Publications by authors named "Amer F Samdani"

154 Publications

Early and late hospital readmissions in adolescent idiopathic scoliosis.

Spine Deform 2021 May 3. Epub 2021 May 3.

Shriners Hospitals for Children-Philadelphia, 3551 N Broad Street, Philadelphia, PA, 19140, USA.

Study Design: Retrospective review of a prospectively collected multicenter database.

Objectives: 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.

Methods: Patients with AIS who were operatively treated from 19 centers specializing in the treatment of pediatric spinal deformity were studied. Data from a minimum 2 years of clinical follow-up and any readmission were available for analysis. Characteristics of patients with no readmission, early readmission (< 90 days), and late readmission (> 90 days) were evaluated. Both univariate and multivariate analyses of risk factors for readmission were performed.

Results: 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.

Conclusions: 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.

Level Of Evidence: 3.
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http://dx.doi.org/10.1007/s43390-021-00294-7DOI Listing
May 2021

What happens to the unfused upper thoracic curve after posterior spinal fusion for adolescent idiopathic scoliosis?

J Neurosurg Pediatr 2021 Apr 23:1-7. Epub 2021 Apr 23.

2Department of Orthopaedic Surgery and Neurosurgery, Shriners Hospitals for Children-Philadelphia, Pennsylvania.

Objective: Spontaneous lumbar curve correction after selective thoracic fusion in surgery for adolescent idiopathic scoliosis (AIS) is well described. However, only a few articles have described the course of the uninstrumented upper thoracic (UT) curve after fusion, and the majority involve a hybrid construct. In this study, the authors sought to determine the outcomes and associated factors of uninstrumented UT curves in patients with AIS.

Methods: The authors retrospectively reviewed a prospectively collected multicenter AIS registry for all consecutive patients with Lenke type 1-4 curves with a 2-year minimum follow-up. UT curves were considered uninstrumented if the upper instrumented vertebra (UIV) did not extend above 1 level from the lower end vertebra of the UT curve. The authors defined progression as > 5°, and divided patients into two cohorts: those with improvement in the UT curve (IMP) and those without improvement in the UT curve (NO IMP). Radiographic, demographic, and Scoliosis Research Society (SRS)-22 survey outcome measures were compared using univariate analysis, and significant factors were compared using a multivariate regression model.

Results: The study included 450 patients (370 females and 80 males). The UT curve self-corrected in 86% of patients (n = 385), there was no change in 14% (n = 65), and no patients worsened. Preoperatively, patients were similar with respect to Lenke classification (p = 0.44), age (p = 0.31), sex (p = 0.85), and Risser score (p = 0.14). The UT curves in the IMP group self-corrected from 24.7° ± 6.5° to 12.6° ± 5.9°, whereas in the NO IMP group UT curves remained the same, from 20.3° ± 5.8° to 18.5° ± 5.7°. In a multivariate analysis, preoperative main thoracic (MT) curve size (p = 0.004) and MT curve correction (p = 0.001) remained significant predictors of UT curve improvement. Greater correction of the MT curve and larger initial MT curve size were associated with greater likelihood of UT curve improvement.

Conclusions: Spontaneous UT curve correction occurred in the majority (86%) of unfused UT curves after MT curve correction in Lenke 1-4 curve types. The magnitude of preoperative MT curve size and postoperative MT curve correction were independent predictors of spontaneous UT curve correction.
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http://dx.doi.org/10.3171/2020.10.PEDS20671DOI Listing
April 2021

Complete paraplegia 36 h after attempted posterior spinal fusion for severe adolescent idiopathic scoliosis: a case report.

Spinal Cord Ser Cases 2021 Apr 20;7(1):33. Epub 2021 Apr 20.

Institute for Spine and Scoliosis, 3100 Princeton Pike, Lawrenceville, NJ, 08648, USA.

Introduction: The incidence of neurologic complications with spinal surgery for adolescent idiopathic scoliosis (AIS) has been reported to be 0.69%. This rare complication typically occurs during surgery or immediately postoperatively. We report the occurrence of a delayed neurologic deficit that presented 36 h after the initial surgery of a staged posterior spinal fusion for severe AIS.

Case Presentation: A 12-year-old girl with severe thoracolumbar AIS of 125° underwent attempted posterior spinal fusion from T2-L4. The case was complicated by a transient loss of transcutaneous motor evoked potentials (TcMEP) that resolved with an increase in the mean arterial pressure (MAP) and relaxation of curve correction with rod removal. The patient awoke with normal neurologic function. She had a transient decrease in MAP 36 h post-op and awoke on postoperative day #2 with nearly complete lower extremity paraplegia (American Spinal Injury Association [ASIA] Impairment Scale B). Emergent exploration and removal of the concave apical pedicles resulted in improvement of TcMEPs and return of function.

Discussion: Delayed postoperative neurologic deficit is a very rare phenomenon, with only a few case reports in the literature to date. The delayed neurologic decline of our patient was likely secondary to a transient episode of postoperative hypotension combined with spinal cord compression by the apical concave pedicles. Close monitoring and support of spinal cord perfusion as well as emergent decompression are imperative in the setting of a delayed neurologic deficit. Further multicenter study on this rare occurrence is underway to identify potential causes and improve treatment.
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http://dx.doi.org/10.1038/s41394-021-00386-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8058337PMC
April 2021

Use of postoperative neurophysiological testing to help guide management in a case of delayed neurological injury.

Childs Nerv Syst 2021 Mar 29. Epub 2021 Mar 29.

Shriners Hospitals for Children-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA.

Bimodal intraoperative neuromonitoring (IONM), combining transcranial motor-evoked potentials (tcMEP) and somatosensory-evoked potentials (SSEP), enables real-time detection and prevention of spinal cord injury during pediatric spinal deformity correction. Although rare, false-positive and false-negative signal alerts have been reported. However, no previously published accounts have described the use of postoperative neurophysiological testing to both identify new-onset neurological injury and guide reintervention. Here, we describe the case of an 18-year-old young man with achondroplasia, thoracolumbar kyphosis, and L2 wedge vertebra who underwent T12-L4 posterior spinal fusion with L2 vertebral column resection. Despite two intraoperative decreases in tcMEP amplitude, corrective measures on both occasions produced a return of IONM signal. Curiously, despite movement of the bilateral lower extremities upon waking, continued observation demonstrated minimal movement of the left lower extremity. Postoperative neurophysiological testing then identified limited muscle group activation below the left quadriceps, prompting operative reintervention. After cage removal and laminectomy lengthening, the patient recovered bilateral lower extremity function. He later returned to surgery for repeat cage placement at L2 via a retroperitoneal exposure, with no noted IONM changes and subsequent neurological improvement.
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http://dx.doi.org/10.1007/s00381-021-05071-5DOI Listing
March 2021

Cost-Utility Analysis of Anterior Vertebral Body Tethering versus Spinal Fusion in Idiopathic Scoliosis from a US Integrated Healthcare Delivery System Perspective.

Clinicoecon Outcomes Res 2021 15;13:175-190. Epub 2021 Mar 15.

Zimmer Biomet, Warsaw, IN, USA.

Purpose: Anterior vertebral body tethering (VBT) is a non-fusion, minimally invasive, growth-modulating procedure with some early positive clinical outcomes reported in pediatric patients with idiopathic scoliosis (IS). VBT offers potential health-related quality of life (HRQoL) benefits over spinal fusion in allowing patients to retain a greater range of motion after surgery. We conducted an early cost-utility analysis (CUA) to compare VBT with fusion as a first-choice surgical treatment for skeletally immature patients (age >10 years) with moderate to severe IS, who have failed nonoperative management, from a US integrated healthcare delivery system perspective.

