Posterior Spinal Instrumentation And Fusion Research Articles

Three-dimensional deformity correction in adolescent idiopathic scoliosis patients: what are the benefits of hybrid apical sublaminar bands versus all-pedicle screws?

The amount of three-dimensional (3D) correction with apical sublaminar band (hybrid-SLB) technique has not been compared to all-pedicle screw instrumentation for adolescent idiopathic scoliosis (AIS) using detailed axial correction metrics or comparable rod types. Our purpose is to compare 3D improvement in AIS deformities following posterior spinal instrumentation and fusion (PSIF) with hybrid-SLB and segmental correction to all-pedicle screw correction. Patients ages 10-18 years with AIS who underwent PSIF between 2015 and 2022 and had preoperative and postoperative EOS imaging were included. Electronic medical records were reviewed for demographic, Lenke classification, operative technique, and 3D EOS data. Average changes in major and minor Cobb angle, axial rotation, thoracic kyphosis, and lumbar lordosis were compared. Ninety-five patients met inclusion criteria with 55 in the hybrid-SLB group (mean age 14.9 ± 1.9 years) and 40 in all-pedicle screw (mean age 14.7 ± 2.1 years). While all-pedicle screw demonstrated greater correction of major (45.7 ± 13.4 vs 37.9 ± 14.3 degrees; P = 0.008) and minor (28.7 ± 13.1 vs 17.8 ± 12.5 degrees; P = 0.001) Cobb angles, hybrid-SLB showed greater increase in T4-T12 kyphosis (13.3 ± 15.3 vs 5.6 ± 13.5 degrees; P = 0.01). Correction of T1-T12 kyphosis, axial rotation, and lumbar lordosis was similar between groups. 3D EOS analysis of AIS patients before and after PSIF revealed that all-pedicle screw constructs had greater overall coronal plane correction and hybrid-SLB had greater thoracic sagittal plane correction. Axial corrective abilities were similar. Hybrid-SLB may have advantages for correction of thoracic lordosis or hypokyphosis. Level of evidence: Level III, retrospective cohort study.

Two AIS Cases, 2 Surgeons, 1 Operating Room, 1 Day: Faster and Safer Than 1 Case in a Day.

To lessen surgical times for patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal instrumentation and fusion (PSIF), our department developed a quality improvement initiative where 2 AIS cases were completed in 1 day by the same 2 surgeons operating together in 1 operating room (OR). We describe the results of this initiative, comparing operative times and outcomes to cases of these surgeons operating individually. From 2017 to 2023, patients aged 10 to 18 years with AIS undergoing PSIF were prospectively enrolled for "Two Spine Tuesday." Patients were matched by age, sex, curve severity, and number of levels fused to historical AIS controls. Outcomes included surgery time, total OR time, estimated blood loss (EBL), volume of cell saver transfused, allogenic blood transfusion, length of stay, 90-day readmissions, Clavien-Dindo-Sink Complication Classification System complication rates, and percentage who achieved the minimal clinically important difference (MCID) for SRS-22. Fifty-five patients composing the 2-spine group (group 2) were compared with 55 historical sex-matched and age-matched controls (group 1). Major coronal curve and average number of levels fused were similar between groups. Overall surgery time (203 vs. 296min, P <0.001), total OR time ( P <0.001), and EBL (400 vs. 550mL, P <0.001) were lower for group 2. Group 2 had fewer complications [n=17 (31%) vs. n=28 (51%), P =0.03]. Performing 2 AIS cases in 1 OR by 2 surgeons the same day resulted in shorter surgery times, less total time in the operating room, lower complication rates, and less blood loss compared with single-surgeon matched controls. Level III-retrospective comparative study.

The effect of surgical time on perioperative complications in adolescent idiopathic scoliosis cases. A propensity score analysis.

