Publications by authors named "Carrie E Bartley"

46 Publications

Perioperative and Delayed Major Complications Following Surgical Treatment of Adolescent Idiopathic Scoliosis.

J Bone Joint Surg Am 2017 Jul;99(14):1206-1212

1Rady Children's Hospital, San Diego, California 2Nemours Alfred I. duPont Hospital for Children, Wilmington, Delaware 3Scoliosis and Spine Associates, New York, NY 4Nicklaus Children's Hospital, Miami, Florida 5British Columbia Children's Hospital, Vancouver, British Columbia, Canada 6Shriner's Hospitals for Children Philadelphia, Philadelphia, Pennsylvania.

Background: Reporting accurate surgical complication rates to patients and their families is important in the management of adolescent idiopathic scoliosis (AIS). In this study, we report the rate of major complications following the surgical treatment of AIS both in the perioperative period and among patients with a minimum of 2 years of follow-up.

Methods: We reviewed the prospectively collected data of a multicenter registry of patients who underwent surgical treatment of AIS during the period of 1995 to 2014 in order to identify all complications. A complication was defined as "major" if it resulted in reoperation or in spinal cord or nerve root injury, or was life-threatening. A total of 3,582 patients with preoperative and early postoperative data (4 to 6 weeks of follow-up) were included. A subset of 2,220 patients with a minimum of 2 years of follow-up comprised the cohort for delayed complications. Overall complication rates were calculated, as was the percentage of complications according to the year of the index surgery and type of surgical approach.

Results: The mean age of the 3,582 patients at the time of surgery was 14.8 ± 2.2 years. The average major curve magnitude was 56° ± 13° for thoracic curves and 51° ± 11° for lumbar. In 365 patients, anterior spinal fusion (ASF) with instrumentation was performed, and in 3,217 patients, posterior spinal fusion (PSF) with instrumentation was performed; 142 patients in the PSF group underwent concomitant anterior release. There were 192 major complications, with 93 (2.6%) occurring perioperatively. Perioperative complications included wound-related (1.0% of the patients), neurologic (0.5%), pulmonary (0.4%), instrumentation-related (0.4%), and gastrointestinal (0.2%) complications. One patient died. The mean annual perioperative major complication rate based on the year of surgery ranged from 0% to 10.5%. The complication rate by surgical approach was 3.0% for ASF and 2.6% for PSF (2.4% for PSF only and 5.6% for PSF with anterior release). The major complication rate for the 2,220 patients with at least 2 years of follow-up was 4.1%; all but 1 had a reoperation (4.1%). The majority of these major complications were wound and instrumentation-related (1.9% and 0.8%, respectively).

Conclusions: After surgery for AIS, a 2.6% rate of perioperative major complications and a 4.1% rate of major complications at 2 or more years after surgery can be anticipated. The complication rate decreased over the period of study.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.16.01331DOI Listing
July 2017

Selective thoracic fusion of a left decompensated main thoracic curve: proceed with caution?

Eur Spine J 2018 02 10;27(2):312-318. Epub 2017 Jun 10.

Rady Children's Hospital, 3030 Children's Way, Suite 410, San Diego, CA, 92123, USA.

Purpose: Previous research has shown that with certain idiopathic scoliosis curve types, performing a selective thoracic fusion (STF) is associated with an increased risk of coronal decompensation post-operatively. The purpose of the current study was to determine the influence of curve correction and fusion level on post-operative balance in STF for adolescent idiopathic scoliosis patients with pre-operative coronal decompensation.

Methods: A multicenter database was queried for subjects with right Lenke 1-4C curves, pre-operative left coronal imbalance, and 2-year follow-up who underwent STF (caudal fusion level of L1 or proximal). Rates of decompensation were compared between groups with different levels of fusion. Thoracic and lumbar curve correction as well as Scoliosis Research Society-22 outcome scores were compared between groups that were post-operatively balanced or persistently decompensated.

