagnosis of type V OI presented with a progressive scoliosis. The patient underwent a T3-L4 posterior instrumented correction and fusion utilising pedicle screws, pedicle hooks and sub-laminar wiring. At 4months after surgery, the pedicle hooks pulled out and required partial metalwork removal after CT scanning confirmed bony union and no evidence of HPC formation. The patient was successfully discharged with satisfactory correction, confirmed bony union, no neurologic complication and absence of any hyperplastic callus formation. Type V OI patients requiring surgical intervention for scoliosis correction can safely undergo posterior instrumented fusion using sublaminar wiring and pedicle hook/screw constructs without apparent risk of HPC formation around neural elements. Surgery in this patient group remains challenging due to the associated poor bone quality. V.