Posterior spinal instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS) can be lengthy and complication-ridden. The aim of this study was to evaluate the effect of surgical time on perioperative complications in this procedure when controlling for confounding variables with propensity score analysis. This was an IRB-approved review of electronic health records from 2010 to 2019 at a single tertiary care children's hospital. Patients undergoing PSIF were grouped into "short" (< 6h) or "long" (≥ 6h) surgical time groups. Outcome measures were estimated blood loss (EBL), cell saver transfusions, packed red blood cell (pRBC) transfusions, length of stay (LOS), intraoperative monitoring (IOM) alerts, hematocrit, ICU transfer, neurologic loss, surgical site infection, and 90-day readmissions. We controlled for age, sex, BMI, curve severity, number of segments fused, and surgeon factors. After propensity score matching there were 113 patients in each group. The short surgical time group had lower EBL (median 715, IQR 550-900 vs median 875, IQR 650-1100cc; p < 0.001), received less cell saver blood (median 120, IQR 60-168 vs median 160, IQR 97-225cc; p = 0.001), received less intraoperative pRBCs (median 0, IQR 0-0 vs median 0, IQR 0-320, p = 0.002), had shorter average LOS (4.8 ± 1.7 vs 5.4 ± 2.5days; p = 0.039), and fewer IOM alerts (4.3% vs 18%, p = 0.003). Patients with shorter surgical times had less blood loss, received less transfused blood, had a shorter LOS, and fewer IOM alerts compared to patients with longer surgical times. Surgical times < 6h may have safety and efficacy advantages over longer times. III.

Combined Anterior Thoracic Vertebral Body Tethering and Posterior Lumbar Tethering Results in Quicker Return to Sport and Activity Compared to Posterior Spinal Instrumented Fusion in Patients with Adolescent Idiopathic Scoliosis.

Retrospective comparative study. To compare patient-reported physical activity between anterior thoracic vertebral body tethering and posterior lumbar spine tethering (ATVBT/PLST) and posterior spinal instrumentation and fusion (PSIF) with minimum 2year follow-up. Consecutive skeletally immature patients with idiopathic scoliosis and a thoracic and lumbar curve magnitude ≥40° who underwent either ATVBT/PLST or PSIF from 2015-2019 were included. The primary outcome was rate of returning to sport. Secondary outcomes included ability to bend and satisfaction with sport performance as well as weeks until return to sport, school, physical education (PE) classes, and running. Ten patients underwent ATVBT/PLST and 12 underwent PSIF. ATVBT/PLST patients reported significantly faster return to sport (13.5weeks vs 27.9weeks, P = .04), running (13.3weeks vs 28.8weeks, P = .02), and PE class (12.6weeks vs 26.2weeks, P = .04) compared to PSIF patients. ATVBT/PLST patients reported that they had to give up activities due to their ability to bend at lower rates than PSIF patients while reporting "no changes" in their ability to bend after surgery at higher rates than PSIF patients (0% vs 4% giving up activities and 70% vs 0% reporting no changes in bending ability for ATVBT/PLST and PSIF, respectively, P = .01). Compared to PSIF patients, ATVBT/PLST patients experienced less main thoracic and thoracolumbar/lumbar curve correction at most recent follow-up (thoracic: 41 ± 19% vs 69 ± 18%, P = .001; thoracolumbar/lumbar: 59 ± 25% vs 78 ± 15%, P = .02). No significant differences in the number of revision surgeries were observed between ATVBT/PLST and PSIF patients (4 (40%) and 1 (8%) for ATVBT/PLST and PSIF, respectively, P = .221). ATVBT/PLST patients reported significantly faster rates of returning to sport, running, and PE. In addition, ATVBT/PLST patients were less likely to have to give up activities due to bending ability after surgery and reported no changes in their ability to bend after surgery more frequently than PSIF patients. However, the overall rate of return to the same or higher level of sport participation was high amongst both groups, with no significant difference observed between ATVBT/PLST and PSIF patients.

Gender-Related Factors Influence the Subjective Perception of Deformity in Patients Undergoing Surgery for Idiopathic Scoliosis.

The present study aims to depict the importance of gender-related factors in the subjective perception of spine deformity in adolescents undergoing posterior instrumented fusion for scoliosis. Patients undergoing posterior spinal instrumentation and fusion (PSF) for idiopathic adolescent scoliosis (AIS) were recruited. The following data were recorded: gender, age, parents' civil status, Tegner Activity Scale (TAS), body mass index (BMI), concomitant diseases, and history of neuropsychological disorders. Each patient underwent clinical and radiological evaluations according to the protocol used at our institution. All the patients were assessed before surgery using the following Patient-Reported Outcome Measures (PROMs): the Italian version of the revised Scoliosis Research Society-22 patient questionnaire (SRS-22R), the Quality-of-Life Profile for Spinal Deformities (QLPSDs) questionnaire, and the Spinal Appearance Questionnaire (SAQ). The present study recruited 80 patients (male: 19, female: 61). A significant correlation was observed between BMI, TAS, and subjective perception scores. A worse deformity perception was observed in female patients and patients with divorced parents. Gender-related factors impact the subjective perception of spine deformity in patients undergoing PSF for AIS. Specific assessment and correction are needed to improve postoperative outcomes in these patients.