Results: 121 patients were identified with average thoracic and lumbar curves of 53° and 41°. Mean pre- and post-operative decompensations were 2.4 ± 1.0 and 1.8 ± 1.1 cm, respectively. Eighteen patients were fused short, 62 to, and 41 were fused past the stable vertebra. Ten patients were fused short, 32 to, and 78 were fused past the neutral vertebra. Incidence of post-operative decompensation was 41%. No differences in post-operative decompensation relative to the stable or neutral vertebra were noted (p = 0.66, p = 0.74). Post-operatively, those patients who were balanced had similar thoracic curve correction (58%) to those decompensated (54%, p = 0.11); however, patients balanced post-operatively had greater SLCC (45 vs 40%, p = 0.04). No differences in SRS-22 outcome scores were noted between groups (p > 0.05).

Conclusions: There was a high rate of post-operative decompensation in patients with pre-operative coronal decompensation undergoing STF. Fusion to or past the stable or neutral vertebra did not affect the risk of persistent decompensation. Attempts to improve SLCC could reduce post-operative decompensation.
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http://dx.doi.org/10.1007/s00586-017-5158-8DOI Listing
February 2018

Predictors of Distal Adding-on in Thoracic Major Curves With AR Lumbar Modifiers.

Spine (Phila Pa 1976) 2017 Feb;42(4):E211-E218

Department of Orthopedics, Rady Children's Hospital, San Diego, CA.

Study Design: Retrospective review of prospectively collected data.

Objective: To determine whether the last substantially touched vertebra (LSTV) is a valid lowest instrumented vertebra (LIV) for both Lenke 1 and 2 curve patterns with AR lumbar modifiers, and to identify preoperative risk factors of distal adding-on.

Summary Of Background Data: Previous studies have recommended selecting the LSTV as the LIV for Lenke 1AR curves (main thoracic curve with A lumbar modifier and L4 tilt to the right (thoracic overhang/King type IV curve).

Methods: One-hundred sixty patients with a Lenke 1 or 2 curve pattern and AR lumbar modifier who underwent posterior spinal fusion between 2008 and 2012 were reviewed. All patients had minimum 2-year follow up. Patients were identified with distal adding-on between first erect radiographs and 2-year follow up based on previously defined parameters. Factors predictive of the adding-on phenomenon were identified in a multivariate binary logistic regression model.

Results: Twenty-seven patients (17%) were identified as having distal adding-on of their primary thoracic curve; however, only 8 of 89 patients (9%) fused to the LSTV developed adding-on (P = 0.005). Three variables were found to be significant predictors of adding-on: LIV proximal to LSTV (odds ratio, OR 3.63; P = 0.01), Risser zero (OR 4.93; P = 0.02), and C7-CSVL distance <2 cm (OR 3.97; P = 0.01). The risk of adding-on increased as the number of predictors increased from 16% with one risk factor to 80% when all three preoperative risk factors were present (P < 0.001).

Conclusion: Choosing the LSTV as the LIV in Lenke 1 and 2 curve patterns with an AR lumbar modifier significantly decreases the risk of distal adding-on. Skeletally immature patients, those fused short of LSTV, and those with relative coronal balance preoperatively are at increased risk of distal adding-on between the initial postoperative visit and 2-year follow up.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000001761DOI Listing
February 2017

New EOS Imaging Protocol Allows a Substantial Reduction in Radiation Exposure for Scoliosis Patients.

Spine Deform 2016 Mar 2;4(2):138-144. Epub 2016 Feb 2.

Department of Orthopedics, Rady Children's Hospital, 3030 Children's Way, San Diego, CA 92123, USA.

Study Design: Prospective.

Objective: To evaluate the reliability of three-dimensional (3D) spinal models from Micro Dose EOS x-rays compared to standard, Low Dose EOS x-rays utilized for evaluating patients with adolescent idiopathic scoliosis (AIS).

Summary Of Background Data: There is a strong suggestion that radiation exposure to scoliosis patients can be further reduced.

Methods: Sixty AIS patients who received biplanar, posteroanterior, and lateral standard Low Dose spine x-rays in our EOS imaging unit (∼0.33 mGy) as part of routine care also underwent an additional set of new reduced "Micro Dose" EOS x-rays (∼0.05 mGy) using a recently developed protocol. Two measurers created 3D models of the images using sterEOS software (Low Dose x2, Micro Dose x2). From this 3D modeling software, coronal Cobb angles, sagittal (T1-T12, T4-T12, L1-L5, L1-S1), and apical axial rotation measurements were obtained. Intraclass correlations (ICCs) and standard error of measurement (upper bound of 95% confidence interval) for the differences between Low Dose and Micro Dose measurements were compared. Interrater reliability was assessed on standard two-dimensional (2D) radiographic measurements.

Results: The ICCs were rated as "substantial" to "almost perfect" for Low Dose 3D, Micro Dose 3D, and 2D measures (range 0.78-0.99). The calculated measurement error was not significantly different between groups except for intrarater error on 3D L1-L5 lordosis (2.9° Micro Dose vs. 2.2°, p = .04), interrater 3D rotation of the lumbar apex (2.6° Micro Dose vs. 1.7°, p = .03), and 2D T12-sacrum lordosis (4.6° Micro Dose vs. 3.4°, p = .04).

Conclusions: Although statistically significant differences in average measurement error were observed in lordosis and lumbar apex rotation, these differences are not believed to be clinically significant. The Micro Dose images have slightly less clarity qualitatively, yet the critical 2D and 3D measures of the curvature were reliably measured with error of measurement comparable to standard radiologic techniques.

Level Of Evidence: Level I, Diagnostic.
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http://dx.doi.org/10.1016/j.jspd.2015.09.002DOI Listing
March 2016

The effects of the three-dimensional deformity of adolescent idiopathic scoliosis on pulmonary function.

Eur Spine J 2017 06 11;26(6):1658-1664. Epub 2016 Aug 11.

Rady Children's Hospital, 3030 Children's Way, Suite 410, San Diego, CA, 92123, USA.

Purpose: Utilizing 2D measurements, previous studies have found that in AIS, increased thoracic Cobb and decreased thoracic kyphosis contribute to pulmonary dysfunction. Recent technology has improved our ability to measure and understand the true 3D deformity in AIS. The purpose of this study was to evaluate which 3D radiographic measures predict pulmonary dysfunction.

Methods: One hundred and sixty-three surgically treated AIS patients with preoperative PFTs (FEV, FVC, TLC) and EOS imaging were identified at a single center. Each spine was reconstructed in 3D to obtain the true coronal, sagittal, and apical rotational deformities. These were then correlated with the patient's preoperative PFT measurements. Regression analysis was performed to determine the relative effect of each radiographic measure.

Results: There were 124 thoracic and 39 lumbar major curves. The range of preoperative thoracic and lumbar 3D coronal angle was 11-115° and 11-98°, respectively. The range of preoperative thoracic 3D kyphosis (T5-T12) and thoracic apical vertebral rotation was -56 to 44° and 0-29°, respectively. Increasing thoracic 3D Cobb and thoracic vertebral rotation and decreasing thoracic 3D kyphosis most significantly correlated with decreasing pulmonary function, especially FEV. In patients with the largest degree of thoracic deformity (3D Coronal Cobb > 80°, 3D thoracic lordosis >20°, and absolute apical rotation >25°), the majority of patients had moderate to severe pulmonary impairment (≤65 % predicted). 3D thoracic kyphosis was the most consistent predictor of FEV (r  = 0.087), FVC (r  = 0.069), and TLC (r  = 0.098) impairment.

Conclusions: Larger thoracic coronal, sagittal, and axial deformities increase the risk of pulmonary impairment in patients with AIS. Of these, decreasing 3D thoracic kyphosis is the most consistent predictor. This information can guide surgeons in the decision making process for determining which surgical techniques to utilize and which component of the deformity to focus on.
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http://dx.doi.org/10.1007/s00586-016-4694-yDOI Listing
June 2017

New EOS Imaging Protocol Allows a Substantial Reduction in Radiation Exposure for Scoliosis Patients.

Spine Deform 2016 Mar 30;4(2):138-144. Epub 2016 Dec 30.

Department of Orthopedics, Rady Children's Hospital, 3030 Children's Way, Suite 410, San Diego, CA, 92123, USA.

Study Design: Prospective.

Objective: To evaluate the reliability of three-dimensional (3D) spinal models from Micro Dose EOS x-rays compared to standard, Low Dose EOS x-rays utilized for evaluating patients with adolescent idiopathic scoliosis (AIS). There is a strong suggestion that radiation exposure to scoliosis patients can be further reduced.

Methods: Sixty AIS patients who received biplanar, posteroanterior, and lateral standard Low Dose spine x-rays in our EOS imaging unit (∼0.33 mGy) as part of routine care also underwent an additional set of new reduced "Micro Dose" EOS x-rays (∼0.05 mGy) using a recently developed protocol. Two measurers created 3D models of the images using sterEOS software (Low Dose x2, Micro Dose x2). From this 3D modeling software, coronal Cobb angles, sagittal (T1-T12, T4-T12, L1-L5, L1-S1), and apical axial rotation measurements were obtained. Intraclass correlations (ICCs) and standard error of measurement (upper bound of 95% confidence interval) for the differences between Low Dose and Micro Dose measurements were compared. Interrater reliability was assessed on standard two-dimensional (2D) radiographic measurements.

Results: The ICCs were rated as "substantial" to "almost perfect" for Low Dose 3D, Micro Dose 3D, and 2D measures (range 0.78-0.99). The calculated measurement error was not significantly different between groups except for intrarater error on 3D L1-L5 lordosis (2.9° Micro Dose vs. 2.2°, p =.04), interrater 3D rotation of the lumbar apex (2.6° Micro Dose vs. 1.7°, p =.03), and 2D T12-sacrum lordosis (4.6° Micro Dose vs. 3.4°, p =.04).

Conclusions: Although statistically significant differences in average measurement error were observed in lordosis and lumbar apex rotation, these differences are not believed to be clinically significant. The Micro Dose images have slightly less clarity qualitatively, yet the critical 2D and 3D measures of the curvature were reliably measured with error of measurement comparable to standard radiologic techniques.

Level Of Evidence: Level I, Diagnostic.
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http://dx.doi.org/10.1016/j.jspd.2015.09.002DOI Listing
March 2016

Does Leveling the Upper Thoracic Spine Have Any Impact on Postoperative Clinical Shoulder Balance in Lenke 1 and 2 Patients?

Spine (Phila Pa 1976) 2016 Jul;41(14):1122-1127

Department of Orthopedics, Rady Children's Hospital, San Diego, CA.

Study Design: Retrospective review of prospective data.

Objective: To determine if surgically leveling the upper thoracic spine in patients with adolescent idiopathic scoliosis results in level shoulders postoperatively.

Summary Of Background Data: Research has shown that preoperatively tilted proximal ribs and T1 tilt are more correlated with trapezial prominence than with clavicle angle.

Methods: Prospectively collected Lenke 1 and 2 cases from a single center were reviewed. Clinical shoulder imbalance was measured from 2-year postoperative clinical photos. Lateral shoulder imbalance was assessed utilizing clavicle angle. Medial imbalance was assessed with trapezial angle (TA), and trapezial area ratio (TAR). First rib angle, T1 tilt, and upper thoracic curve were measured from 2-year radiographs. Angular measurements were considered level if ≤ 3° of zero. TAR was considered level if ≤ 1 standard deviation of the natural log of the ratio. Upper thoracic Cobb at 2-years was categorized as at or below the mean value (≤ 14°) versus above the mean.

Results: Eighty-four patients were identified. There was no significant difference in the percentage of patients with a level clavicle angle or TAR based on first rib being level, T1 tilt being level, or upper thoracic Cobb being at/below versus above the mean (P < 0.05). There was a significant difference in the proportion of patients with level TA based on first rib angle (P = 0.006), T1 tilt (P ≤ 0.001), and postoperative upper thoracic Cobb (P = 0.04). The odds ratios of having a level TA were 3.9 (1.4-10.6) if first rib was level, 5 (1.9-12.9) if T1 tilt was level, and 2.6 (1.0-6.3) if postoperative upper thoracic Cobb was ≤ 14°.

Conclusion: Leveling the upper thoracic spine does not guarantee clinically balanced shoulders or clavicles. Trapezial prominence was impacted by leveling T1 and the first rib and by minimizing the upper thoracic curve. How to achieve laterally balanced shoulders postoperatively remains unclear.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000001497DOI Listing
July 2016

Surgical Correction of Scoliosis in Patients With Duchenne Muscular Dystrophy: 30-Year Experience.

J Pediatr Orthop 2017 Dec;37(8):e464-e469

*Department of Orthopedics, Carolinas Medical Center, Charlotte, NC †Orthopedic and Scoliosis Center, Rady Children's Hospital ‡Department of Orthopedic Surgery, University of California, San Diego, CA.

Background: The natural history of scoliosis in Duchenne muscular dystrophy (DMD) is progressive and debilitating if neglected. The purpose of this study was to evaluate outcomes related to spinal deformity surgery in patients with DMD over a 30-year period.

Methods: This was a single center retrospective study of all operatively treated scoliosis in DMD patients over 30 years. Minimum follow-up was 2 years. Owing to changes in instrumentation over time, patients were divided into 2 groups: Luque or pedicle screws (PS) constructs. Radiographic, perioperative variables, pulmonary function test (preoperatively and postoperatively), and complication data were evaluated.

Results: There were 60 subjects (Luque: 47, PS: 13). The Luque group was on average 13 years old, 53 kg, and had 7 years of follow-up. Coronal Cobb was 31±12 degrees preoperatively, 16±11 degrees at first postoperatively, and 21±15 degrees at final follow-up (P≤0.001). Pelvic obliquity was 7±6 degrees preoperatively, 5±5 degrees at first postoperatively (P=0.43), and 5±4 degrees at final follow-up (P=0.77). The majority of this group was fused to L5 (45%) or the sacrum (49%). The PS group was on average 14 years old, 65 kg, and had 4 years of follow-up. Coronal Cobb was 43±19 degrees preoperatively, 12±9 degrees at first postoperatively (P≤0.001), and 12±8 degrees at final follow-up. Pelvic obliquity was 6±5 degrees preoperatively, 3±3 degrees at first postoperatively (P=0.06), and 2±2 degrees at final follow-up (P=0.053). The majority were fused to the pelvis (92%). Both groups' pulmonary function declined with time. Both groups had high complication rates (Luque 68%; PS group 54%). The Luque group had more implant-related complications (26%); the PS group had a higher rate of early postoperative infections (23%).

Conclusions: Over a 30-year period of operative treatment of scoliosis in DMD, both PS constructs and Luque instrumentation improved coronal Cobb. The PS group had improved and maintained pelvic obliquity. Both groups had high complication rates.

Level Of Evidence: Level IV-therapeutic.
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http://dx.doi.org/10.1097/BPO.0000000000000717DOI Listing
December 2017

The 15-Year Evolution of the Thoracoscopic Anterior Release: Does It Still Have a Role?

Asian Spine J 2015 Aug 28;9(4):553-8. Epub 2015 Jul 28.

Department of Orthopedic Surgery, Rady Children's Hospital and Health Center, San Diego, CA, USA. ; Department of Orthopedic Surgery, University of California San Diego, San Diego, CA, USA.

Study Design: Retrospective.

Purpose: To determine how the indications for anterior thoracoscopic release and fusion have evolved over time.

Overview Of Literature: Anterior release was commonly performed to correct severe spinal deformities before the advent of pedicle screw fixation. The thoracoscopic approach significantly reduced the morbidity, as compared to open thoracotomy procedures.

Methods: We reviewed charts and radiographs of pediatric spinal deformity patients who underwent thoracoscopic release/fusion for their deformity from 1994 to 2008. Indications for the thoracoscopic procedure were assigned to one of the following categories: hyperkyphosis, large/stiff scoliosis, crankshaft prevention, and 'other'. We analysed indications grouped in 3-year intervals to determine how the indications for this procedure evolved over the past 15 years.

Results: One hundred and thirty-eight patients (mean age, 15 years; range, 2-28 years) underwent the procedure, with 160 identified indications. The frequency of thoracoscopic anterior release/fusion decreased after peaking in the years 2000-2002. Initially, hyperkyphosis was the most frequent indication (15/33, 45%; 1994-1996), but declined to an intermittent indication since 2006. The use of thoracoscopy to prevent crankshaft has also declined, but remains an indication for the most immature cases (2/17, 12%; 2006-2008). Severe or rigid scoliosis is currently the most common indication for thoracoscopic release/fusion at our center (11/17, 65%; 2006-2008).

Conclusions: The indications for a thoracoscopic anterior release/fusion has evolved with our increased understanding of this procedure and improved posterior fixation with pedicle screw instrumentation. Thoracoscopy in select spinal deformity patients still has an important role despite its less frequent use, as compared to the past decade.
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http://dx.doi.org/10.4184/asj.2015.9.4.553DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4522445PMC
August 2015

Comparison of Typical Thoracic Curves and Atypical Thoracic Curves Within the Lenke 1 Classification.

Spine Deform 2014 Jul 2;2(4):308-315. Epub 2014 Jul 2.

Department of Orthopedic Surgery, Rady Children's Hospital, 3030 Children's Way, Suite 410, San Diego, CA 92123, USA. Electronic address:

Study Design: Retrospective study.

Objectives: To examine the characteristics of Lenke type 1 curves based on the level of the apical vertebra.

Summary Of Background Data: The Lenke classification is the most used system for adolescent idiopathic scoliosis, with approximately 50% of the curves falling into the Lenke 1 curve type category.

Methods: A total of 611 Lenke 1 curves in a prospectively collected multicenter adolescent idiopathic scoliosis study were analyzed. Minimum follow-up was ≥ 2 years. Curves were subdivided into 3 groups according to their apex: the typical Lenke 1 curve group included apices from T7/8 to T10 (511 patients), the proximal group included apices from T4 to T7 (45 patients), and the distal group included apices from T10/11 to T11/12 (50 patients). Preoperative and postoperative radiographic and clinical outcomes were compared among the 3 groups.

Results: The proximal and distal groups included significantly more left thoracic curves (proximal: 29%; typical: 1.8%; distal: 19%; p < .01). Flexibility of the main thoracic curve was significantly different among the 3 groups (proximal: 32% ± 17%; typical: 46% ± 18%; distal: 57% ± 18%; p < .001). The distal group included significantly more "A" lumbar modifiers (proximal: 29%; typical: 53%; distal: 96%; p < .01) and had curves characteristics similar to King type 4 curves (L4 tilted to the right: Lenke 1AR). The average lowest instrumented vertebra was significantly lower in the distal group (proximal: T12; typical: L1; distal: L2; p < .01). The proximal group had significantly greater thoracic kyphosis (proximal: 30° ± 18°; typical: 20° ± 13°, distal: 20° ± 10°; p < .001) and more fusion segments (proximal: 10; typical: 9; distal: 9; p < .03).

Conclusions: Curves categorized as Lenke 1 curves were less homogeneous than expected. Using only the Lenke type 1 designation to define a study population may introduce unintended bias to the study design.
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http://dx.doi.org/10.1016/j.jspd.2014.03.009DOI Listing
July 2014

Blood Loss Reduction During Surgical Correction of Adolescent Idiopathic Scoliosis Utilizing an Ultrasonic Bone Scalpel.

Spine Deform 2014 Jul 2;2(4):285-290. Epub 2014 Jul 2.

Rady Children's Hospital, 3020 Children's Way, Suite 410, San Diego, CA 92123, USA. Electronic address:

Study Design: Retrospective review of prospectively collected data.

Objectives: To evaluate blood loss associated with posterior spinal fusion in adolescent idiopathic scoliosis patients performed with and without the use of an ultrasonic bone scalpel (UBS).

Summary Of Background Information: After using an ultrasonic-powered bone-cutting device with recent Food and Drug Administration approval for use in the spine, the authors perceived a reduction in bone bleeding associated with the cut boney surfaces.

Methods: The first 20 patients with adolescent idiopathic scoliosis who underwent posterior spinal fusion using the UBS by a single surgeon were compared with 2 control groups: 1) the 20 most recent prior cases of the same surgeon before beginning use of the bone scalpel; and 2) 20 cases of the same surgeon before using the bone scalpel matched based on Cobb angle magnitudes. Both cases and controls had Ponte-type posterior apical releases; none had an anterior procedure. Patient demographic and surgical data were analyzed using analysis of variance (p < .05).

Results: Preoperatively, the UBS group was similar to both control groups in terms of primary and secondary curve magnitudes, number of levels fused, number of levels with Ponte release, antifibrinolytic use, and patient age (p > .05). The UBS group had significantly less estimated blood loss (EBL) (550 ± 359 mL), Cell Saver blood transfused (94 ± 146 mL), and EBL per level fused (48 ± 30 mL) than the most recent controls (EBL: 799 ± 376 mL; Cell Saver: 184 ± 122 mL; EBL/level fused: 72 ± 28 mL) and Cobb-matched controls (EBL: 886 ± 383 mL; Cell Saver: 198 ± 115 mL; EBL/level fused: 78 ± 30 mL) (p < .05). Surgical times were equivalent and there were no dural tears in any group.

Conclusions: The use of an ultrasonic bone scalpel to perform the bone cuts associated with facetectomies and apical Ponte-type posterior releases resulted in significantly less bleeding compared with cuts made with standard osteotomes and rongeurs, limiting overall blood loss by 30% to 40%.
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http://dx.doi.org/10.1016/j.jspd.2014.03.008DOI Listing
July 2014

Safety of pedicle screws and spinal instrumentation for pediatric patients: comparative analysis between 0- and 5-year-old, 5- and 10-year-old, and 10- and 15-year-old patients.

Spine (Phila Pa 1976) 2014 Apr;39(7):541-9

*Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, CA; and †Department of Orthopedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.

Study Design: Retrospective study.

Objective: To investigate the safety of pedicle screws and constructs for infantile and juvenile patients with spinal deformity.

Summary Of Background Data: Few studies have examined the safety and complication rates associated with the usage of pedicle screw for children younger than 10 years.

Methods: Radiographical and clinical data were collected of patients treated with pedicle screws at a single institution. Patients were divided into 2 groups based on age (0-5 yr old, 5-10 yr) and compared with an older cohort of 10- to 15-year-old patients. Patient demographics, screw adjustment, and complication data were collected for each group. Outcomes were analyzed using analysis of variance (P < 0.05).

Results: In total, 5054 pedicle screws were analyzed: 176 in the 0- to 5-year-old group (31 patients), 659 in the 5- to 10-year-old group (68 patients), and 4219 in the 10- to 15-year-old group (234 patients). Mean follow-up was 3.1 ± 1.8 years (range, 3 mo-9 yr). There were 7 pedicle screw-associated complications (3 required revision surgery). Overall pedicle screw-associated complication rates were 2.1% per patient and 0.1% per screw. There were no neurological complications associated with misplacement of a pedicle screw. The pedicle screw-associated complication rates per patient and per screw were 3.2% and 0.6% in the 0- to 5-year-old group, 2.9% and 0.3% in the 5- to 10-year-old group, and 1.7% and 0.1% in the 10- to 15-year-old group (P > 0.05). The 5- to 10-year-old group had a significantly higher overall surgically related complication rate (34%) than the 0- to 5-year-old group (7%) and the 10- to 15-year-old group (6%) (P = 0.005), primarily due to the "growth friendly" constructs common in this age group.

Conclusion: Pedicle screws can be used for infantile or juvenile patients, although complication rates associated with pedicle screws tended to be slightly higher in the younger groups.
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http://dx.doi.org/10.1097/BRS.0000000000000202DOI Listing
April 2014

Maintenance of Thoracic Kyphosis in the 3D Correction of Thoracic Adolescent Idiopathic Scoliosis Using Direct Vertebral Derotation.

Spine Deform 2013 Jan 3;1(1):46-50. Epub 2013 Jan 3.

Department of Orthopedics, Rady Children's Hospital, 3030 Children's Way, San Diego, CA 92123, USA. Electronic address:

Objectives: Through a review of prospectively collected data, we sought to analyze the outcomes related to 3-dimensional correction of adolescent idiopathic scoliosis (AIS) after posterior spinal fusion (PSF) and instrumentation using an aggressive combination of correction strategies.

Background Summary: New techniques have been used to address sagittal plane deformity while maximizing coronal and axial correction, including Ponte osteotomy, differential rod over-contouring, and direct vertebral rotation with uniplanar screws.

Methods: This is a consecutive single-center series of AIS patients with thoracic curves (Lenke 1 and 2) with 2-year follow-up who underwent PSF and instrumentation with the use of the following correction strategies: segmental uniplanar screws, ultra high-strength 5.5 mm steel rods, aggressive differential rod contouring, periapical Ponte osteotomies, and segmental direct vertebral derotation. