Treatment Of Pediatric Spinal Deformity Research Articles

Evaluating the Readability of Patient Education Materials for Anterior Vertebral Body Tethering, Distraction-Based Methods, and Posterior Spinal Fusion for the Treatment of Pediatric Spinal Deformity.

The Internet is an important source of information for patients, but its effectiveness relies on the readability of its content. Patient education materials (PEMs) should be written at or below a sixth-grade reading level as outlined by agencies such as the American Medical Association. This study assessed PEMs' readability for the novel anterior vertebral body tethering (AVBT), distraction-based methods, and posterior spinal fusion (PSF) in treating pediatric spinal deformity. An online search identified PEMs using the terms "anterior vertebral body tethering," "growing rods scoliosis," and "posterior spinal fusion pediatric scoliosis." We selected the first 20 general medical websites (GMWs) and 10 academic health institution websites (AHIWs) discussing each treatment (90 websites total). Readability tests for each webpage were conducted using Readability Studio software. Reading grade levels (RGLs), which correspond to the US grade at which one is expected to comprehend the text, were calculated for sources and independent t tests compared with RGLs between treatment types. The mean RGL was 12.1 ± 2.0. No articles were below a sixth-grade reading level, with only 2.2% at the sixth-grade reading level. AVBT articles had a higher RGL than distraction-based methods (12.7 ± 1.6 vs 11.9 ± 1.9, P = 0.082) and PSF (12.7 ± 1.6 vs 11.6 ± 2.3, P = 0.032). Materials for distraction-based methods and PSF were comparable (11.9 ± 1.9 vs 11.6 ± 2.3, P = 0.566). Among GMWs, AVBT materials had a higher RGL than distraction-based methods (12.9 ± 1.4 vs 12.1 ± 1.8, P = 0.133) and PSF (12.9 ± 1.4 vs 11.4 ± 2.4, P = 0.016). Patients' health literacy is important for shared decision-making. Assessing the readability of scoliosis treatment PEMs guides physicians when sharing resources and discussing treatment with patients. Both GMWs and AHIWs exceed recommended RGLs, which may limit patient and parent understanding. Within GMWs, AVBT materials are written at a higher RGL than other treatments, which may hinder informed decision-making and patient outcomes. Efforts should be made to create online resources at the appropriate RGL. At the very least, patients and parents may be directed toward AHIWs; RGLs are more consistent.

Incidence and causes of instrument-related complications after primary definitive fusion for pediatric spine deformity.

Various complications have been reported in the treatment of pediatric spinal deformities. Among these, instrument-related complications could be critical concerns and risks of reoperation. This study aimed to identify the incidence and causes of complications after primary definitive fusion for pediatric spine deformities. The authors retrospectively collected data from 14 institutions about patients who underwent primary definitive fusion between 2015 and 2017. There were 1490 eligible patients (1184 female and 306 male), with a mean age of 13.9 years. The incidence, causes, and reoperation rates were analyzed according to 4 etiologies of pediatric spine deformity (congenital, neuromuscular, syndromic, idiopathic). The complications were also categorized as screw-, hook-, or rod-related complications, implant loosening or backout, and junctional problems. The incidence of overall instrument-related complications was 5.6% (84 cases). Regarding etiology, the incidence rates were 4.3% (idiopathic), 6.8% (syndromic), 7.9% (congenital), and 10.4% (neuromuscular) (p < 0.05). The most common causes were pedicle screw malposition (60.7%), followed by implant backout or loosening (15.4%), junctional problems (13.1%), rod breakage (4.8%), and other complications (6.0%). Univariate analysis showed that etiology, type of deformity (kyphosis), surgical procedure, operation time, and estimated blood loss were significant factors. Multivariate analysis revealed that etiology (neuromuscular), surgical procedure (combined approach), and operation time (> 5 hours) remained as significant risk factors. Among all patients with instrument-related complications, 45% (38/84) required revision surgery. Of these cases, > 50% were related to pedicle screw malposition. Medial breach was the most common complication regardless of location, from upper thoracic to lumbar spine. Pedicle screw malposition was the primary cause of overall complications and subsequent reoperation. In addition to more precise screw insertion techniques, meticulous confirmation of pedicle screw placement, especially of medial breach, may reduce the overall instrument-related complications and revision rates.

Posterior Column Osteotomies in Adolescent Idiopathic Scoliosis: Panel Discussion

The role of the posterior column osteotomy (PCO) in the treatment of pediatric spinal deformity is controversial. Differences in perceived clinical benefit and associated risk exist between surgeons along with differences in technique and indications. In this panel discussion, four experienced spine surgeons provide insight into their use of PCOs for the surgical treatment of scoliosis.

To tether or fuse? Significant equipoise remains in treatment recommendations for idiopathic scoliosis.

Vertebral body tethering (VBT) continues to grow in interest from both a patient and surgeon perspective for the treatment of scoliosis. However, the data are limited when it comes to surgeon selection of both procedure type and instrumented levels. This study sought to assess surgeon variability in treatment recommendation and level selection for VBT versus posterior spinal fusion (PSF) for the management of scoliosis. Surgeon members of the Pediatric Spine Study Group and Harms Study Group were queried for treatment recommendations and proposed upper instrumented vertebra (UIV) and lower instrumented vertebra (LIV) selection for PSF and VBT based on 17 detailed clinical vignettes. Responses were subdivided in each clinical vignette according to surgeon experience and treatment recommendations with assessment of intra-rater reliability. Binomial distribution tests were used to establish equipoise, selecting p < 0.10 to indicate the presence of a treatment choice with consensus set > 70% agreement. For treatment choice, responses were assessed first for consensus on the decision to proceed with PSF or VBT. Thirty-five surgeons with varied experience completed the survey with 26 surgeons (74%) completing the second follow-up survey. Overall, VBT was the recommended treatment by 47% of surgeons, ranging by clinical vignette. Consensus in treatment recommendation was present for 6 clinical vignettes including 3 for VBT and 3 for PSF, with equipoise present for the remaining 11. Of the 17 vignettes, 12 demonstrated moderate intra-observer reliability including the 3 consensus vignettes for VBT. Sanders stage ≤ 3 and smaller curve magnitude were related with VBT recommendation but neither age nor curve flexibility significantly influenced the decision to recommend VBT. Surgeons with high VBT volume, ≥ 11 VBT cases/year, were more likely to recommend VBT than those with low volumes (0-10 cases per year (p < 0.0001)). High VBT volume surgeons demonstrated consensus in VBT recommendation for Lenke 5/6 curves (75% mean recommendation). High VBT volume surgeons had a significantly higher VBT recommendation rate for Lenke 1A, 2A curves (71.8% vs 48.0%, p = 0.012), and Lenke 3 curves (62% vs 26.9%, p = 0.023). Equipoise was present for all vignettes in low volume surgeons. In addition, high VBT volume surgeons trended toward including more instrumented levels than low VBT volume surgeons (7.17 vs 6.69 levels). Significant equipoise is present among pediatric spine surgeons for treatment recommendations regarding VBT and PSF. Surgeon-, patient-, and curve-specific variables were identified to influence treatment recommendations, including surgeon experience, curve subtype, deformity magnitude, and skeletal maturity. This study highlights the need for continued research in identifying the optimal indications for VBT and PSF in the treatment of pediatric spinal deformity.

A Clinical Risk Model for Surgical Site Infection Following Pediatric Spine Deformity Surgery.

Despite tremendous efforts, the incidence of surgical site infection (SSI) following the surgical treatment of pediatric spinal deformity remains a concern. Although previous studies have reported some risk factors for SSI, these studies have been limited by not being able to investigate multiple risk factors at the same time. The aim of the present study was to evaluate a wide range of preoperative and intraoperative factors in predicting SSI and to develop and validate a prediction model that quantifies the risk of SSI for individual pediatric spinal deformity patients. Pediatric patients with spinal deformity who underwent primary, revision, or definitive spinal fusion at 1 of 7 institutions were included. Candidate predictors were known preoperatively and were not modifiable in most cases; these included 31 patient, 12 surgical, and 4 hospital factors. The Centers for Disease Control and Prevention definition of SSI within 90 days of surgery was utilized. Following multiple imputation and multicollinearity testing, predictor selection was conducted with use of logistic regression to develop multiple models. The data set was randomly split into training and testing sets, and fivefold cross-validation was performed to compare discrimination, calibration, and overfitting of each model and to determine the final model. A risk probability calculator and a mobile device application were developed from the model in order to calculate the probability of SSI in individual patients. A total of 3,092 spinal deformity surgeries were included, in which there were 132 cases of SSI (4.3%). The final model achieved adequate discrimination (area under the receiver operating characteristic curve: 0.76), as well as calibration and no overfitting. Predictors included in the model were nonambulatory status, neuromuscular etiology, pelvic instrumentation, procedure time ≥7 hours, American Society of Anesthesiologists grade >2, revision procedure, hospital spine surgical cases <100/year, abnormal hemoglobin level, and overweight or obese body mass index. The risk probability calculator encompassing patient, surgical, and hospital factors developed in the present study predicts the probability of 90-day SSI in pediatric spinal deformity surgery. This validated calculator can be utilized to improve informed consent and shared decision-making and may allow the deployment of additional resources and strategies selectively in high-risk patients. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Early and late hospital readmissions in adolescent idiopathic scoliosis.

Retrospective review of a prospectively collected multicenter database. To identify risk factors for early and late readmission of surgically treated patients with adolescent idiopathic scoliosis (AIS). Specific risk factors associated with readmission in patients with AIS remain poorly understood. Patients with AIS who were operatively treated from 19 centers specializing in the treatment of pediatric spinal deformity were studied. Data from a minimum 2years of clinical follow-up and any readmission were available for analysis. Characteristics of patients with no readmission, early readmission (< 90days), and late readmission (> 90days) were evaluated. Both univariate and multivariate analyses of risk factors for readmission were performed. 2049 patients were included in our cohort, with 1.6% requiring early readmission and 3.3% late readmission. In the multivariate analysis, greater preoperative coronal imbalance was associated with early readmission. Longer operative time was associated with late readmission. Finally, greater preoperative pain (SRS-22 pain scale) was associated with both early and late readmission. GI complications accounted for a higher proportion of early readmissions than previously reported in the literature. Preoperative counseling of patients with higher levels of pain and coronal imbalance and the implementation of a thorough postoperative bowel regimen may help optimize patient outcomes. 3.

Application of a Halo Fixator for the Treatment of Pediatric Spinal Deformity.

In spine surgery, the halo fixator was initially utilized to stabilize cervical fusions in patients with poliomyelitis. More recently, the indications for halo fixation have evolved to include stabilization and definitive treatment for upper cervical spine injuries (Jefferson fractures, atlanto-occipital dissociations, odontoid fractures, etc.), treatment of atlantoaxial rotatory subluxation, stabilization of long cervical fusions, and preoperative traction. In the realm of pediatric spinal deformity, halo fixation has proved to be a valuable resource for severe or neglected spinal deformities. In this video article, we demonstrate the application of a halo fixator in a pediatric patient with severe scoliosis. The procedure includes appropriate pin placement in the safe zones of the skull performed under either general anesthesia or local anesthesia. Pins are secured to a halo frame that is sized to be 2 cm larger than the circumference of the skull and are tightened according to age-specific torque guidelines. Alternative treatments vary from cervical spine immobilization to definitive surgical treatment in the spine, or even spinal osteotomies, depending on the underlying spinal pathology. The halo fixator works by limiting motion of the cervical spine in flexion, extension, and axial rotation. The halo is also able to control and correct translational injuries of the cervical spine. In the setting of spinal deformity, the halo fixator can also be utilized to overcome the effects of gravity and lengthen the spine. For spinal deformities, the halo fixator can be expected to lengthen the spine and increase deformity flexibility prior to definitive surgical treatment in the spine or growth-friendly spinal instrumentation. Correct identification of safe zones for pin placement is vital to correct pin placement.For pediatric patients, it is important to obtain fixation with a minimum of 6 to 8 pins.Pins should be tightened with use of a torque-limiting wrench, up to no more than 1 in/lb (55.9 mm/kg) per year of age, up to a maximum of 8 in/lb (447.9 mm/kg).Applied traction should be a maximum of 50% of the body weight of the patient.Neurovascular examination is vital following application of weight.

Initial intraoperative experience with robotic-assisted pedicle screw placement with stealth navigation in pediatric spine deformity: an evaluation of the first 40 cases.

Pedicle screw fixation in pediatric spine surgery has become common practice given the fixation stability and improved curve correction. However, due to proximity to vital structures, accuracy is paramount. Literature has reported accuracy rates from 87.5 to 90% using traditional freehand techniques. This study presents our initial experience with pedicle screw placement using the newest generation of spinal robotics for treatment of pediatric spinal deformity. A cohort of patients, aged 8-21years, undergoing spinal fusion surgery using robotic-assisted technology was reviewed. Diagnoses, Cobb angles, surgical time, robot time, number of screws placed, and complications were recorded. Accuracy of screw placement was assessed based on analysis of successful screw execution, evaluation screw position using intraoperative fluoroscopy and post-operative radiographs, and clinical evaluation. The average age was 14.5years. Prevalent diagnoses included idiopathic (65%) and neuromuscular scoliosis (13%). Mean preoperative curve measured 66.8°. The median time for operation was 235 minutes with medians of 8 levels fused and 5 screws placed per patient. Of the 314 screws placed, we recorded a 98.7% accuracy rate. Lateral deviation was the most common cause of malpositioning. Post-operative plain films revealed no grossly misplaced screws. There were no perioperative neurologic deficits or malpositioned screws requiring reoperation. This is the first reported series of navigated spinal robotics used for pedicle screw placement in children. Our clinical success rate was 98.7% and there were no clinically relevant screw related complications. The study shows promising initial results of combined robotic-navigation techniques in pediatric patients.

What's Important: Managing the Impact of Coronavirus on Pediatric Spine Surgery.

What's Important: Managing the Impact of Coronavirus on Pediatric Spine Surgery.

4273 An innovative rib construct for treatment of pediatric spinal deformity

OBJECTIVES/GOALS: The rib construct is a novel device for treating childhood hyperkyphosis and kyphoscoliosis. The purpose of this study was to investigate the biomechanics, mechanism, and clinical outcomes of this device. The overarching hypothesis was that the rib construct is safe and effective for correcting hyperkyphotic spinal deformity. METHODS/STUDY POPULATION: Biomechanical evaluation: An ex vivo porcine spine biomechanical study compared traditional pedicle screw proximal fixation to the rib construct in terms of proximal fixation strength and construct stiffness. Porcine model hyperkyphosis correction with rib construct: An in vivo hyperkyphotic porcine model was used to study the ability of the rib construct to correct hyperkyphosis in the developing porcine spine. Human hyperkyphotic correction with rib construct: A retrospective study was conducted to examine the radiographic outcomes, complication rates, procedure times, and blood losses experienced by human patients that received rib construct surgery. RESULTS/ANTICIPATED RESULTS: Biomechanical evaluation: The rib construct was significantly less prone to proximal fixation failure and less stiff compared to pedicle screws. Porcine model hyperkyphosis correction with rib construct: The average T6-T14 thoracic kyphosis was 35.8 ± 3.2° at the time of hyperkyphosis creation surgery. In response to corrective surgery with the rib-hook construct, T6-T14 thoracic hyperkyphosis decreased immediately post-op to 11.3 ± 7.8° and continued to decrease to 7.8 ± 7.6° until final follow-up 8 weeks post-op (n = 3). Human hyperkyphosis correction with rib construct: Pre-op sagittal Cobb angle was 81 ± 31° and fell to 43 ± 24° post-op and to 38 ± 24° at final follow-up; indicating ~100% correction (normal thoracic kyphosis is 40°). DISCUSSION/SIGNIFICANCE OF IMPACT: The results suggest that the rib construct is a highly effective technique and superior to existing methods.

Surgical Technique: Power Pedicle Preparation and Screw Insertion in the Treatment of Pediatric Spinal Deformity

Pedicle screw fixation has been shown to be safe and effective treatment for spinal deformity 1-6, and is the mainstay of posterior spinal instrumentation. Classically, pedicle preparation and screw insertion has been performed with manual tools and a manual technique. At our institution, power pedicle preparation and screw insertion has been used for the last 12 years with over 20,000 pedicle screws. Power pedicle preparation has the potential to decrease the force required for insertion on the patient, increase proprioception for the surgeon, increase accuracy, and possibly decreasing the incidence of overuse injuries for the spine surgeon.

The use of sublaminar bands in treatment of spinal deformity: an operative technique

Background: Pedicle screws are commonly used in the surgical treatment and correction of spinal deformity. In recent years, polyester bands have been used as adjuncts to pedicle screws and hooks. Currently, the implementation of polyester sublaminar bands in the treatment of pediatric spinal deformity has led to improved results with similar complications as other techniques. This paper further highlights the innovative use of sublaminar bands utilized in a hybrid construct leading to improved results. Furthermore, we describe the surgical technique and indications for sublaminar bands in pediatric spinal deformity. Methods: Innovative sublaminar band hybrid construct description and comparison to current practices regarding surgical indications, complications, and comparative outcomes compared to the use of pedicle screw fixation. Results: The described hybrid sublaminar band implementation further validates the use of hybrid constructs as an innovative method and approach to pediatric spinal deformity. Hybrid constructs with sublaminar band utilization may become more favored in the future as they continue to have a safe track record within the literature and are able to optimize sagittal correction better than an all-pedicle screw construct, all while reducing operative time, blood loss, and radiation exposure. Conclusions: This novel surgical technique of sublaminar band utilization offers a user-friendly procedure with a short learning curve. This technique, if applied in the correct surgical candidates, has been proven to be a successful method of spinal deformity correction in pediatric spinal fusions. Level of Evidence: Level IV.

Posterolateral Diskectomies for Treatment of Pediatric Spinal Deformities.

Retrospective. To investigate the indications, radiographic outcomes, and complications in children with spinal deformities treated with posterolateral diskectomy with posterior fusion (PLDF), and to compare them against those of patients treated with anteroposterior spinal fusion (APSF). A novel technique for treating large, rigid spinal deformities in children has been proposed, consisting of PLDF at the apex of the deformity using an all-posterior approach. We evaluated records of all patients 21 years or younger who underwent treatment for spinal deformity between 2010 and 2015 by one surgeon using PLDF (n = 56) or APSF (n = 21). The indications for PLDF were large, rigid curves (37 patients); focal curves with severe rotation (10 patients); or large curves with open triradiate cartilage (nine patients). PLDF patients had a mean (± standard deviation) of 3 ± 1 diskectomies and 14 ± 3 posterior spinal levels fused. Compared with the APSF group, the PLDF group had significantly greater major curve correction (86% vs. 57%, P = 0.006), less blood transfused (mean, 2.5 ± 2.6 vs. 4.0 ± 3.3 units, P = 0.038), and a lower rate of staged surgery (1.8% vs. 86%, P < 0.001). There were no significant differences between the PLDF and APSF groups in T1-S1 length gained (mean, 6.2 ± 3.4 vs. 6.6 ± 8.8 cm, respectively; P = 0.77) or in the rate of major complications (P = 0.557). PLDF is an effective alternative to APSF for treating children with severe spinal deformities. It is effective for treating large, rigid curves with severe rotation and may be useful for treating large curves in children with open triradiate cartilage. 4.

Treatment of pediatric spinal deformity with use of recombinant human bone morphogenetic protein-2

In pediatric spine surgery nonunion is a challenging issue. Instability may cause neurological impairment and lead to numerous surgeries in order to achieve fusion. The use of rhBMP-2 for pediatric spinal fusion has not been widely reported. In this study, a series of 13 children (14 procedures) that underwent spinal rhBMP-2 application were analyzed in order to measure clinical and radiographic outcome. Therefore, patient data, diagnosis, construct of instrumentation, type of bone graft, quantity of BMP used, and fusion outcome were reviewed. The study cohort included four female and nine male patients with a mean age of 11.2 years (range 2.6-19.2 years) at the time of rhBMP-2 application. Rh-BMP-2 was used in both primary (n = 6) and revision surgery (n = 8) in patients with a high risk for the development of nonunion. The mean follow-up was 51 months (range 12-108 months). Fusion occurred in 11 patients. Complications that may be due to application of rhBMP-2 were seen after four operations. Three patients had an increased body temperature and in one case prolonged wound secretion was evident, treated by local wound care or observation. In one of these patients an extensive postoperative hematoma occurred, necessitating surgical treatment. In conclusion, we could detect high fusion rates following the use of rhBMP-2 in pediatric spine surgery without an increased complication rate attributable to its application. Therefore we consider recombinant human BMP-2 to be an option in selected pediatric spinal procedures, especially in cases with compromised bone healing due to congenital, systemic, or local conditions.

What Is the Frequency of Intraoperative Alerts During Pediatric Spinal Deformity Surgery Using Current Neuromonitoring Methodology? A Retrospective Study of 218 Surgical Procedures

Introduction: There is variability in intraoperative neuromonitoring (IONM), anesthetic and surgical techniques for the treatment of pediatric spinal deformity. This study evaluates a series of patients treated at multiple centers utilizing transcranial motor and somatosensory evoked potentials (TcMEP and SSEP) and electromyography (EMG). The frequency of alerts and the intraoperative follow-up is reported.Methods: Standard patient demographics and IONM data were collected from a two-month cohort of pediatric spine deformity cases.Results: Data from 218 scoliosis patients were included from 46 facilities and 72 surgeons. Baseline upper and lower extremity TcMEP data were present in 96.7% and 93.9% patients respectively. Baseline upper and lower SSEPs were present in 99.5% and 95.4% respectively. Surgical TCMEP alerts occurred in 19 (8.7%) patients during deformity correction (n = 11), placement of instrumentation (n = 5), decompression (n = 2), and closing (n = 1) with concurrent SSEP alerts occurring in five patients. Nine had TCMEP recovery, eight showed partial recovery and two did not recover. Additional alerts occurred due to: positioning (n = 16), inhalational agent change (n = 4), global physiological change (n = 4) and technical reasons (n = 2).A total of 2164 pedicle screws were tested. Of 197 (9.1%) screws that tested from 6–9 mA, 171 (65.4%) were left unchanged, 10 (5.1%) removed, eight (4.1%) repositioned with improved threshold, and eight (4.1%) without improvement. Of 26 screws that tested ≤5 milliamperes (mA), 17 (65.4%) were left unchanged, five (19.2%) removed, two (7.7%) repositioned with improved threshold, and two (7.7%) without improvement.Conclusions: IONM provides data that causes re-evaluation in about 10% of pediatric spinal deformity cases.

Impact of Pedicle Screw Instrumentation with Addition of Crosslink on Growth of Spinal Canal in Young Children

Introduction The use of pedicle screws has been popularized in the treatment of pediatric spinal deformity. Despite many studies regarding the effect of pedicle screws on the immature spine, there is a paucity of data concerning the impact of the screw-rod-crosslink complex on the development of spinal canal in young children. The objective of this study is to determine the influence of the screw-rod-crosslink complex on the development of spinal canal. Materials and Methods This study reviewed 34 patients with congenital scoliosis (14 boys and 20 girls) who were treated with posterior-only hemivertebrectomy and pedicle-screw-based short-segment instrumentation before the age of 5 years. They were followed-up for at least 24 months. Of these patients, 10 underwent only pedicle screw instrumentation without crosslink, and 24 with additional crosslink placement. The vertebrae were divided into three regions as follows: (1) S-CL (screw-crosslink) region, in which the vertebrae were inserted with bilateral pedicle screws and two rods connected with the crosslink; (2) S (screw) region, in which the vertebrae were inserted with bilateral pedicle screws but without crosslink; (3) NS (no screws) region, which comprised vertebrae cephalad or caudal to the instrumented region. The area, anteroposterior and transverse diameters of the spinal canal were measured at all vertebrae on the postoperative and last follow-up computed tomography axial images. The instrumentation-related parameters were also measured, including the distance between the bilateral screws and the screw base angle. The changes in the above measurements were compared between each region to evaluate the instrumentation's effect on the spinal canal growth. Results The mean age at surgery was 37 ± 11 months (range, 21–57 months) and the mean follow-up was 37 ± 13 months (range, 24–68 months). In each region, the spinal canal dimensions significantly increased during the follow-up period. There was no significant difference in the spinal canal growth rate between the S and NS regions or between the S-CL and NS regions. In addition, a comparison of the S-CL and S regions regarding the changes in measurements of the instrumentation construct revealed no significant differences. Conclusion Pedicle-screw-based instrumentation does not cause retardation of the development of spinal canal in young children. Moreover, use of the crosslink added to the screw-rod instrumentation also demonstrates no negative effect on the growth of the spinal canal. Thus, the addition of the crosslink to screw-based instrumentation is recommended to increase fixation stability in growing patients, even in very young pediatric population.

Does addition of crosslink to pedicle-screw-based instrumentation impact the development of the spinal canal in children younger than 5 years of age?

Use of pedicle screws has been popularized in the treatment of pediatric spinal deformity. Despite many studies regarding the effect of pedicle screws on the immature spine, there is no study concerning the impact of addition of crosslink to pedicle-screw-based instrumentation on the development of the spinal canal in young children. This study aims to determine the influence of the screw-rod-crosslink complex on the development of the spinal canal. This study reviewed 34 patients with congenital scoliosis (14 boys and 20 girls) who were treated with posterior-only hemivertebrectomy and pedicle-screw-based short-segment instrumentation before the age of 5 years. The mean age at surgery in this cohort was 37 ± 11 months (range 21-57 months). They were followed up for at least 24 months. Of these patients, 10 underwent only pedicle screw instrumentation without crosslink, and 24 with additional crosslink placement. The vertebrae were divided into three regions as follows: (1) S-CL (screw-crosslink) region, in which the vertebrae were inserted with bilateral pedicle screws and two rods connected with the crosslink; (2) S (screw) region, in which the vertebrae were inserted with bilateral pedicle screws but without crosslink; (3) NS (no screws) region, which comprised vertebrae cephalad or caudal to the instrumented region. The area, anteroposterior and transverse diameters of the spinal canal were measured at all vertebrae on the postoperative and last follow-up computed tomography axial images. The instrumentation-related parameters were also measured, including the distance between the bilateral screws and the screw base angles. The changes in the above measurements were compared between each region to evaluate the instrumentation's effect on the spinal canal growth. The mean follow-up was 37 ± 13 months (range 24-68 months) and the mean age at the last follow-up was 74 ± 20 months (range 46-119 months). In each region, the spinal canal dimensions significantly increased during the follow-up period. There was no significant difference in the spinal canal growth rate between the S and NS regions or between the S-CL and NS regions. Besides, a comparison of the S-CL and S regions regarding the changes in the measurements of the instrumentation construct revealed no significant differences. Pedicle-screw-based instrumentation does not cause retardation of the development of the spinal canal in young children. Moreover, use of the crosslink added to the screw-rod instrumentation also demonstrates no negative effect on the growth of the spinal canal. Thus, the addition of the crosslink to short screw-based instrumentation is recommended as an alternative to increase fixation stability in growing patients, even in very young pediatric population.

Preoperative Evaluation and Decreasing Errors in Pediatric Spine Surgery

The treatment of pediatric spinal deformity has changed dramatically over the past several decades, and surgeons face new challenges when managing the complications associated with these treatments. Care of the patient can be considered in 3 phases: preoperative evaluation, perioperative period, and postoperative management period. There are opportunities to identify and prevent potential complications during each of these phases of treatment. Comprehensive safety protocols that include the participation of all team members should make surgery safer over time, and the use of postoperative management protocols and multidisciplinary teams to manage complex patients can improve patient outcomes and shorten hospital stays. Surgeons, patients and payers are motivated to continue to improve safety for the pediatric spinal deformity patient, and there will be heightened interest in defining specific measures that positively affect outcomes.

Minimally Invasive Treatment of Pediatric Spinal Deformity

Minimally invasive surgery (MIS) has been extensively used for the treatment of adult spinal disorders, including degenerative, trauma, and deformity. More recently, MIS techniques have been applied for the treatment of pediatric spine deformity. Several features of the pediatric spine allow for the natural application of MIS techniques. These include its greater inherent flexibility and tendency to form robust fusion. MIS techniques have been used at the top of long constructs to minimize junctional kyphosis, in treatment of adolescent idiopathic scoliosis, and for growing rods to minimize spine auto fusion. As in adult patients, these patients sustain less blood loss and shorter hospital stays. However, the surgical procedures are longer with extensive fluoroscopy, particularly in the early stages of the learning curve. Future prospective studies will clarify the true benefits of MIS techniques versus open in the treatment of pediatric spine deformity.

Pedicle Screw Instrumentation for Adult Idiopathic Scoliosis

A matched cohort comparison of adult idiopathic scoliosis (AdIS) patients treated with all pedicle screw constructs compared to hook/hybrid constructs. To compare clinical and radiographic results of AdIS treatment using all pedicle screw constructs versus hook/hybrid constructs. Pedicle screw instrumentation has demonstrated excellent clinical efficacy in the treatment of pediatric spinal deformity. No prior reports have compared the outcomes of pedicle screw only constructs to hook/hybrid constructs in the treatment of AdIS. We analyzed 34 consecutive patients undergoing posterior-only correction for AdIS, using pedicle screw instrumentation at minimum 2-year follow-up. Thirty-four matching patients (11 with anterior releases) were selected from a cohort of 58 patients treated with hook/hybrid constructs based on similar age, curve type, magnitude, and fusion levels. Significantly greater curve correction was seen in the pedicle screw compared to the hook/hybrid group (56 vs. 40%, P < 0.01). Coronal and sagittal imbalance were equivalent between the groups (P = 0.91 and 0.23, respectively). Thoracic kyphosis (T5-T12) was maintained in the pedicle screw patients but significantly increased in the hybrid/hook patients over time (P < 0.05). Scoliosis Research Society outcome scores significantly improved in both groups. Blood loss was equivalent but operative time was longer in the hook/hybrid patients.No pedicle screw patients were revised for instrumentation complications with 1 lumbosacral nonunion revised at 5 years postoperative (3% revision rate). Eight of 58 patients among the hook/hybrid cohort underwent 9 revisions for instrumentation failure (n = 3) or nonunion (n = 6) (14% revision rate; P = 0.04). Pedicle screw correction of AdIS is safe and effective. Compared to hook/hybrid constructs, these patients displayed significantly improved correction of the major curve (even in the absence of anterior releases), maintenance of thoracic kyphosis, and a lower revision rate. Similar SRS scores and blood loss were noted. The hook/hybrid patients had significantly longer operative times. The use of BMP-2 in 7 patients and TLIF/ALIF also in 7 of the pedicle screw patients may have decreased the need for revision surgery up to the latest follow-up.