Spinal Fusion For Idiopathic Scoliosis Research Articles

Effects of Spinal Fusion for Idiopathic Scoliosis on Lower Body Kinematics During Gait*

Study DesignProspective. ObjectivesThe purpose of this study was to compare gait among patients with scoliosis undergoing posterior spinal fusion and instrumentation (PSFI) to typically developing subjects and determine if the location of the lowest instrumented vertebra impacted results. Summary of Background DataPSFI is the standard of care for correcting spine deformities, allowing the preservation of body equilibrium while maintaining as many mobile spinal segments as possible. The effect of surgery on joint motion distal to the spine must also be considered. Very few studies have addressed the effect of PSFI on activities such as walking and even fewer address how surgical choice of the lowest instrumented vertebra (LIV) influences possible motion reduction. MethodsIndividuals with scoliosis undergoing PSFI (n = 38) completed gait analysis preoperatively and at postoperative years 1 and 2 along with a control group (n = 24). Comparisons were made with the control group at each time point and between patients fused at L2 and above (L2+) versus L3 and below (L3–). ResultsThe kinematic results of the AIS group showed some differences when compared to the Control Group, most notably decreased range of motion (ROM) in pelvic tilt and trunk lateral bending. When comparing the LIV groups, only minor differences were observed, and the results showed decreased coronal trunk and pelvis ROM at the one-year visit and decreased hip rotation ROM at the two-year visit in the L3– group. ConclusionsPatients with AIS showed decreased ROM preoperatively with further decreases postoperatively. These changes remained relatively consistent following the two-year visit, indicating that most kinematic changes occurred in the first year following surgery. Limited functional differences between the two LIV groups may be due to the lack of full ROM used during normal gait, and future work could address tasks that use greater ROM. Level of EvidenceLevel II.

Propionibacterium acnes infections in patients with idiopathic scoliosis: a case-control study and review of the literature.

PurposeSurgical site infection (SSI) caused by Propionibacterium acnes is an infrequent but devastating complication after spinal fusion. The purpose of this study was to identify risk factors for SSI with Propionibacterium acnes after spinal fusion for juvenile and adolescent idiopathic scoliosis (JIS and AIS).MethodsA case-control study was performed. Each case was matched 2:1 for age, gender and diagnosis. Retrospective chart review was performed to obtain relevant demographic, surgical and clinical data for all cases and controls. Statistical analysis included paired t-test and McNemar test, as well as exact logistic regression and robust regression models.ResultsThis study included ten infection cases (eight AIS, two JIS) and 20 controls (16 AIS, four JIS). In total, six infected cases presented within two weeks of the index procedure (acute infection) and four infected cases presented more than one year from the index procedure (delayed infection). The most common presentation for acute infections was wound drainage, while back pain was more common in delayed infections. All infections were successfully treated with surgical irrigation and debridement and postoperative antibiotics. Hardware was removed for patients with delayed infections. The strongest risk factor for infection was increased requirement for blood transfusion, but it did not reach statistical significance.ConclusionSSI with Propionibacterium acnes is an important complication after spinal fusion for idiopathic scoliosis. These infections can be successfully treated, but larger studies are needed to further identify risk factors and establish standardized guidelines for the treatment and prevention of this complication.Level of Evidence Level III

Anesthetic Care of a Patient With Bernard-Soulier Syndrome for Posterior Spinal Fusion

Bernard-Soulier syndrome (BSS), a rare autosomal recessive disorder first identified in 1948, is characterized by excessive and prolonged bleeding due to thrombocytopenia and platelet dysfunction with increased platelet size and deformability. The primary defect in BSS involves the glycoprotein (GP) Ib-IX-V complex, which is important in initiating platelet aggregation and thrombosis after vascular injury by facilitating the adhesion of platelets to von Willebrand factor. The coagulation defect in BSS can lead to significant bleeding during traumatic injury or surgical intervention. We present a 17-year-old adolescent with BSS who presented for posterior spinal fusion for idiopathic scoliosis. Previous reports of perioperative care of patients with BSS are reviewed and options for anesthetic care including perioperative control of the coagulation defect are presented. J Med Cases. 2018;9(10):341-344 doi: https://doi.org/10.14740/jmc3142w

Delayed Dural Leak Following Posterior Spinal Fusion for Idiopathic Scoliosis Using All Posterior Pedicle Screw Technique.

In pediatric patients, pedicle screws are malpositioned 5% to 15% of the time. Complications associated with malpositioned screws are infrequently reported in the literature. We present a series of adolescent idiopathic scoliosis (AIS) patients who presented in a delayed manner with positional headache and chronic dural leak adjacent to the pedicle screw tract. Scoliosis databases at 2 centers were reviewed, and cases of delayed positional headaches following posterior spinal fusion for AIS were identified. Demographic and clinical data were collected. Of 322 patients, 4 patients presented with positional headaches at a mean of 12.8 weeks following posterior spinal fusion surgery for AIS, with an interval time to diagnosis of 5 months. Computed tomographic myelogram demonstrated severe pedicle screw malposition in 1 patient, and minimal malposition in 3 patients (<2 mm violation). The patients had delayed presentation with positional headaches secondary to dural leak. All patients successfully underwent revision surgery with repair of the dural leak. At the time of latest follow-up, all patients are asymptomatic. Pedicle screw malposition can result in dural leaks. Patients may present in a delayed manner with positional headaches and an acquired Chiari malformation. Clinical suspicion should prompt imaging of the brain or cervical spine followed by computed tomographic myelogram to determine site of leak. This is a rare complication from pedicle screw malposition. Level IV-case series.

Patient-controlled Intermittent Epidural Bolus Versus Epidural Infusion for Posterior Spinal Fusion After Adolescent Idiopathic Scoliosis

A prospective, randomized, double-blinded study. The aim of this study was to compare the efficacy and side effects of patient-controlled intermittent bolus epidural analgesia (PCIEA) and patient-controlled continuous epidural analgesia (PCCEA) for postoperative pain control in adolescent idiopathic scoliosis. Epidural analgesia is an accepted efficacious and safe procedure for postoperative pain management in scoliosis surgery. However, the PCIEA has not been adequately investigated for postoperative pain control in adolescent idiopathic scoliosis. Forty-seven patients, 8 to 18 years of age, who were undergoing posterior spinal fusion for idiopathic scoliosis were randomized to either the PCIEA or PCCEA group. An epidural catheter was inserted by a surgeon under direct visualization. The PCIEA group received 0.2 mg/mL of morphine, 0.25 mL/kg of morphine bolus, additional doses of 0.25 mL/kg morphine with a 1-hour lockout given by patient-controlled demand, and no infusion. The PCCEA group received the following: 0.2 mg/mL morphine, an initial morphine loading set at 0.1 mL/kg, followed by a 0.05 mL/kg/h continuous infusion of morphine, and a 0.025 mL/kg bolus dose of morphine. There was a 30-minute lockout interval. The primary outcome was morphine usage. The secondary outcomes were pain score, postoperative nausea and vomiting, and pruritus. Cumulative morphine consumption was lower in the PCIEA group than in the PCCEA group. Both methods provided effective pain control. There were no differences in pain scores between the groups. Postoperative nausea, vomiting, and pruritus were lower in the PCIEA group. The two epidural analgesia techniques studied are both safe and effective methods for postoperative pain control after posterior spinal fusion in idiopathic scoliosis. Nausea, vomiting and pruritus were considerably higher in the PCCEA group. Concerns regarding side effects associated with epidural opioids can be avoided by an intermittent bolus with a relatively lower amount of opioid. 2.

Iliac Crest Regeneration: A Retrospective Study of 14 Years of Follow-up.

This is a retrospective study analysis. The purpose of our study was to evaluate the healing process of the ilium after being used as a bone graft donor site in the treatment of adolescent idiopathic scoliosis. Iliac crest bone grafts have been proven to be the most reliable means for solid fusion in spine surgery. Nevertheless, few reports in the literature describe the ability of the iliac crest to regenerate. Thirty-one patients with a mean age of 15.1 years had undergone posterior spinal fusion for idiopathic scoliosis. An autogenous bone graft was harvested from the right posterior iliac crest in all cases. Computed tomography scans of the pelvis were performed preoperatively and shortly after operation to evaluate the presence of any deformity and the size of the defect formed during surgery, respectively. All patients were reexamined 14 years postoperatively, and computed tomography scans were performed to evaluate the status of ossification at the donor site. In 21 cases (67.74%), bone deficits were fully restored (mean volume 12.053 cm), whereas partial regeneration was present in the remaining 10 cases (mean volume 8.766 cm). Hounsfield units (HUs) revealed that cancellous bone quality had been restored in 21 cases, whereas cysts with sclerotic bone margins were present in the remaining 10 cases. Immature patients [Risser sign (RS) 3, 4] have greater ability in restoring bone stock compared with patients with almost complete growth (RS 5; P<0.001). In addition, the gluteus maximus muscle preserved its volume and quality in cases with complete bone restoration (volume 51.3 cm, HU 55.9) compared with cases with partial regeneration (volume 43.43 cm, HU 38.35; P<0.001). The iliac wing of skeletally immature patients has considerable ability to fully regenerate and could probably be used as a graft donor site again.

Relaxation Training and Postoperative Music Therapy for Adolescents Undergoing Spinal Fusion Surgery

Spinal fusion for idiopathic scoliosis is one of the most painful surgeries experienced by adolescents. Music therapy, utilizing music-assisted relaxation with controlled breathing and imagery, is a promising intervention for reducing pain and anxiety for these patients. It can be challenging to teach new coping strategies to post-operative patients who are already in pain. This study evaluated the effects of introducing music-assisted relaxation training to adolescents before surgery. Outcome measures were self-reported pain and anxiety, recorded on 0-10 numeric rating scale, and observed behavioral indicators of pain and relaxation. The training intervention was a 12-minute video about music-assisted relaxation with opportunities to practice before surgery. Forty-four participants between the ages of 10 and 19 were enrolled. Participants were randomly assigned to the experimental group that watched the video at the preoperative visit or to the control group that did not watch the video. All subjects received a music therapy session with a board certified music therapist on post-operative day 2 while out of bed for the first time. Pain and anxiety were significantly reduced from immediately pre-therapy to post-therapy (paired t-test; p).

Are We Prescribing Our Patients Too Much Pain Medication? Best Predictors of Narcotic Usage After Spinal Surgery for Scoliosis.

Physicians play a role in the current prescription drug-abuse epidemic. Surgeons often prescribe more postoperative narcotic pain medication than patients routinely need. Although narcotics are effective for severe, acute, postoperative pain, few evidence-based guidelines exist regarding the routinely required amount and duration of use post-hospital discharge. Patients in a prospective cohort undergoing posterior spinal fusion for idiopathic scoliosis were asked preoperatively to rate their pain level, the level of pain expected each week postoperatively, and their pain tolerance. Post-discharge pain scores and narcotic use were reported at weekly intervals for 4 weeks postoperatively. Demographic data, preoperative Scoliosis Research Society (SRS)-22 scores, operative details, perioperative data, and self-reported pain levels were analyzed with respect to their association with total medication use and refills received. Disposal plans were also assessed. Seventy-two patients were enrolled, and 85% completed the surveys. The mean patient age was 14.9 years; 69% of the patients were female. The cohort was divided into 3 groups on the basis of total medication usage. The mean number of pills used in the middle (average-use) group was 49 pills. In postoperative week 4, narcotic usage was minimal (a mean of 2.9 pills by the highest-use group). Also by this time point, pain scores had, on average, returned to preoperative levels. Older age, male sex, a higher body mass index, and a higher preoperative pain score were associated with increased narcotic use. Sixty-seven percent of the patients planned to dispose of their unused medication, although only 59% of those patients planned on doing so in a manner recommended by the U.S. Food and Drug Administration. Postoperative narcotic dosing may be improved by considering patient age, weight, sex, and preoperative pain score. The precise estimation of individual narcotic needs is complex. Patient and family education on the importance and proper method of narcotic disposal is an essential component of minimizing the availability of unused postoperative medication. Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Rapid Recovery Pathway After Spinal Fusion for Idiopathic Scoliosis.

Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) is associated with significant pain and prolonged hospitalization. There is evidence that early mobilization and multimodal analgesia can accelerate functional recovery and reduced length of stay (LOS). Using these principles, we implemented a quality improvement initiative to enable earlier functional recovery in our AIS-PSF population. We designed and implemented a standardized rapid recovery pathway (RRP) with evidence-based management recommendations for children aged 10 to 21 years undergoing PSF for AIS. Our primary outcome, functional recovery, was assessed using statistical process control charts for LOS and average daily pain scores. Our process measures were medication adherence and order set utilization. The balancing measure was 30-day readmission rate. We included 322 patients from January 1, 2011 to June 30, 2015 with 134 (42%) serving as historical controls, 104 (32%) representing our transition population, and 84 (26%) serving as our RRP population. Baseline average LOS was 5.7 days and decreased to 4 days after RRP implementation. Average daily pain scores remained stable with improvement on postoperative day 0 (3.8 vs 4.9 days) and 1 (3.8 vs 5 days) after RRP implementation. In the second quarter of 2015, gabapentin (91%) and ketorolac (95%) use became routine and order set utilization was 100%. Readmission rates did not increase as a result of this pathway. Implementation of a standardized RRP with multimodal pain management and early mobilization strategies resulted in reduced LOS without an increase in reported pain scores or readmissions.

Risk of revision surgery for adult idiopathic scoliosis: a survival analysis of 517 cases over 25years.

Little is known about the long-term status of patients operated for spine deformities. The aim of this study was to determine the survival of primary fusion in adult idiopathic scoliosis and identify the risk factors of revision surgery. Adult patients who underwent primary fusion for idiopathic scoliosis between 1983 and 2011 were included in a continuous monocentric retrospective series. Any additional surgery was registered for survival analysis. Survival and follow-up were estimated by the Kaplan-Meier method and an analysis was performed to identify the risk factors of revision surgery. This series included 447 women (86.5%) and 70 men (13.5%) reviewed after a mean follow-up of 7years (range 0-26.4). Mean age was 44.4years. Fusion was performed on a median 11 levels (range 3-15); revision rate was 13% (CI 10-17), 18% (CI 14-23) and20% (CI 16-26) at 5, 10 and 15years, respectively. Revision surgery was associated with age, anterior release, length of fusion, the inferior limit of fusion, post-operative sagittal balance and junctional kyphosis. The length of fusion (HR 1.13 per vertebrae fused, p=0.007) and the lower limit of fusion (HR 5.9, p<0.001) remained independent predictors of revision surgery on multivariate analysis. This series evaluated the risk of revision surgery following spinal fusion for idiopathic scoliosis. Our results show that the risk seemed to increase linearly with a rate of nearly 20% after 10years. The length and lower limit of fusion are the main risk factors for revision surgery. Level IV (e.g. case series).

Gelatine matrix with human thrombin decreases blood loss in adolescents undergoing posterior spinal fusion for idiopathic scoliosis: a multicentre, randomised clinical trial.

In a multicentre, randomised study of adolescents undergoing posterior spinal fusion for idiopathic scoliosis, we investigated the effect of adding gelatine matrix with human thrombin to the standard surgical methods of controlling blood loss. Patients in the intervention group (n = 30) were randomised to receive a minimum of two and a maximum of four units of gelatine matrix with thrombin in addition to conventional surgical methods of achieving haemostasis. Only conventional surgical methods were used in the control group (n = 30). We measured the intra-operative and total blood loss (intra-operative blood loss plus post-operative drain output). Each additional hour of operating time increased the intra-operative blood loss by 356.9 ml (p < 0.001) and the total blood loss by 430.5 ml (p < 0.001). Multiple linear regression analysis showed that the intervention significantly decreased the intra-operative (-171 ml, p = 0.025) and total blood loss (-177 ml, p = 0.027). The decrease in haemoglobin concentration from the day before the operation to the second post-operative day was significantly smaller in the intervention group (-6 g/l, p = 0.013) than in the control group. The addition of gelatine matrix with human thrombin to conventional methods of achieving haemostasis reduces both the intra-operative blood loss and the decrease in haemoglobin concentration post-operatively in adolescents undergoing posterior spinal fusion for idiopathic scoliosis. A randomised clinical trial showed that gelatine matrix with human thrombin decreases intra-operative blood loss by 30% when added to traditional surgical haemostatic methods in adolescents undergoing posterior spinal fusion for idiopathic scoliosis.

Infection after anterior spinal fusion for idiopathic scoliosis using the Cotrel-Dubousset-Hopf system: A clinical case series of three patients.

Three patients with late-onset infection after multilevel instrumented anterior spinal fusion for idiopathic scoliosis, using the Cotrel-Dubousset-Hopf (CDH) system, are presented. The CDH-system is an anterior instrumentation with high biomechanical stability and rigidity, ensuring a stable primary fixation. Unlike after posterior spinal fusion, infection after anterior spinal fusion (ASF) for idiopathic scoliosis has rarely been reported. The files of three patients who developed an infection after ASF for scoliosis using the CDH-system, were reviewed. The clinical presentation and diagnostic and therapeutic options are discussed. All three patients had a late-onset infection of the CDH-system, which was difficult to diagnose because of nonspecific symptoms. Radiographs and technetium bone scan appeared to be of low value. When an abscess was present, this could accurately be diagnosed with MRI or CT imaging. Operative treatment with implant removal and antibiotic therapy was successful in all cases. Late onset infections after ASF using the CDH-system presented with few and nonspecific symptoms. The clinical presentation was mainly characterized by vague abdominal- or back-pain after an interval of normal postoperative recovery, moderately raised infection parameters and inconclusive findings with imaging modalities. As treatment, implant removal, debridement and parenteral antibiotics are recommended. It should be noted though that implant removal poses serious risks for vascular and visceral structures.

High-Volume Hospitals and Surgeons Experience Fewer Early Reoperation Events After Adolescent Idiopathic Scoliosis Surgery

Study DesignRetrospective analysis of relevant in-hospital patient records from the New York State Inpatient Database. ObjectiveWe aimed to assess reoperation risk in adolescent idiopathic scoliosis (AIS) by surgeon and hospital operative volume. Summary of Background DataThe need for early reoperation can be devastating for patient and family, is a burden to the physician and adds significant cost. Previous studies have shown improved outcomes associated with higher volume surgeons and hospitals, but reoperation events have not yet been explored. MethodsThe 2008-2011 New York State Inpatient Database was queried using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for adolescent idiopathic scoliosis patients aged 10-21 undergoing spine arthrodesis. Patient identifiers and revisit linkage variables were used to identify reoperation events. Annual surgeon and hospital volumes were stratified into tertiles (low, medium, high) via identifier codes. The relative risk of reoperation after spine arthrodesis was computed based on relevant patient inpatient stays. ResultsOver 2008 to 2011, a total of 3,928 primary fusion operations for AIS were identified. The overall rate of reoperation after spine fusion for idiopathic scoliosis was 7.1%. Low volume surgeons performed less than 6 AIS fusions per year, medium volume surgeons performed less than 43, and high volume surgeons performed from 43 to 228. Reoperation after a primary fusion for adolescent idiopathic scoliosis showed reduced frequency among higher volume surgeons (14.1% for low vs. 5.1% for high, p<0.001, see Table for Hospitals). ConclusionsEarly reoperation after spine fusion for idiopathic scoliosis is seen more frequently in lower volume institutions and surgeons. Appreciating the resources and limitations at a clinician's institution is important to developing practices to prevent these devastating events. This work also has implications for strategies that aim to direct limited healthcare resources to centers with low complication rates.

Are routine postoperative radiographs necessary during the first year after posterior spinal fusion for idiopathic scoliosis? A retrospective cohort analysis of implant failure and surgery revision rates.

Radiographs are routinely obtained at postoperative visits during the first year after posterior spinal fusion (PSF) for idiopathic scoliosis (IS). The goal of this study was to determine how often radiographic findings change postoperative care. A total of 227 consecutive patients aged 10 to 21 years who underwent surgery for IS at our institution from 2004 to 2010 were identified. Charts were reviewed to determine the frequency of the following clinical symptoms during the first year after surgery: pain greater than expected, implant prominence, and sensory/motor disturbance. Radiographs were reviewed to identify implant failure and curve change. Logistic regression analysis was used to identify clinical symptoms associated with treatment deviation. During the first year after surgery, an average of 6 (range, 2 to 12) radiographs were obtained from patients during an average of 3 (range, 2 to 10) follow-up visits. Pain (14%) was the most common symptom. Neurologic symptoms (13%) and implant prominence (4%) were less common. Implant failure was identified in 4 subjects (2%), of which 3 required revision surgery. The incidence of revision surgery was 2.9/1000 radiographs (95% confidence interval, 0.6-8.3). Curve progression >5 degrees in the uninstrumented curve occurred in 2 patients (0.9%). Curve progression did not result in a change in treatment for any of the patients. Pain was the only clinical symptom associated with implant failure (P=0.0047). 169/227 patients did not have any symptoms and only one of these underwent revision surgery. The sensitivity of a clinical test, which uses the presence of pain to guide the need for radiographic evaluation and rule out implant failure, was 75%, specificity 87%, positive predictive value 10%, and negative predictive value 99.5%. After obtaining baseline postoperative radiographs, additional radiographs during the first year after surgery for IS may not be required in the absence of clinical symptoms. Reducing the number of radiographs taken during the first year after surgery for IS in patients without symptoms can reduce radiation exposure to patients and health care costs without affecting treatment. Level II, Diagnostic Study.

Anthropometric estimation of body height after surgical correction of scoliosis.

To estimate the height loss in 28 patients who had undergone surgery for scoliosis before skeletal maturity. 28 women patients aged 11 to 18 (mean, 15) years underwent Harrington instrumentation, segmental sublaminar wiring, and posterior spinal fusion for idiopathic scoliosis. The patients' mean age at menarche was 13 (range, 10-16) years. Pre- and post-operative radiographs of the spine were taken to determine curve types, the Cobb angle, and the degree of correction. The standing and sitting heights were measured using a flexible steel tape, and the expected standing and sitting heights were derived using formulae. At the final follow up, the mean patient age was 20 (16-32) years. The mean standing height was 155.2 cm and the mean sitting height was 77.4 cm. Using the formulae, the mean expected standing height was 158.4 cm, indicating height loss of 3.2 cm (t=4.6, p=0.0001), and the mean expected sitting height was 79.9 cm, indicating height loss of 2.6 cm (t=3.84, p=0.001). The curve types of the 28 patients were sub-divided as thoracic (n=7), thoracolumbar (n=18), and double major (n=3). Patients with thoracolumbar curves achieved better correction and less loss of standing and sitting heights. Percentage loss of standing and sitting heights were not correlated with the apex of the curve or the degree of correction. Height loss after surgery was acceptable in comparison with height loss associated with progression of scoliosis without surgery.

Pulmonary function after less invasive anterior instrumentation and fusion for idiopathic thoracic scoliosis

PurposeStandard thoracotomy for anterior instrumentation and fusion of the thoracic spine in idiopathic scoliosis may have detrimental effects on pulmonary function. In this study we describe a less invasive anterior surgical technique and show the pre- and postoperative pulmonary function with a minimum follow-up of 2 years.MethodsTwenty patients with Lenke type 1 adolescent thoracic idiopathic scoliosis were treated with anterior spinal fusion and instrumentation. The mean preoperative Cobb angle of the thoracic curve was 53° ± 5.8. Pulmonary function tests (PFT) and radiographic evaluation was performed.ResultsThe mean postoperative correction in Cobb angle of the thoracic curve was 27° ± 8.2 (49%).The mean preoperative FEV1 was 2.81 ± 0.43 L, which increased to 3.14 ± 0.50 L at 2 years postoperatively (P = 0.000). The mean FEV1% did not change (89.60 ± 7.49% preoperatively, versus 90.53 ± 5.95% at 2 years follow-up, P = 0.467). The TLC increased from 4.62 ± 0.62 L preoperatively to 5.17 ± 0.63 L at 2 years follow-up (P = 0.000). The FEV1% at two years of follow-up improved to 104% of the FEV1% predicted value. The FEV1 improved to 97% of the FEV1 predicted value.ConclusionAnterior spinal fusion for idiopathic scoliosis by means of a minimal open thoracotomy proved to be a safe surgical technique that resulted in an improvement of pulmonary function. Our results are similar to those of thoracoscopic procedures reported in literature.

Index of Suspicion * Case 1: Lower Extremity Weakness 2 Years After Scoliosis Surgery in a Teenager * Case 2: Fever, Cough, Shortness of Breath, Jaundice, and Hepatomegaly in a Teenager * Case 3: Recurrent Infections in a Teenager

A 14-year-old girl presents with 10 days of progressive lower extremity weakness together with numbness from her umbilicus to her feet. She denies incontinence but notes difficulty starting her urinary stream as well as constipation. She has no fevers or headaches. There is no recent history of trauma, illness, travel, camping, or insect bites. Two years before presentation, she underwent a posterior spinal fusion for idiopathic scoliosis without complications. She has done well, and her progress is monitored regularly by her orthopedic surgeon, who notes that she has complained intermittently of mild back discomfort but has had no back pain in the past few weeks. There is no family history of tumors, neurologic disorders, or autoimmune diseases. On physical examination, the girl is afebrile and has stable vital signs. She is alert and in no distress. Her skin is free of rashes and acne. Her cranial nerves are intact, and her neck is supple. There is no spine tenderness or erythema on her back. Her upper extremity strength is normal. Lower extremity strength is decreased to 2–3/5 on the left and 4/5 on the right, with normal tone, bilateral 4+ hyperreflexia, and 3 beats of clonus. She has normal rectal tone and decreased sensation to touch, pinprick, and vibration in her legs. Proprioception is difficult to elicit. She walks with support and without ataxia. Laboratory evaluation shows white blood cell (WBC) count of 10.7 × 103/μL and hemoglobin concentration of 10.2 g/dL. Her cerebrospinal fluid WBC count is 13/μL, her glucose level is 63 mg/dL, and the protein concentration is 225 mg/dL. Her erythrocyte sedimentation rate is 27 mm/h, and her C-reactive protein level is 4.6 mg/L. An imaging study reveals the diagnosis. A 13-year-old boy presents with fever, cough, breathing difficulty, and reduced oral intake for 6 …

Radiographic and Clinical Outcomes of Posterior Spinal Fusion for Idiopathic Scoliosis in African Patients: A Comparison of All Pedicle Screw Versus Hybrid Instrumentation

Radiographic and Clinical Outcomes of Posterior Spinal Fusion for Idiopathic Scoliosis in African Patients: A Comparison of All Pedicle Screw Versus Hybrid Instrumentation

Does an orthotic treatment help the outcome of the spinal fusion in idiopathic scoliosis?

The purpose of this retrospective study was to evaluate the post surgical stability of the spine in patients suffering for idiopathic scoliosis and treated with the Dynamic SpineCor brace. Does the brace treatment alter in any way the post surgical results?

Continuous Intravenous Morphine Infusion for Postoperative Analgesia Following Posterior Spinal Fusion for Idiopathic Scoliosis

A retrospective study of postoperative pain management. Evaluate the efficacy and safety of continuous intravenous morphine infusion for postoperative pain management in patients with idiopathic scoliosis (IS) undergoing posterior spinal fusion (PSF) and segmental spinal instrumentation (SSI). Postoperative pain is a common problem following surgery for IS. There are no published reports regarding the use of a continuous intravenous morphine infusion for this patient population. We retrospectively reviewed data regarding 339 consecutive patients with IS who underwent PSF and SSI between 1992 and 2006. All patients received intrathecal morphine after the induction of general anesthesia. Following surgery, preordered morphine infusion (0.01 mg/kg/h) was started at first reported pain. The infusion rate was titrated based on vital signs, visual analog scale (VAS) pain scores (0-10), and clinical status. It was continued until patients were able to take oral analgesics. We reviewed intrathecal morphine dosage, VAS pain scores through the third postoperative day, interval to start of morphine infusion, total morphine requirements in the first 48 hours, and any adverse reactions (nausea/vomiting, pruritus, respiratory depression, and pediatric intensive care unit admission). Mean intrathecal morphine dose was 15.5 +/- 3.9 microg/kg and mean interval to start of the intravenous morphine infusion was 17.5 +/- 5 hours. Mean VAS pain scores were 3.1, 4.5, 4.5, and 4.6 at 12 hours, 1, 2, and 3 days after surgery, respectively.The total mean morphine dose in the first 48 hours postoperatively was 0.03 +/- 0.01 mg/kg/h. Total morphine received was 1.44 +/- 0.5 mg/kg. Nausea/vomiting and pruritus, related to the morphine infusion occurred in 45 patients (13.3%) and 14 patients (4.1%), respectively. No patients had respiratory depression or required Pediatric Intensive Care Unit admission. A low frequency of adverse events and a mean postoperative VAS pain score of 5 or less demonstrate that a continuous postoperative morphine infusion is a safe and effective method of pain management in patients with IS following PSF and SSI.