Determining the factors associated with a prolonged length of stay for adolescent idiopathic scoliosis patients undergoing posterior spinal instrumentation and fusion in a single-payer health care system: are these factors different than those in the United States?

Rapid recovery pathways (RRP) for adolescent idiopathic scoliosis patients undergoing posterior spinal instrumentation and fusion (PSIF) have been shown to be successful in reducing hospital length of stay (LOS). Although the majority of patients are discharged within 3 days, some patients require longer hospital admission. Previous studies in the United States have identified predictors of prolonged LOS for this patient population. The goal of this project was to determine if these predictors are the same for Canadian scoliosis patients and to identify those features which are different under this single-payer system. A RRP for scoliosis surgery was implemented in March 2015 at a single, tertiary referral children's hospital in Canada. Previously identified features, along with numerous other patient factors, were collected. Spearman correlations were used to determine the factors most associated with hospital LOS and those factors were used in a multivariable regression model. A total of 161 patients were included in the analysis. Of the previously identified patient factors, only receiving a peri-operative transfusion was found to be significant (ρ = 0.24; p = 0.002). None of the other pre-identified variables were found to be significantly correlated with LOS. Variables not previously examined that were found to be significantly correlated with hospital LOS included ASA status (ρ = 0.19, p = 0.046), fusion involving both the thoracic and lumbar spine (ρ = 0.18, p = 0.025), and receiving celecoxib on post-operative day 1 (ρ = - 0.16; p = 0.038). The features that had the greatest association with LOS through multivariable regression was receiving a blood transfusion (B = 0.48; 95%CI 0.096-0.89; p = 0.017). In this study, we found that many of the features found to be significantly correlated with prolonged hospital LOS in the United States are not transferable to the Canadian healthcare system. This is important for the Canadian, and other surgeons in a single-payer system, in order to identify pre-operative or immediate post-operative factors that may extend patient LOS following PSIF and plan resources accordingly. III; therapeutic.

Long-Term Health-Related Quality of Life After Harrington Instrumentation and Fusion for Adolescent Idiopathic Scoliosis: A Minimum 40-Year Follow-up.

Despite its importance for clinical decisions, the long-term consequences of posterior spinal instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS), particularly in the lower lumbar spine, remain unclear. This study evaluates the long-term health-related quality of life and the need for a further surgical procedure in patients treated with Harrington instrumentation from 1961 to 1977 according to the lowest instrumented vertebra (LIV) and in comparison with age-matched norms. A search was performed to identify and contact the 314 identified patients with AIS treated with PSIF by Dr. L.A. Goldstein. The assessment included identified subsequent spine surgery, the Oswestry Disability Index (ODI), Scoliosis Research Society-7 (SRS-7), EuroQol-5 Dimensions (EQ-5D), and Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29). The health-related quality of life was compared with U.S. norms and, within the cohort, was compared by patient factors, LIV, and subsequent spine surgery. In this study, 134 patients (42.7%) were identified; 24 (7.6%) had died, 81 (25.8%) consented to participate in the study, and 29 (9.2%) declined participation. The mean follow-up was 45.4 years (range, 40 to 56 years). There were 81 patients who completed the surveys, 77 patients who completed the SRS-7, 77 patients who completed the ODI, and 76 patients who completed the PROMIS-29 and EQ-5D. There were 12.8% of patients with LIV L3 or proximal and 36.4% with LIV L4 or distal who had an additional surgical procedure (odds ratio, 3.98). Comparing the ODI of patients who had undergone an additional surgical procedure with those who had not showed 42% and 73% minimal disability, 53% and 23% moderate disability, and 5% and 2% severe disability. Of the patients who had not undergone an additional surgical procedure, those with LIV L3 or proximal had mean scores of 14.12 points for the ODI and 23.3 points for the SRS-7 and those with LIV L4 or distal had mean scores of 17.9 points for the ODI and 22.7 points for the SRS-7; these differences were not significant. The mean PROMIS-29 and EQ-5D scores were not different from normal U.S. age-based means. Patients with AIS treated with PSIF at a mean 45-year follow-up and LIV L4 or distal had a higher rate of undergoing an additional surgical procedure than those with LIV L3 or proximal. Patients undergoing an additional surgical procedure had lower health-related quality of life than those who did not. Despite this, there was no difference in health-related quality of life for patients with LIV L4 or distal compared with patients with LIV L3 or proximal. This cohort of patients with AIS treated with PSIF demonstrates normal self-reported health-related quality of life compared with the age-matched general population. These long-term outcomes of PSIF for AIS are encouraging. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Subjective perception of spinal deformity after selective versus non-selective fusion of Lenke 1C curves

PurposeTo assess the self-image perception and the Quality-of-Life (QoL) in female adolescents, with Lenke 1C scoliosis curves, treated with selective versus non-selective posterior spinal instrumentation and fusion (PSF).MethodsPatients undergoing PSF for idiopathic adolescent scoliosis (AIS) were recruited and divided into two groups: patients managed with selective thoracic fusion (STF) were included in Group A, whereas patients treated with non-selective fusion (N-STF) in Group B. Each patient completed the Italian version of the Scoliosis Research Society-22R questionnaire (SRS-22R), the Quality-of-Life Profile for Spinal Deformities questionnaire (QLPSD) and the Spinal Appearance Questionnaire (SAQ), before surgery and at 24-month follow-up.ResultsOne hundred and fifty seven female patients (mean age 16.38) were included in this study. 80 patients underwent STF, while 77 patients received N-STF. At 24-month follow-up, patients managed with N-STF showed better SRS-22R self-image mean score (p = .012), SRS-22R satisfaction mean score (p = .033), QLPSD body image mean score (p = .005), but worse SRS-22 function mean score (p = .006) and QLPSD back flexibility mean score (p = .007), compared with patients who underwent STF. In terms of self-image perception, patients undergoing STF showed significantly worse SAQ total mean score (p = .002), SAQ appearance mean score (p = .001) and SAQ expectation (p = .001). We found a significant correlation between SAQ appearance mean score and SRS-22R self-image (R = − 0.721), SRS-22 mental health (R = − 0.8), QLPSD psychosocial functioning (R = 0.7) and QLPSD back flexibility (R = 0.8).ConclusionAlthough the STF of Lenke 1C curves provides better functional outcomes, in the present study, female patients receiving STF revealed a worse perceived body image, compared with patients treated with N-STF, at 24-month follow-up. Particular attention should be addressed to the preoperative patient’s mental health and body image perception, when choosing between STF and N-STF.

Phrenic nerve palsy after cervical laminectomy and fusion

BackgroundPhrenic nerve palsy is a rare complication of cervical spine surgery. There are no previously reported cases of unilateral diaphragmatic paralysis following posterior cervical spine surgery. Here, we present a case of a 69 year-old Caucasian male with severe cervical stenosis with myelopathy who underwent posterior spinal instrumentation and fusion (PSIF) from C2 to T2, with laminectomies at C3-C7. OutcomeThe patient developed respiratory distress post-operatively and was found to have an elevated hemidiaphragm secondary to phrenic nerve palsy. He was treated with respiratory support, with significant improvement in dyspnea. He was also noted to have a left C5 palsy affecting his deltoid function and proximal upper extremity sensation which gradually improved. ConclusionsThis is the first reported case of unilateral diaphragmatic paralysis causing dyspnea due to phrenic nerve palsy following cervical spine surgery. This rare complication should be kept in mind when assessing any patient with respiratory distress following cervical spine surgery.

Plasma Technology Reduces Blood Loss in Adolescent Idiopathic Scoliosis Surgery: A Prospective Randomized Clinical Trial.

Study Design:Prospective randomized clinical trial.Objectives:To assess the effectiveness of PEAK Plasmablade (PPB), compared with bipolar sealer and standard electrocautery, in the posterior spinal instrumentation and fusion (PSF) surgery performed for adolescent idiopathic scoliosis (AIS).Methods:Ninety-three patients undergoing PSF surgery for AIS were randomized in 2 groups: group-A patients (n = 45) underwent PSF surgery using PPB; group-B patients (n = 48) were treated with bipolar sealer and standard electrocautery. Demographic and surgical data was recorded. All the patients underwent serial blood tests on the day before surgery (T0) and at 24 (T1), 48 (T2), 72 (T3), and 96 (T4) hours postoperatively. Visual analogue scale for pain (VAS) score, the percentage of paracetamol assumption, and the blood transfusion rate were recorded in the time-lapse T1 to T4. Intergroup variability was assessed. Pearson correlation test was performed. A P value <.05 was considered significant.Results:In group A, a significantly shorter total operative time (P = .0087), a significantly lower total intraoperative blood loss (TBL) (P = .001), and a higher postoperative hemoglobin (Hb) (P = .01) were recorded. A significant higher mean Hb concentration and mean albumin value was recorded in group A at 24 and 48 hours postoperatively. A significant correlation between TBL and hospital stay was recorded in both groups (group A, P = .00 001; group B, P = .00 006); moreover, in both groups, a significant correlation was observed between TBL and mean VAS at 72 hours postoperatively (group A, P = .0009; group B, P = .0001) and at 96 hours postoperatively (group A, P = .000 044; group B, P = .00 001).Conclusions:PPB reduces the intraoperative blood loss in PSF performed for AIS, thus allowing a patient’s faster recovery.

Skip constructs in spinal muscular atrophy: outcomes of a novel approach for posterior spinal instrumentation and fusion.

Many children with spinal muscular atrophy (SMA) develop progressive spinal deformity, worsening already compromised pulmonary function and global spinal balance. Early results demonstrate that intrathecal administration of nusinersen, a recent FDA-approved drug, improves motor function and ventilator-free survival, necessitating preservation of intrathecal access when considering PSIF. The purpose of this study is to assess medium-term outcomes of a specialized approach for posterior spinal instrumentation and fusion (PSIF) to preserve intrathecal access in patients with SMA. A retrospective review of patients with SMA undergoing PSIF at a single tertiary academic medical center during a 3-year period was completed. To facilitate intrathecal drug administration, the traditional approach to PSIF was modified to "skip" one or more intervertebral levels at the thoracolumbar junction. Clinical notes and radiographs were reviewed for postoperative outcomes including major coronal curve correction and complications, including loss of correction, hardware failure and surgical revision. Eight patients were identified, with a mean age of 12.7 ± 1.6years and follow-up of 4years. These patients had a mean preoperative major coronal curve of 56.4°, with mean curve correction of 35.2°. At follow-up, no patients experienced rod breakage, loss of correction, or postoperative chronic pain. Only one patient required revision surgery due to bony overgrowth at the skipped level after three and a half years. Implementing the skip construct approach for PSIF in patients with SMA allows for scoliosis correction without compromising intrathecal drug delivery. Follow-up at 4years reveals no adverse clinical events, hardware failure or loss of correction. IV.

Do We Need Postoperative Chest Radiographs After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis?

Study DesignThe question was addressed in three ways: (1) a query of Kids' Inpatient Database (KID) to obtain nationally representative data; (2) retrospective review of cases at a single institution; (3) survey of Scoliosis Research Society (SRS) spine surgeons. ObjectivesEvaluate the rate of immediate postoperative pulmonary complications, risk factors, and relevant surgeon practice patterns, to determine the usefulness of routine postoperative chest radiographs after posterior spinal instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS). Summary of Background DataRoutine postoperative chest radiography after PSIF for AIS is performed in many institutions to evaluate for acute pulmonary complications, particularly pneumothorax (PTX). The incidence of pneumothorax and its effect on management is unknown. MethodsThe frequency of PTX and surgical intervention were recorded. We evaluated associations between PTX and patient demographics or comorbidities, as well as survey respondent demographics and their practice patterns. ResultsIn the KID data sets, the risk of PTX after PSIF for AIS patients was 0.3% (30/9,036), with intervention required in 13.3% (4/30) of PTX-positive patients (0.04% of all cases). Review of cases at our institution revealed a PTX rate of 3.3% (8/244) by radiology report. No surgical intervention was required. Patients with PTX had, on average, an increased number of vertebrae fused (p = .012), a proximal thoracic scoliosis curve location (p = .009), and/or an intraoperative blood transfusion (p = .002). SRS respondents reported a PTX risk of 0.8% (87/11,318), and 32.2% (89/276) of respondents indicated routine use of postoperative chest radiographs. Of those, 46.1% (41/89) specified willingness to change practice patterns if provided evidence of low PTX rates. ConclusionsPneumothorax is uncommon after PSIF for AIS. The need for intervention is even less common. Routine postoperative chest radiographs are of questionable value after PSIF for AIS. Level of EvidenceLevel III.

Quality, Safety, and Value of Innovating Classic Operative Techniques in Scoliosis Surgery: Intraoperative Traction and Navigated Sequential Drilling

Study DesignRetrospective cohort study. ObjectivesThis study aims to measure and describe the clinical and financial implications of the systematic implementation of intraoperative skull-femoral traction (IOSFT) and navigated sequential drilling (NSD) for posterior spinal instrumentation and fusion (PSIF) in adolescent idiopathic scoliosis (AIS) at our institution. Summary of Background DataPSIF has been the standard surgical treatment for AIS. This retrospective single-center quality improvement study describes the perioperative outcomes and impact on health resource utilization following the systematic application of two classic surgical strategies modified using current technology: IOSFT and NSD. MethodsWe reviewed the medical records of 125 patients who underwent a single-stage PSIF for AIS. We identified three cohorts based on surgical strategies used intraoperatively. Traditional techniques (n = 28), IOSFT (n = 45), and IOSFT plus NSD (n = 52). The primary outcome measures were operative time, prevalence of cases requiring extended operating room time, need for blood transfusion, length of hospital stay, and cost per surgery. Secondary outcomes included implant density, degree of spine deformity correction, and perioperative complications. ResultsAll primary outcome measures improved significantly (p < .001). Median operating time decreased by 59%. Use of late operating room hours fell from 89% to 0% and transfusion rates from 64% to 1.9%. Length of hospital stay decreased from 6 to 4 days. Comprehensive cost per case decreased by 24%. DiscussionTogether, IOSFT and NSD improved the quality, safety, and value of care. These surgical strategies were performed without increased perioperative complications, while reducing cost per case by 24%. ConclusionsThe data presented may have significant implications in health resource utilization for AIS surgery. Level of EvidenceLevel III.

Post-Operative Pain Assessment and Management in Cerebral Palsy (CP): A Two-Pronged Comparative Study on the Experience of Surgical Patients

IntroductionThis study compares the current practice patterns of pain assessment and management between children with and without CP following either posterior spinal instrumentation and fusion (PSIF) or hip osteotomy (HO). MethodsTwo cohorts of CP patients were retrospectively identified and matched with non-CP patients based on age, surgical procedure, and approach to post-operative pain management. Sixteen CP patients undergoing PSIF and twenty-two undergoing HO were respectively matched with the same numbers of non-CP patients receiving the same procedures. The frequency of assessments conducted, highest pain scores recorded on each post-operative day (POD), and the amount of adjuvant analgesics administered were collected for POD 0–4. ResultsPatients with CP were significantly more frequently evaluated for pain post-operatively, tended to have lower pain scores as measured by current scales, and received slightly fewer analgesics. Patients with CP differed from their non-CP counterparts in both frequency and method of post-operative pain assessment. ConclusionsThe purpose of this study is to elucidate the current state of post-operative pain assessment and management in children with CP undergoing major orthopaedic surgeries, to improve CP patient/caregiver understanding and expectation of the post-operative experience regarding pain, and to provide recommendations for improving the post-operative care for these patients.

Reinventing the wheel in scoliosis surgery: effective strategies for safely improving efficiency

Posterior spinal instrumentation and fusion (PSIF) has been the standard operative treatment for adolescent idiopathic scoliosis (AIS) and is one of the most frequently performed elective pediatric surgeries in North America, incurring an expenditure of more than $1.1 billion annually in the United States alone. This commentary reflects on the outcomes of systematically implementing intraoperative skull femoral traction (IOSFT) combined with navigated sequential drilling (NSD) during PSIF for AIS as strategies for quality improvement at our tertiary children’s hospital.

Flatback Revisited: Reciprocal Loss of Lumbar Lordosis Following Selective Thoracic Fusion in the Setting of Adolescent Idiopathic Scoliosis

Study DesignRetrospective review of prospective multicenter adolescent idiopathic scoliosis (AIS) database. ObjectiveTo investigate the relationship between iatrogenic loss of thoracic kyphosis (TK) after selective thoracic posterior spinal instrumentation and fusion (PSIF) for AIS with straightening of lumbar lordosis (LL). Summary of Background DataSegmental PSIF has become the standard of care for surgical treatment of severe AIS. Studies show that adults with flattening of TK and LL can develop pain and dysfunction associated with flatback syndrome. Analysis of post-fusion sagittal alignment is lacking in the AIS population. MethodsQuery of prospective multicenter database for AIS patients with Lenke 1, 2, or 3 curves who underwent selective thoracic PSIF (lowest instrumented vertebra equal or cephalad to L1) identified 123 patients with a minimum of 2 years' follow-up. Thoracic kyphosis (T5–T12), LL (T12–S1), and global sagittal alignment were measured preoperatively and at 2 years postoperatively. Health-related quality of life measures were examined. ResultsA total of 31% of patients had loss of TK and 42% lost LL. Patients with decreased TK had significantly higher rates of decreased LL (68%) than patients without decreased TK (31%). Multivariate regression confirmed that TK had significant predictive effect on LL (p < .001). Specifically, change in TK of 2° was associated with roughly 3° change in LL. There were no significant associations between changes in TK or LL and health-related quality of life. ConclusionsLoss of TK occurs commonly in selective fusion for AIS. This loss of kyphosis is strongly associated with reciprocal loss of LL. Spinal fusion can have unintended effects on sagittal alignment; these effects may have consequences that remain to be fully elucidated.

Minimally invasive surgical options for adolescent idiopathic scoliosis

Early results of MIS in AIS have been promising; however, longer-term follow-up data remains limited. Our objective was to compare perioperative outcomes as well as radiographic and clinical outcomes between MIS and standard open posterior spinal instrumentation and fusion (PSIF) at 2-year follow-up. Advantages of MIS in AIS were related to intra-operative blood loss, cell saver transfusion rates, and LOS; however, significant increases in ORT, lower mean percent curve correction, and a higher complication rate of MIS in AIS were also noted. Despite these variations, no clinical differences in SRS-22 scores were found at 2 years postop between the groups.

Risk Factors for Coronal Decompensation After Posterior Spinal Instrumentation and Fusion in Adolescent Idiopathic Scoliosis

Study DesignRetrospective review of multicenter data set with adolescent idiopathic scoliosis (AIS) patients with at least 2 years of follow-up after posterior spinal instrumentation and fusion (PSIF). ObjectivesThe purpose of this study is to investigate risk factors for coronal decompensation 2 years after PSIF for AIS. Summary of Background DataCoronal decompensation is a potential complication of spinal instrumentation for AIS. This can result in problems requiring revision surgery. MethodsDemographic, clinical, and radiographic measures were reviewed on 890 identified patients. Coronal decompensation was defined as a change farther away from midline from 6 weeks postoperatively to 2 years in any one of the following radiographic parameters: change in coronal balance >2 cm; change in coronal position of the lowest instrumented vertebra (LIV) >2 cm; change in thoracic trunk shift >2 cm; or change in LIV tilt angle >10°. Patients with decompensation were compared to those without. The relationship between the LIV and lowest end vertebra (LEV) was examined as an independent variable. ResultsTwo years postoperation, 6.4% (57/890) of patients exhibited coronal decompensation. Multivariate regression revealed that decompensated patients were twice as likely to be male, have lower preoperative Risser score, and lower percentage major curve correction. The relationship between the LIV and LEV as well as quality of life surveys were not significantly different between decompensated and nondecompensated patients at 2 years. ConclusionsTwo years after PSIF, 6.4% of patients with AIS exhibit radiographic coronal decompensation. Although this study did not demonstrate a significant association between the relationship of LIV and LEV and decompensation 2 years postoperation, results of this study indicate that skeletal immaturity, male gender, and less correction of the major curve may be related to higher rates of coronal decompensation.

Predicting excessive hemorrhage in adolescent idiopathic scoliosis patients undergoing posterior spinal instrumentation and fusion

Background contextBlood loss in patients with adolescent idiopathic scoliosis (AIS) who are undergoing posterior spinal instrumentation and fusion (PSIF) varies greatly. The reason for this wide range is not clear. There are reports of unexpected massive hemorrhage during these surgeries. Many studies reflect authors' preferences for describing blood loss in terms of levels fused, weight, or percent blood volume. PurposeWe sought to define excessive blood loss clinically, determine its incidence in our study population, and identify associated variables. Results are intended to inform perioperative preparation for these cases. Results may be used to inform prospective study designs. Study designThis was a retrospective uncontrolled case series. Patient sampleA total of 311 consecutive AIS PSIF cases during the years 2005–2010 performed at Children's Hospital Colorado were studied. Outcome measuresWe measured estimated blood loss (EBL) and its association with multiple patient, surgical, and anesthetic variables. MethodsThirty-one variables potentially related to blood loss were collected retrospectively from electronic medical records for analysis. When no cases of clearly excessive blood loss were identified on the basis of visual examination of EBL distribution, we chose to use the top 10% of blood loss cases as an arbitrary determinant of excessive blood loss. Three cut-off strategies captured the top 10% of EBL cases with little variation in who was selected: 1) >1,700 mL of EBL, 2) >50% EBL/estimated blood volume, and 3) >150 mL/level fused EBL. Variables were compared with the χ2 test, Fisher exact, or t-tests, when appropriate. A generalized linear mixed logistic model was used to determine the probability of excessive blood loss based on the number of levels fused. ResultsThe average EBL was 89.17 mL/level fused (range, 45–133 mL). EBL fit a progressively wider distribution as surgical complexity (number of levels fused) increased. Number of levels fused (p<.0001), operative time (p=.0139), number of screws (p<.0001), and maximal preoperative Cobb angle (p=.0491) were significantly associated with excessive blood loss. The variable that was most strongly associated with excessive blood loss was the number of levels fused, with ≥12 levels having a probability of >10% of excessive hemorrhage. ConclusionExcessive blood loss may be an arbitrary number until future research suggests otherwise. We show that the probability of exceeding one of our arbitrary definitions is approximately 10% when 12 or more levels are fused. If a 10% incidence of excessive blood loss is determined to be clinically relevant, teams might wish to pursue hematologic consultation and maximal blood conservation strategy when 12 or more levels are planned for fusion.

Evaluation des sagittalen Profils nach operativer Therapie der thorakalen adoleszenten idiopathischen Skoliose Lenke Typ 1

The principle philosophy of posterior spinal instrumentation and fusion (PSIF) for the treatment of adolescent idiopathic scoliosis (AIS) has changed during recent decades. In the past the treatment of AIS mainly focused on correction of the major curve in the frontal plane while the sagittal profile and balancing were only of inferior interest in treatment planning. Various long-term outcome studies have demonstrated that many AIS patients developed a flatback syndrome (decrease of thoracic kyphosis and lumbar lordosis) associated with pain. It was concluded that treatment of AIS should consider the sagittal profile and balance; however, there are only few studies addressing additional procedures, which include the correction of the sagittal profile. The purpose of this study was to evaluate the effects of different posterior correction techniques on sagittal profile and balance. A total of 36 consecutive patients with thoracic AIS, who were treated with selective thoracic posterior correction were included in this retrospective study. The patients were further assigned to three different subgroups according to different surgical strategies: A: pedicle screws, B: long-head pedicle screws and C: additional Ponte osteotomy. Standardized radiographs in the standing position of the whole spine in two planes were evaluated before and at least 2 years after correction for all patients and a subgroup analysis was done to identify differences between the three groups. A significant correction of the major curve was achieved in all three groups (p < 0.001). There was a significant difference between the groups with groups B and C showing significantly higher levels of major curve correction in comparison to group A (p < 0.001). Concerning the sagittal profile, there was a significant difference in the development of thoracic kyphosis (TK) and lumbar lordosis (LL). While a significant reduction of TK and LL was found in groups A and B after surgery, a significant increase of TK and LL was noted in group C which was associated with a decrease of pelvic tilt and an increase of sacral slope. The 2-year follow-up showed the lowest ODI-% value only in group C which was positively correlated with reduction in pelvic tilt. The results of this study underline that the PSIF technique alone using pedicle screws leads to a satisfactory correction in the frontal plane but is associated with adverse effects on the sagittal profile (flat back syndrome), corroborating previous studies. It was further shown that significant improvements of sagittal parameters were achieved by adding techniques for the lengthening of the dorsal thoracic column. This approach can therefore be recommended for the treatment of AIS Lenke type 1.