Patients And Methods: The CUA uses a Markov state transition model, capturing a 15-year period following index surgery. Transition probabilities, including revision risk and subsequent fusion, were based on published surgical outcomes and an ongoing VBT observational study (NCT02897453). Patients were assigned utilities derived from published patient-reported outcomes (PROs; SRS-22r mapped to EQ-5D) following fusion and the above VBT study. Index and revision procedure costs were included. Probabilistic (PSA) and deterministic sensitivity analyses (DSA) were performed.

Results: VBT was associated with higher costs but also higher quality-adjusted life years (QALYs) than fusion (incremental costs: $45,546; QALYs gained: 0.54). The subsequent incremental cost-effectiveness ratio for VBT vs fusion was $84,391/QALY gained. Mean PSA results were similar to the base case, indicating that results were generally robust to uncertainty. The DSA indicated that results were most sensitive to variations in utility values.

Conclusion: This is the first CUA comparing VBT with fusion in pediatric patients with IS and suggests that VBT may be a cost-effective alternative to fusion in the US, given recommended willingness-to-pay thresholds ($100,000-$150,000). The results rely on HRQoL benefits for VBT compared with fusion. For improved model accuracy, further analyses with longer-term PROs for VBT, and comparative effectiveness studies, would be needed.
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http://dx.doi.org/10.2147/CEOR.S289459DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7979350PMC
March 2021

Crossing the cervicothoracic junction in complex pediatric deformity using anterior cervical discectomy and fusion: a case series.

Childs Nerv Syst 2021 Jun 17;37(6):1957-1964. Epub 2021 Mar 17.

Shriners Hospitals for Children-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA.

Purpose: Proximal instrumentation failure is a challenge in posterior spinal fusions (PSFs) crossing the cervicothoracic junction. High rates of proximal junctional kyphosis (PJK) and loss of fixation have been reported. In this single-center retrospective cohort study, we evaluate the utility of anterior cervical discectomy and fusion (ACDF) in addition to traditional PSF crossing the cervicothoracic junction in order to mitigate implant-related complications.

Methods: All patients who underwent PSF across the cervicothoracic junction with ACDF with 2 years of follow-up data were reviewed. We analyzed clinical, surgical, and radiographic measures such as operative details, presence of PJK, complications, instrumentation migration, curve angles, and vertebral translation. Measurements were compared statistically using paired samples t-tests.

Results: Ten patients (6 girls, 4 boys) met inclusion criteria with a mean age at surgery of 12.8 ± 3.3 years and follow-up of 3.38 ± 0.9 years. All patients underwent ACDF (range 1-3 levels), and 8 (80%) underwent traction. The average number of levels fused posteriorly was 16.7 ± 4.7 and anteriorly was 2.4 ± 0.7. The major coronal curve averaged 48.8 ± 34.7° preoperatively and 23.3±13.3° postoperatively (p = 0.028). The average major sagittal curve was 83.5 ± 24.2° preoperatively, resolving to 53.9 ± 25.5° (p=0.001). One patient suffered rod breakage at T7, and another developed symptomatic PJK 19 months postoperatively.

Conclusion: Our data suggest that ACDF procedures added to PSFs crossing the cervicothoracic junction offer promise for reducing risk for instrumentation-related complications. ACDF also significantly helps improve and maintain both coronal and sagittal correction over 2 years.

Level Of Evidence: 4.
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http://dx.doi.org/10.1007/s00381-021-05109-8DOI Listing
June 2021

Congenital Scoliosis of the Pediatric Cervical Spine: Characterization of a 17-Patient Operative Cohort.

J Pediatr Orthop 2021 Mar;41(3):e211-e216

Departments of Orthopaedic Surgery and Neurosurgery, Shriners Hospitals for Children-Philadelphia, Philadelphia, PA.

Background: Congenital cervical scoliosis is rare, and there is a paucity of literature describing surgical outcomes. We report surgical outcomes in a 17-patient cohort with surgical correction for congenital cervical scoliosis and identify risk factors associated with complications.

Methods: Data were retrospectively collected from a single-center cohort of 17 consecutive patients (9 boys, 8 girls) receiving surgical deformity correction for congenital cervical scoliosis. The mean age at surgery was 7.1±3.4 years with an average follow-up of 3.6±1.1 years.

Results: There were 24 operations performed on 17 patients, and 4 complications (17%) were reported in the series, including one each of pressure ulcer, asystole, vertebral artery injury, and pseudarthrosis. The mean preoperative major curve angle was 36±20 degrees, which improved to 24±14 degrees (P=0.02). The mean operative time was 8±2 hours with a mean estimated blood loss of 298±690 mL. Halo-gravity traction was used in 5 patients and 6 cases were staged with anterior/posterior procedures.

Conclusions: Congenital scoliosis of the cervical spine is a complex process. The spinal deformity of this nature can be managed successfully with carefully planned and executed surgical correction.

Level Of Evidence: Level IV-retrospective review.
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http://dx.doi.org/10.1097/BPO.0000000000001718DOI Listing
March 2021

Growth-Friendly Spine Surgery in Arthrogryposis Multiplex Congenita.

J Bone Joint Surg Am 2021 Apr;103(8):715-726

Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Cleveland, Ohio.

Background: Arthrogryposis multiplex congenita (AMC) is a condition that describes neonates born with ≥2 distinct congenital contractures. Despite spinal deformity in 3% to 69% of patients, inadequate data exist on growth-friendly instrumentation (GFI) in AMC. Our study objectives were to describe current GFI trends in children with AMC and early-onset scoliosis (EOS) and to compare long-term outcomes with a matched idiopathic EOS (IEOS) cohort to determine whether spinal rigidity or extremity contractures influenced outcomes.

Methods: Children with AMC and spinal deformity of ≥30° who were treated with GFI for ≥24 months were identified from a multicenter EOS database (1993 to 2017). Propensity scoring matched 35 patients with AMC to 112 patients with IEOS with regard to age, sex, construct, and curve. Multivariable linear mixed modeling compared changes in spinal deformity and the 24-item Early Onset Scoliosis Questionnaire (EOSQ-24) across cohorts. Cohort complications and reoperations were analyzed using multivariable Poisson regression.

Results: Preoperatively, groups did not differ with regard to age (p = 0.87), sex (p = 0.96), construct (p = 0.62), rate of nonoperative treatment (p = 0.54), and major coronal curve magnitude (p = 0.96). After the index GFI, patients with AMC had reduced percentage of coronal correction (35% compared with 44%; p = 0.01), larger residual coronal curves (49° compared with 42°; p = 0.03), and comparable percentage of kyphosis correction (17% compared with 21%; p = 0.52). In GFI graduates (n = 81), final coronal curve magnitude (55° compared with 43°; p = 0.22) and final sagittal curve magnitude (47° compared with 47°; p = 0.45) were not significantly different at the latest follow-up after definitive surgery. The patients with AMC had reduced T1-S1 length (p < 0.001), comparable T1-S1 growth velocity (0.66 compared with 0.85 mm/month; p = 0.05), and poorer EOSQ-24 scores at the time of the latest follow-up (64 compared with 83 points; p < 0.001). After adjusting for ambulatory status and GFI duration, patients with AMC developed 51% more complications (incidence rate ratio, 1.51 [95% confidence interval (CI), 1.11 to 2.04]; p = 0.009) and 0.2 more complications/year (95% CI, 0.02 to 0.33 more; p = 0.03) compared with patients with IEOS.

Conclusions: Patients with AMC and EOS experienced less initial deformity correction after the index surgical procedure, but final GFI curve magnitudes and total T1-S1 growth during active treatment were statistically and clinically comparable with IEOS. Nonambulatory patients with AMC with longer GFI treatment durations developed the most complications. Multidisciplinary perioperative management is necessary to optimize GFI and to improve quality of life in this complex population.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.20.00600DOI Listing
April 2021

Risk factors for gastrointestinal complications after spinal fusion in children with cerebral palsy.

Spine Deform 2021 Mar 17;9(2):567-578. Epub 2020 Nov 17.

Department of Orthopaedic Surgery, University Hospital Cleveland Medical Center, Rainbow Babies and Children's Hospital, 201 Adelbert Road, Cleveland, OH, 44106, USA.

Design: Prospective cerebral palsy (CP) registry review.

Objectives: (1) Evaluate the incidence/risk factors of gastrointestinal (GI) complications in CP patients after spinal fusion (SF); and (2) investigate the validity of the modified Clavien-Dindo-Sink classification.

Background: Perioperative GI complications result in increased length of stay (LOS) and patient morbidity/mortality. However, none have analyzed the outcomes of GI complications using an objective classification system.

Methods: A prospective/multicenter CP database identified 425 children (mean, 14.4 ± 2.9 years; range, 7.9-21 years) who underwent SF. GI complications were categorized using the modified Clavien-Dindo-Sink classification. Grades I-II were minor complications and grades III-V major. Patients with and without GI complications were compared.

Results: 87 GI complications developed in 69 patients (16.2%): 39 minor (57%) and 30 major (43%). Most common were pancreatitis (n = 45) and ileus (n = 22). Patients with preoperative G-tubes had 2.2 × odds of developing a GI complication compared to oral-only feeders (OR 2.2; 95% CI 0.98-4.78; p = 0.006). Similarly, combined G-tube/oral feeders had 6.7 × odds compared to oral-only (OR 6.7; 95% CI 3.10-14.66; p < 0.001). The likelihood of developing a GI complication was 3.4 × with normalized estimated blood loss (nEBL) ≥ 3 ml/kg/level fused (OR 3.41; 95% CI 1.95-5.95; p < 0.001). Patients with GI complications had more fundoplications (29% vs. 17%; p = 0.03) and longer G-tube fasting periods (3 days vs. 2 days; p < 0.001), oral fasting periods (5 days vs. 2 days; p < 0.001), ICU admissions (6 days vs. 3 days; p = 0.002), and LOS (15 days vs. 8 days; p < 0.001). LOS correlated with the Clavien-Dino-Sink classification.

Conclusion: Gastrointestinal complications such as pancreatitis and ileus are not uncommon after SF in children with CP. This is the first study to investigate the validity of the modified Clavien-Dindo-Sink classification in GI complications after SF. Our results suggest a correlation between complication severity grade and LOS. The complexity of perioperative enteral nutritional supplementation requires prospective studies dedicated to enteral feeding protocols.

Level Of Evidence: Therapeutic-level III.
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http://dx.doi.org/10.1007/s43390-020-00233-yDOI Listing
March 2021

Risk Factors for Proximal Junctional Kyphosis Following Surgical Deformity Correction in Pediatric Neuromuscular Scoliosis.

Spine (Phila Pa 1976) 2021 Feb;46(3):169-174

Departments of Orthopaedic Surgery and Neurosurgery, Shriners Hospitals for Children-Philadelphia, Philadelphia, PA.

Study Design: Single-center retrospective cohort analysis.

Objective: The aim of this study was to evaluate risk factors associated with the development of proximal junctional kyphosis (PJK) in pediatric neuromuscular scoliosis (NMS).

Summary Of Background Data: PJK is a common cause of reoperation in adult deformity but has been less well reported in pediatric NMS.

Methods: Sixty consecutive pediatric patients underwent spinal fusion for NMS with a minimum 2-year follow-up. PJK was defined as >10° increase between the inferior end plate of the upper instrumented vertebra (UIV) and the superior end plate of the vertebra two segments above. Regression analyses as well as binary correlational models and Student t tests were employed for further statistical analysis assessing variables of primary and compensatory curve magnitudes, thoracic kyphosis, proximal kyphosis, lumbar lordosis, pelvic obliquity, shoulder imbalance, Risser classification, and sagittal profile.

Results: The present cohort consisted of 29 boys and 31 girls with a mean age at surgery of 14 ± 2.7 years. The most prevalent diagnoses were spinal cord injury (23%) and cerebral palsy (20%). Analysis reflected an overall radiographic PJK rate of 27% (n = 16) and a proximal junctional failure rate of 7% (n = 4). No significant association was identified with previously suggested risk factors such as extent of rostral fixation (P = 0.750), rod metal type (P = 0.776), laminar hooks (P = 0.654), implant density (P = 0.386), nonambulatory functional status (P = 0.254), or pelvic fixation (P = 0.746). Significant risk factors for development of PJK included perioperative use of halo gravity traction (38%, P = 0.029), greater postoperative C2 sagittal translation (P = 0.030), decreased proximal kyphosis preoperatively (P = 0.002), and loss of correction of primary curve magnitude at follow-up (P = 0.047). Increase in lumbar lordosis from post-op to last follow-up trended toward significance (P = 0.055).

Conclusion: Twenty-seven percent of patients with NMS developed PJK, and 7% had revision surgery. Those treated with halo gravity traction or with greater postoperative C2 sagittal translation, loss of primary curve correction, and smaller preoperative proximal kyphosis had the greatest risk of developing PJK.Level of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000003755DOI Listing
February 2021

New neurologic deficit and recovery rates in the treatment of complex pediatric spine deformities exceeding 100 degrees or treated by vertebral column resection (VCR).

Spine Deform 2021 Mar 9;9(2):427-433. Epub 2020 Oct 9.

Department of Orthopedics, Washington University School of Medicine, St. Louis, MO, USA.

Study Design: Prospective multicenter international observational study.

Objective: To investigate incidence of new neurologic deficit (NND) and the long-term recovery patterns following complex pediatric spine deformity surgery. The SRS M&M reports identify pediatric patients as having higher rate of new neurologic deficit compared with adults, while congenital and neuromuscular deformities are associated with higher new neurologic risks. Very few studies have had the large numbers of pediatric patients with curves exceeding 100 deg to ascertain the new neurologic deficit (NND) rates and recovery patterns as it relates to curve laterality and diagnosis.

Method: The FOX pediatric database from 17 international sites was queried for New Neurologic Deficit (NND) as characterized by change in American Spinal Injury Association (ASIA) Lower or Upper Extremity Motor Score. Recovery rates at specific intervals were recorded and related to the curve type and etiology.

Results: Data of 286 consecutive patients with normal pre-operative neurologic exams were reviewed. There were 160 females vs 125 males with an average age of 14.6 years. NND occurred in 27 patients (9.4%) in the immediate post-operative period. Diagnostic categories included idiopathic scoliosis (3 patients); idiopathic kyphoscoliosis(5 patients); congenital scoliosis (7 patients); congenital kyphoscoliosis (4 patients); congenital kyphosis (6 patients), other kyphosis (1 patient) and syndromic (1 patient). 1 patient was lost to follow-up (f/u) after discharge; 1 had chronic deficits at the first post-operative erect visit (from discharge to 9 months f/u) and was subsequently lost to follow-up; 2 patients were improving at 1-year f/u but lost to subsequent f/u. 16 patients had normal neurologic function by the time of the first post-operative erect visit, 21 patients at 1-year f/u and 21 patients at the 2-year f/u. 2 patients (0.69%) had improved NND at 2-year mark.

Conclusion: A significant proportion of patients with complex spine deformity experience NND. However, significant improvement in neurologic function can be expected over time as seen in this study without additional surgical intervention in most cases. Congenital deformities accounted for 63% of the patients experiencing NND.
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http://dx.doi.org/10.1007/s43390-020-00211-4DOI Listing
March 2021

Restoration of Thoracic Kyphosis in Adolescent Idiopathic Scoliosis Over a Twenty-year Period: Are We Getting Better?

Spine (Phila Pa 1976) 2020 Dec;45(23):1625-1633

Orthopedics and Scoliosis Division, Rady Children's Hospital, San Diego, CA.

Study Design: A multicenter, prospectively collected database of 20 years of operatively treated adolescent idiopathic scoliosis (AIS) was utilized to retrospectively examine pre- and postoperative thoracic kyphosis at 2-year follow-up.

Objective: To determine if the adoption of advanced three-dimensional correction techniques has led to improved thoracic kyphosis correction in AIS.

Summary Of Background Data: Over the past 20 years, there has been an evolution of operative treatment for AIS, with more emphasis on sagittal and axial planes. Thoracic hypokyphosis was well treated with an anterior approach, but this was not addressed sufficiently in early posterior approaches. We hypothesized that patients with preoperative thoracic hypokyphosis prior to 2000 would have superior thoracic kyphosis restoration, but the learning curve with pedicle screws would reflect initially inferior restoration and eventual improvement.

Methods: From 1995 to 2015, 1063 patients with preoperative thoracic hypokyphosis (<10°) were identified. A validated formula for assessing three-dimensional sagittal alignment using two-dimensional kyphosis and thoracic Cobb angle was applied. Patients were divided into 1995-2000 (Period 1, primarily anterior), 2001-2009 (Period 2, early thoracic pedicle screws), and 2010-2015 (Period 3, modern posterior) cohorts. Two-way repeated measures analysis of variance and post-hoc Bonferroni corrections were utilized with P < 0.05 considered significant.

Results: Significant differences were demonstrated. Period 1 had excellent restoration of thoracic kyphosis, which worsened in Period 2 and improved to near Period 1 levels during Period 3. Period 3 had superior thoracic kyphosis restoration compared with Period 2.

Conclusion: Although the shift from anterior to posterior approaches in AIS was initially associated with worse thoracic kyphosis restoration, this improved with time. The proportion of patients restored to >20° kyphosis with a contemporary posterior approach has steadily improved to that of the era when anterior approaches were more common.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003659DOI Listing
December 2020

Does thoracoplasty adversely affect lung function in complex pediatric spine deformity? A 2-year follow-up review.

Spine Deform 2021 Jan 18;9(1):105-111. Epub 2020 Aug 18.

Department of Orthopedics, Washington University School of Medicine, St. Louis, Missouri, USA.

Study Design: Retrospective review of prospective multi-center cohort.

Objective: To investigate the impact of thoracoplasty on pulmonary function at 2-year follow-up among complex pediatric spine deformity patients. Complex pediatric spine deformities may be associated with significant rib prominence causing body image concerns. Surgical correction of spine deformity may include thoracoplasty to correct the rotational prominence. Some surgeons refrain from performing thoracoplasty due to its purported negative effect on pulmonary function. There is paucity of literature on the effect of thoracoplasty on pulmonary function at 2-year follow-up in pediatric patients with complex spine deformity.

Methods: We reviewed data of 312 patients (> 100°, with or without vertebral column resection (VCR)) or (< 100° with VCR)) from an international multicenter database. Data of 106 patients with complete radiographic and pulmonary function test (PFT) assessment with a minimum of 2-year follow-up was analyzed. Paired t test was performed to compare pre-op and 2-year PFT results. PFT comparison was stratified based on thoracoplasty status (thoracoplasty: Group 1 vs. no thoracoplasty: Group 2).

Results: 106 patients (61 patients Group 1 vs. 45 in Group 2). The average age and gender ratio were similar in both groups (p  >  0.05). Group 1 had significantly lower body mass index (BMI) compared to Group 2 (18.4 kg m ± 2.8 vs. 19.9 kg m  ±  4.8, p  =  0.0351). The average baseline coronal and sagittal Cobbs were larger for Group 1 relative to Group 2 (p  < 0.05). The distribution of deformity etiology and curve types, and apices were similar between the two groups (p  >  0.05). The rate of pre-op utilization of halo gravity traction (HGT) was 52.5% vs. 26.7% (p  =  0.008), at an average duration of 103 days vs. 47 days, p  =  0.0001. The rate of surgical osteotomies was similar in both groups. Estimated blood volume (EBV) loss was greater in Group 1 (63.1% vs. 43.1%, p  =  0.0012). Post-op coronal and sagittal Cobb correction was similar in both groups. The incidence of post-op pulmonary complication was similar in both groups (8.2% vs. 8.9%, p  =  0.899). Baseline and 2-year follow-up PFT did not differ significantly between and within the groups. Vertebral column resection (VCR) did not negatively affect PFT in both groups.

Conclusion: Despite higher curve magnitudes in patients undergoing surgical correction and thoracoplasty for complex pediatric spine deformity, our findings revealed that thoracoplasty does not negatively affect pulmonary function at 2-year follow-up.
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http://dx.doi.org/10.1007/s43390-020-00188-0DOI Listing
January 2021

Major complications following surgical correction of spine deformity in 257 patients with cerebral palsy.

Spine Deform 2020 12 27;8(6):1305-1312. Epub 2020 Jul 27.

Division of Orthopedics and Scoliosis, Rady Children's Hospital, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA.

Study Design: Observational.

Objectives: To report on the rate of major complications following spinal fusion and instrumentation to treat spinal deformity in patients with cerebral palsy (CP). Understanding the risk of major complications following the surgical treatment of spine deformities in patients with CP is critical.

Methods: A prospectively collected, multicenter database of patients with CP who had surgical correction of their spinal deformity (scoliosis or kyphosis) was reviewed for all major complications. Patients with ≥ 2 year follow-up or who died ≤ 2 years of surgery were included. A complication was defined as major if it resulted in reoperation, re-admission to the hospital, prolongation of the hospital stay, was considered life-threatening, or resulted in residual disability. Overall complication and revision rates were calculated for the perioperative (Peri-op; occurring ≤ 90 days postoperative) and delayed postoperative (Delayed; > 90 days) time periods.

Results: Two hundred and fifty-seven patients met inclusion. Seventy-eight (30%) patients had a major complication, 18 (7%) had > 1. There were 92 (36%) major complications; 64 (24.9%) occurred Peri-op. The most common Peri-op complications were wound (n = 16, 6.2%) and pulmonary issues (n = 28, 10.9%), specifically deep infections (n = 12, 4.7%) and prolonged ventilator support (n = 21, 8.2%). Delayed complications (n = 28, 10.9%) were primarily deep infections (n = 8, 3.1%) and instrumentation-related (n = 6, 2.3%). There were 42 additional surgeries for an overall unplanned return to the operating room rate of 16% (Peri-op: 8.6%, Delayed: 7.8%). Thirty-six (14.0%) reoperations were spine related surgeries (wound or instrumentation-related). Eleven (4.3%) patients died between 3 months to 5.6 years postoperatively; 4 occurred ≤ 1 year of surgery. Two deaths were directly related to the spinal deformity surgery.

Conclusion: Spinal deformity surgery in CP patients with greater than 2 years of follow-up have a postoperative major complication rate of 36% with a spine-related reoperation rate of 14.0%.

Level Of Evidence: Therapeutic-IV.
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http://dx.doi.org/10.1007/s43390-020-00165-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7384279PMC
December 2020

Comparing short-term AIS post-operative complications between ACS-NSQIP and a surgeon study group.

Spine Deform 2020 12 27;8(6):1247-1252. Epub 2020 Jul 27.

Rady Children's Hospital, Encinitas, USA.

Study Design: Prospective cohort review.

Objective: To compare two AIS databases to determine if a performance improvement-based surgeon group has different outcomes compared to a national database. The American College of Surgeon's National Quality Improvement Program (ACS-NSQIP) and a surgeon study group (SG) collect prospective data on AIS surgery outcomes. NSQIP offers open enrollment to all institutions, and SG membership is limited to 15 high-volume institutions, with a major initiative to improve surgeon performance. While both provide important outcome benchmarks, they may reflect outcomes that are not relatable nationwide.

Methods: The ASC-NSQIP Pediatric Spine Fusion and SG database were queried for AIS 30- and 90-day complication data for 2014 and 2015. Prospective enrollment and a dedicated site coordinator with rigorous data quality assurance protocols existed for both registries. Outcomes were compared between groups with respect to superficial and deep surgical site infections (SSI), neurologic injury, readmission, and reoperation.

Results: There were a total of 2927 AIS patients included in the ASC-NSQIP data and 721 in the SG database. Total complication rate was 9.4% NSQIP and 3.6% SG. At 90 days, there were fewer surgical site infections reported by SG than ASC-NSQIP (0.6% vs. 1.6%, p = 0.03). Similarly, there were less spinal cord injuries (0.8% vs 1.5%, p = 0.006), 30-day readmissions (0.8% vs. 2.6%, p = 0.002), and 30-day reoperations (0.6% vs. 1.7%, p = 0.02) in the SG cohort.

Conclusions: Comparison of these two data sets suggests a range of complications and readmission rates, with the SG demonstrating lower values. These results are likely multi-factorial with the performance improvement initiative of the SG playing a role. Understanding the rate and ultimate risk factors for readmission and complications from big data sources has the potential to further drive quality improvement.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s43390-020-00170-wDOI Listing
December 2020

Single-Staged Management of Pediatric Neuropathic Scoliosis with Intradural-Extramedullary Schwannoma and Improvement in Intraoperative Neuromonitoring: A Case Report.

JBJS Case Connect 2020 Apr-Jun;10(2):e0352

1Departments of Orthopaedic Surgery and Neurosurgery, Shriners Hospitals for Children-Philadelphia, Philadelphia, Pennsylvania 2Division of Intraoperative Neuromonitoring, SpecialtyCare, Brentwood, Tennessee.

Case: A 16-year-old girl with lumbar prominence presented to our outpatient clinic complaining of sporadic back pain without paresthesia. Radiographic investigation revealed a 68° left thoracolumbar curve with the apex at L1. Preoperative magnetic resonance imaging identified a mass at T10-11, subsequently confirmed by pathology as a schwannoma. She was treated surgically with resection and posterior spinal fusion in a single-staged procedure under neuromonitoring guidance. Intraoperative improvement in motor evoked potentials after resection informed the decision to perform simultaneous deformity correction.

Conclusion: We discuss the unusual coincidence of a schwannoma with scoliosis and our management algorithm based on operative changes in neuromonitoring.
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http://dx.doi.org/10.2106/JBJS.CC.19.00352DOI Listing
February 2021

Novel Use of Subcostal Polyethylene Bands to Manage Tumor-Related Scoliosis Requiring Serial Imaging: A Case Report.

JBJS Case Connect 2020 Jan-Mar;10(1):e0351

Departments of Orthopaedic Surgery and Neurosurgery, Shriners Hospitals for Children-Philadelphia, Philadelphia, Pennsylvania.

Case: A 16-year-old male patient with severe kyphoscoliosis, paraplegia, and neurogenic bowel/bladder caused by a juvenile pilocytic astrocytoma was treated surgically using a hybrid fusion construct with polyethylene bands after neoplasm resection. Owing to the necessity of serial postoperative magnetic resonance imaging studies to evaluate the recurrence of pathology and known effect of metal artifact from spinal instrumentation, preservation of radiographic resolution was critical.

Conclusion: We describe the novel utility of polyethylene bands placed around the ribs as a safe and effective form of hybrid construct for reducing radiographic metal artifact in spinal deformity cases requiring serial imaging.
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January 2021

Of Major Complication Types, Only Deep Infections After Spinal Fusion Are Associated With Worse Health-related Outcomes in Children With Cerebral Palsy.

Spine (Phila Pa 1976) 2020 Jul;45(14):993-999

Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD.

Study Design: Retrospective review.

Objective: The aim of this study was to determine whether major postoperative complications ("complications") are associated with 2-year improvements in Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) scores after scoliosis surgery, and whether complications and preoperative characteristics predict 2-year improvements in CPCHILD Total score.

Summary Of Background Data: Spinal arthrodesis can halt the progression of spinal deformity in patients with cerebral palsy (CP)-related scoliosis. However, these patients are prone to postoperative complications.

Methods: Using a multicenter CP registry, we identified 222 patients aged ≤21 years who underwent spinal fusion from 2008 to 2015 and had ≥2-year follow-up. We compared CPCHILD score improvement between 71 patients who had 1 or more complications ("complications group") versus 151 who did not ("no-complications group"). Complications were deep infections, thromboembolic events, and cardiopulmonary, gastrointestinal, and neurologic complications. Multiple linear regression was used to identify predictors of 2-year postoperative CPCHILD score improvement (alpha = 0.05).

Results: At 2-year follow-up, the complications group had similar mean improvement in CPCHILD score across all domains compared with the no-complications group (P > 0.05). When stratifying by complication type, deep infection was associated with less improvement in CPCHILD Comfort and Emotions (P = 0.02), Quality of Life (P < 0.01), and Total (P = 0.04) scores. When controlling for Gross Motor Function Classification System subcategory, age, and body mass index, only preoperative CPCHILD Total score and postoperative deep infection (F[4, 176] = 14; P < 0.0001; R = 0.24) predicted 2-year improvement in CPCHILD Total score. Higher preoperative Total score and postoperative deep infection independently predicted less improvement in Total score.

Conclusion: Postoperative deep infection and higher preoperative CPCHILD Total score independently predicted less improvement in CPCHILD Total score. Other major postoperative complications were not associated with differences in 2-year postoperative improvements in CPCHILD scores across all domains.

Level Of Evidence: 3.
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July 2020

Early and late hospital readmissions after spine deformity surgery in children with cerebral palsy.

Spine Deform 2020 06 4;8(3):507-516. Epub 2020 Mar 4.

Shriners Hospitals for Children-Philadelphia, 3551 N Broad Street, Philadelphia, PA, 19140, USA.

Study Design: Retrospective review of a prospectively collected multicenter registry of pediatric patients with cerebral palsy (CP) and neuromuscular scoliosis (NMS) undergoing spinal fusion.

Objective: To define risk factors for unplanned readmission after elective spinal deformity surgery. Patients with CP and NMS have high rates of hospital readmission; however, risk factors for readmission are not well established.

Methods: Univariate and multivariate analyses were used to compare the demographics, operative and postoperative course, radiographic characteristics, and preoperative Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaires of patients who did not require readmission to those who required either early readmission (within 90 days of the index surgery) or late readmission (readmission after 90 days).

Results: Of the 218 patients identified, 19 (8.7%) required early readmission, while 16 (7.3%) required late readmission. Baseline characteristics were similar between the three cohorts. On univariate analysis, early readmission was associated with longer duration of surgery (p < 0.001) and larger magnitude of residual deformity (p = 0.003 and p = 0.029 for postoperative major and minor angles, respectively). The health score of the CPCHILD Questionnaire was lower in patients who required early readmission than in those who did not require readmission (p = 0.032). On multivariate analysis, oral feeding status was inversely related to early readmission (less likely to require readmission), while decreasing lumbar lordosis and increasing length of surgery were related to an increased likelihood of early readmission.

Conclusions: In patients with CP and NMS, longer surgical time, larger residual major and minor Cobb angles, lumbar lordosis, feeding status, and overall health may be related to a greater likelihood for early hospital readmission after elective spinal fusion. No factors were identified that correlated with an increased need for late hospital readmission after elective spinal fusion in patients with CP.

Level Of Evidence: IV.
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June 2020

The variability in the management of acute surgical site infections: an opportunity for the development of a best practice guideline.

Spine Deform 2020 06 19;8(3):463-468. Epub 2020 Feb 19.

Division of Orthopedics & Scoliosis, Rady Children's Hospital, 3030 Children's Way, MC5062, San Diego, CA, 92123, USA.

Background: Multiple studies have reported on the risks and preventative measures associated with acute surgical site infection (SSI) in patients with adolescent idiopathic scoliosis (AIS). Few studies have evaluated treatment and results. The purpose of this study was to evaluate the need for development of best practice guidelines based on the management of an acute SSI across 9 different centers.

Methods: A prospectively collected, multicenter database of patients undergoing surgical correction of AIS was reviewed for all acute SSI. Infection characteristics, treatment methods, and outcomes were summarized.

Results: Twenty-three (0.6%) from a total of 3926 AIS patients were treated for an acute SSI, all of which resolved. Twenty patients had documentation of the infection treatment (10 deep infections, 10 superficial). All ten patients with deep infections underwent operative incision and drainage. Six patients ultimately found to have a superficial infection underwent I&D and another 3 had dressing changes in the office. In the deep group, one patient had instrumentation exchanged and seven patients had bone graft removed. All 16 patients who underwent operative I&D had cultures obtained with 11 positive cultures. All deep infection patients were started on IV antibiotics for 2 days to 6 weeks prior to conversion to oral antibiotics. Five of six operative superficial infections were begun on IV antibiotics with conversion to oral antibiotics. Total antibiotic administration ranged from 5 days to 7 months in the deep infection group and 1 to 6 weeks in the superficial group.

Conclusions: While deep infections are consistently treated with I&D, there is significant variability in the surgical and medical management of acute SSI. Considering the universal resolution of the infection, there is opportunity for the development of BPG to minimize treatment morbidity and cost, while optimizing outcomes for this major complication.

Level Of Evidence: Therapeutic-IV.
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http://dx.doi.org/10.1007/s43390-020-00079-4DOI Listing
June 2020

Preoperative SRS pain score is the primary predictor of postoperative pain after surgery for adolescent idiopathic scoliosis: an observational retrospective study of pain outcomes from a registry of 1744 patients with a mean follow-up of 3.4 years.

Eur Spine J 2020 04 28;29(4):754-760. Epub 2020 Jan 28.

Department of Orthopaedic Surgery, Shriners Hospitals for Children-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA.

Background: Traditionally, adolescent idiopathic scoliosis (AIS) has not been associated with back pain, but the increasing literature has linked varying factors between pain and AIS and suggested that it is likely underreported.

Purpose: Our objective was to investigate factors associated with post-op pain in AIS.

Methods: A prospectively collected multicenter registry was retrospectively queried. Pediatric patients with AIS having undergone a fusion with at least 2 years of follow-up were divided into two groups: (1) patients with a postoperative SRS pain score ≤ 3 or patients having a reported complication specifically of pain, and (2) patients with no pain. Patients with other complications associated with pain were excluded.

Results: Of 1744 patients, 215 (12%) experienced back pain after postoperative recovery. A total of 1529 patients (88%) had no complaints of pain, and 171 patients (10%) had pain as a complication, with 44 (2%) having an SRS pain score ≤ 3. The mean time from date of surgery to the first complaint of back pain was 25.6 ± 21.6 months. In multivariate analysis, curve type (16% of Lenke 1 and 2 curves vs. 10% of Lenke 5 and 6, p = 0.002) and a low preoperative SRS pain score (no pain 4.15 ± 0.67 vs. pain 3.75 ± 0.79, p < 0.001) were significant. When comparing T2-4 as the upper instrumented vertebrae in a subgroup of Lenke 1 and 2 curves, 9% of patients had pain when fused to T2, 13% when fused to T3, and 18% when fused to T4 (p = 0.002).

Conclusion: 12% of all AIS patients who underwent fusion had back pain after postoperative recovery. The most consistent predictive factor of increased postoperative pain across all curve types was a low preoperative SRS pain score. These slides can be retrieved under Electronic Supplementary Material.
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http://dx.doi.org/10.1007/s00586-020-06293-yDOI Listing
April 2020

Diffuse intrinsic pontine gliomas: Diagnostic approach and treatment strategies.

J Clin Neurosci 2020 Feb 20;72:15-19. Epub 2019 Dec 20.

Division of Pediatric Neurosurgery, Department of Neurosurgery, UT Southwestern Medical Center, Dallas, TX, United States; Department of Neurosurgery, University of Pennsylvania Hospital, United States.

Diffuse intrinsic pontine gliomas (DIPG) are high grade gliomas of the brainstem with fatal outcomes. Radiation is known to be partially effective to control the immediate flare but relapse is frequent. There has been ongoing research to study the role of molecular subgroups and identification of specific targets but this is not possible with histopathological diagnosis alone. The authors' objective is to highlight the need for and discuss ongoing molecular research. There is an inherent need for the availability of tumor tissue to be able to conduct research studies. The authors advocate the use of neuronavigation assisted stereotactic technique for tumor biopsy. The technique is feasible with a predefined surgical trajectory. After obtaining tissue diagnosis further work can be performed to isolate and identify histone protein genetic mutations and methylation changes responsible for DIPG molecular subgrouping. Moreover, convection enhanced delivery of therapeutic agents is being developed for better instillation of future drug agents. Despite identification of genetic/epigenetic mutations, growth factors, receptors, and tissue biomarkers, the oncogenesis of DIPG remains elusive. The authors' effort to provide a comprehensive review on DIPG to better understand the disease, need for tissue diagnosis, described surgical technique, and need for pre-clinical and clinical future research is novel.
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http://dx.doi.org/10.1016/j.jocn.2019.12.001DOI Listing
February 2020

Do seizures compromise correction maintenance after spinal fusion in cerebral palsy scoliosis?

J Pediatr Orthop B 2020 Nov;29(6):538-541

Johns Hopkins University, Baltimore, Maryland.

Seizure disorder in cerebral palsy (CP) has been described as a risk factor for postoperative complications after posterior spinal fusion. However, the effect of seizures on the maintenance of curve correction has not been reported. The aim of this study is to investigate associations between seizure history and maintenance of curve correction after posterior spinal fusion in children with CP. We analyzed records of 201 children with CP who underwent posterior spinal fusion with two-year follow-up. Patients were classified as having no seizures (31%); controlled seizures (54%); or poorly controlled seizures (PCS, 15%). Perioperative data, radiographic measurements, and complications were compared between groups. Groups were similar in operative time, estimated blood loss, and rates of deep wound infection and implant-related complications. The PCS group had a higher rate of respiratory complications (27%) than the no seizures (10%; P = 0.03) and controlled seizures (12%; P = 0.04) groups. Controlled seizures and PCS groups had longer ICU stays than the no seizures group (P= 0.02 and P= 0.04). Major coronal curve and pelvic obliquity were corrected significantly in all groups, and correction was maintained at 2 years. Loss of correction during follow-up was similar between groups. Although seizures were associated with longer ICU stays and more respiratory complications, there was no association between seizure history and loss of curve correction at two years of follow-up after CP scoliosis surgery.
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http://dx.doi.org/10.1097/BPB.0000000000000705DOI Listing
November 2020

Lower SRS Mental Health Scores are Associated With Greater Preoperative Pain in Patients With Adolescent Idiopathic Scoliosis.

Spine (Phila Pa 1976) 2019 Dec;44(23):1647-1652

Shriners Hospitals for Children-Philadelphia, Philadelphia, PA 19140.

Study Design: Retrospective review of a prospectively collected multicenter database.

Objective: The aim of this study was to investigate factors associated with low preoperative SRS pain scores.

Summary Of Background Data: The prevalence of preoperative pain in patients with adolescent idiopathic scoliosis (AIS) has become increasingly evident and is a primary concern for patients and families. Greater preoperative pain is associated with more postoperative pain; however, less is understood about what contributes to preoperative pain.

Methods: A prospectively collected, multicenter database was queried for patients with AIS. Patients were divided into 2 cohorts based on preoperative SRS pain scores: ≤ 3 (Pain cohort), 4 to 5 (No Pain cohort). Univariate analysis was performed identifying which factors were associated with a low preoperative SRS score and used for a CART analysis.

Results: Of 2585 patients total, 2141 (83%) patients had SRS pain scores of 4 to 5 (No Pain) and 444 (17%) had SRS pain scores ≤3 (Pain). Female sex, older age, greater % body mass index, larger lumbar curves, greater T5-12 kyphosis, and lower mental health scores were associated with greater preoperative pain. In multivariate CART analysis, lower mental health SRS scores (P = 0.04) and older age (P = 0.003) remained significant, with mental health scores having the greatest contribution. In subdividing the mental health component questions, anxiety-related questions appeared to have the greatest effect followed by mood/depression (SRS Question 13: OR 2.04; Q16: OR 1.35; Q7: OR 1.31; Q3: OR 1.20).

Conclusion: Anxiety and mood are potentially modifiable risk factors that have the greatest impact on pre- and postoperative pain. These results can be used to identify higher-risk patients and develop preoperative therapeutic protocols to improve postoperative outcomes.

Level Of Evidence: 3.
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December 2019

Thirty-day readmission risk after intracranial tumor resection surgeries in children.

J Neurosurg Pediatr 2020 02 1;25(2):97-208. Epub 2019 Nov 1.

1Division of Pediatric Neurosurgery, Department of Neurosurgery, UT Southwestern Medical Center, Dallas, Texas.

Objective: The risk of readmission after brain tumor resection among pediatric patients has not been defined. The authors' objective was to evaluate the readmission rates and predictors of readmission after pediatric brain tumor resection.

Methods: Nationwide Readmissions Database (NRD) data sets from 2010 to 2014 were searched for unplanned readmissions within 30 days of the discharge date after pediatric brain tumor resection. Patient demographic variables included sex, age, expected payment source (Medicaid or private insurance), and median annual household income. Readmission events for chemotherapy, radiation therapy, or further tumor resection were not included.

Results: Of 282 patients (12.7%) readmitted within 30 days of the index event, the median time to readmission was 10 days (IQR 5-19 days). The most common reason for readmission was hydrocephalus, which accounted for 19% of readmission events. Other CNS-related complications (24%), surgical site infections or septicemia (14%), seizures (7%), and hematological disorders (7%) accounted for other major readmission events. The median charge for readmission events was $35,431, and the median length of readmission stay was 4 days. In multivariate regression, factors associated with a significant increase in readmission risk included Medicaid as the primary payor, discharge from the index event with home health services, and fluid and electrolyte disorders during the index event.

Conclusions: More than 10% of pediatric brain tumor patients have unplanned readmission events within 30 days of discharge after tumor resection. Medicaid patients and those with preoperative or early postoperative fluid and electrolyte disturbances may benefit from early or frequent outpatient visits after tumor resection.
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http://dx.doi.org/10.3171/2019.7.PEDS19272DOI Listing
February 2020

The Role of Cross-Links in Posterior Spinal Fusion for Cerebral Palsy-Related Scoliosis.

Spine (Phila Pa 1976) 2019 Nov;44(21):E1256-E1263

Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD.

Study Design: Retrospective review of a multicenter, prospective database.

Objective: Our aim was to compare complication rates and maintenance of radiographic correction at 2 years after posterior spinal fusion (PSF) with or without cross-links in patients with cerebral palsy (CP)-related scoliosis.

Summary Of Background Data: Cross-links are frequently used in PSF to correct scoliosis in patients with CP because they are thought to increase the stiffness and torsional rigidity of the construct.

Methods: We reviewed the records of patients with CP who underwent primary PSF with or without cross-links between August 2008 and April 2015. Inclusion criteria were minimum follow-up of 2 years, availability of complications data (implant failure, surgical site infection, revision), and pre- and postoperative measurements of the major curve (measured using the Cobb method). The 256 patients included in this analysis had a mean age of 14.1 ± 2.7 years. Ninety-four patients had cross-links (57% using one cross-link; 43% using two cross-links) and 162 patients did not have cross-links. P < 0.05 was considered statistically significant.

Results: The two groups did not differ significantly with regard to sex, age at surgery, preoperative menarche status, Gross Motor Function Classification System level, major curve magnitude, pelvic obliquity, kyphosis, and lordosis angles. There were no significant differences between groups in the correction achieved or the maintenance of correction at 2 years for the major curve, pelvic obliquity, kyphosis, or lordosis (all P > 0.05). Complication rates were similar between the cross-link group (16%, N = 15) and the non-cross-link group (14%, N = 22).

Conclusion: At 2 years after PSF to treat CP-related scoliosis, patients had no significant differences in the degree of correction achieved, the maintenance of correction, or the rate of complications between those whose fusion constructs used cross-links and those whose constructs did not.

Level Of Evidence: 3.
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November 2019

Occipital neuralgia: A neurosurgical perspective.

J Clin Neurosci 2020 Jan 9;71:263-270. Epub 2019 Oct 9.

Department of Orthopedic Surgery, University of Pennsylvania Hospital System, Philadelphia, PA, United States.

Occipital neuralgia typically arises in the setting of nerve compression by fibrosis, surrounding anatomic structures, or osseous pathology, such as bone spurs or hypertrophic atlanto-epistropic ligament. It generally presents as paroxysmal bouts of sharp pain in the sensory distribution of the first three occipital nerves. Due to the long course of the greater occipital nerve (GON), and its peculiar anatomy, and location in a mobile region of the neck, it is unsurprising that the GON is at high risk for compression. Little is known how to diagnose or treat this neuropathic pain syndrome. The objective of this paper is to isolate the etiology involved, and treat this condition promptly. After all nonoperative efforts are exhausted, surgical transection of the nerve is the treatment of choice in these cases. An isolated C2 neurectomy or ganglionectomy is performed for an optimal pain relief. C1-2 instrumented fusion can be considered if, extensive facet arthropathy with instability is identified. Authors review the spectrum of treatment options for this debilitating condition, and discuss the case example of a patient who required conversion to a C1-C2 instrumented fusion following C2 ganglionectomy due to an underlying extensive degenerative disease and intraoperative findings suggestive of atlantoaxial instability.
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January 2020

Antifibrinolytic Therapy in Surgery for Adolescent Idiopathic Scoliosis Does the Level 1 Evidence Translate to Practice?

Bull Hosp Jt Dis (2013) 2018 Sep;76(3):165-170

Introduction: Previous randomized controlled trials have demonstrated the efficacy of antifibrinolytic agents in the reduction of intraoperative blood loss in adolescent idiopathic scoliosis (AIS) surgery. Tranexamic acid (TXA) was found to be more effective at reducing total blood loss compared with epsilon-aminocaproic acid (AM) than placebo. We set out to study whether or not the level 1 evidence can be corroborated in a large multicenter, multisurgeon cohort.

Methods: Estimated blood loss (EBL), cell saver transfused, and percent of total blood volume (%EBL) was retrospectively assessed from a prospective-collected multicenter AIS registry. Volume of allogeneic blood transfusion data was not uniformly available. The cohort was divided into: 1. TXA (N = 525; 2006-2014), 2. Amicar (N = 117; 2005- 2014), and 3. no antifibrinolytic (N = 1127; 2005-2013) groups. Comparisons between the three groups and between antifibrinolytic (Amicar or TXA) versus no antifibrinolytic (NA) groups were performed using ANOVA with Bonferroni correction and the t-test, respectively. Multivariate analysis was used to control for surgical and surgeon factors.

Results: EBL, %EBL, and cell saver transfused was significantly lower in TXA (742.3 mL, 21.3% and 191.8 mL, respectively) than NA (1,010.6 mL, 29.8% and 276.6 mL, respectively) and AM (1,420.6 mL, 38.9% and 456.0 mL, respectively), (p < 0.0001), with AM having the greatest values among the three groups. These parameters were normalized by number of levels fused and Cobb magnitude. A similar pattern was observed, with AM having the highest normalized values and TXA group the lowest among all three groups. After further controlling for surgeon, total operative time, and osteotomy performed, multivariable analysis revealed that EBL/level, %EBL/level, and cell saver/level transfused were significantly lower in the TXA group compared to the NA group (p = 0.0014, p = 0.0058, and p = 0.0031, respectively), whereas, no difference was observed between the AM and NA groups (p = 0.1028, p = 0.2523, and p = 0.5274, respectively). The differences between TXA and AM were diminished (p = 0.5512, p = 0.6751, and p = 0.0978, respectively).

Conclusion: Intraoperative administration of TXA significantly reduces EBL, %EBL, and cell saver transfused during AIS surgery. After taking operative and surgeon factors into consideration, %EBL was not significantly different between TXA and Amicar groups in the practice setting.
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September 2018

L3 translation predicts when L3 is not distal enough for an "ideal" result in Lenke 5 curves.

Eur Spine J 2019 06 12;28(6):1349-1355. Epub 2019 Apr 12.

Rady Children's Hospital, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA.

Purpose: Determining whether to fuse a Lenke 5 curve to L3 or to L4 is often a difficult decision. The purpose of this study was to determine preoperative variables predictive of an "ideal" or "less than ideal" outcome for Lenke 5 curves instrumented to L3.

Methods: A multicentre registry of adolescent idiopathic scoliosis patients was queried for surgically treated Lenke 5 curves with a lowest instrumented vertebra (LIV) of L3 and minimum 2 years of follow-up. Five seasoned surgeons qualitatively rated the 2-year postoperative images as "ideal" or "less than ideal" with respect to correction and alignment. Preoperative and postoperative radiographic variables were compared between the two groups. Multivariate regression analysis was performed to determine variables most predictive of a "less than ideal" outcome.

Results: One hundred and thirty-nine patients met criteria. Twenty-three were considered "less than ideal" by ≥ 3 surgeons; 81 were unanimously "ideal". Preoperatively, the "less than ideal" group had significantly stiffer curves, greater apical translation, and greater LIV angulation and translation. Multivariate regression found that preoperative L3 translation (p = 0.009) was the single most important predictor of a "less than ideal" outcome: < 3.5 cm consistently resulted in an "ideal" outcome, while > 3.5 cm risked a "less than ideal" result.

Conclusion: While multiple variables are important in achieving an "ideal" outcome in Lenke 5 curves, this study found preoperative L3 translation was the most important predictor of success with an L3 translation < 3.5 cm being a potential threshold for selecting L3 as the LIV. These slides can be retrieved under Electronic Supplementary Material.
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June 2019

Predictors of 90-Day Readmission in Children Undergoing Spinal Cord Tumor Surgery: A Nationwide Readmissions Database Analysis.

World Neurosurg 2019 Jul 1;127:e697-e706. Epub 2019 Apr 1.

Department of Pediatric Neurosurgery, UT Southwestern Medical Center, Dallas, Texas, USA.

Objective: A fair number of hospital admissions occur after 30 days; thus, the true readmission rate could have been underestimated. Therefore, we hypothesized that the 90-day readmission rate might better characterize the factors contributing to readmission for pediatric patients undergoing spinal tumor resection.

Methods: The Nationwide Readmissions Database was used to study the patient demographic data, comorbidities, admissions, hospital course, spinal tumor behavior (malignant vs. benign), complications, revisions, and 30- and 90-day readmissions.

Results: Of the 397 patients included in the 30-day cohort, 43 (10.8%) had been readmitted. In comparison, the 90-day readmission rate was significantly greater; 52 of 325 patients were readmitted (16.0%; P < 0.04). Patients aged 16-20 constituted the largest subgroup. However, the highest readmission rate was observed for patients aged <5 years (30-day, 21.7%; 90-day, 26.4%). Medicaid patients were more likely to be readmitted than were private insurance patients (30-day odds ratio [OR], 3.3 [P < 0.001]; 90-day OR, 2.29 [P < 0.02]). In both cohorts, patients with malignant tumors required readmission more often than did those with benign tumors (30-day OR, 2.78 [P < 0.02]; 90-day OR, 1.92 [P = 0.08]). In the 90-day cohort, the patients had been readmitted 26.4 days after discharge versus 10.6 days in the 30-day cohort. Within the 90-day cohort, 18.6% of the readmissions were for spinal reoperation, 28.3% for chemotherapy or hematologic complications, and 25.6% for other central nervous system disorders. The median charges for each readmission were ∼$50,000 and ∼$40,000 for the 30- and 90-day cohorts, respectively. Medicaid insurance, malignant tumors, and younger age were significant predictors of readmission in the 90-day cohort.

Conclusions: The prevalence and charges associated with unplanned hospital readmissions after spinal tumor resection were remarkably high. Younger age, Medicaid insurance, malignant tumors, and complications during the initial admission were significant predictors of 90-day readmission.
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http://dx.doi.org/10.1016/j.wneu.2019.03.245DOI Listing
July 2019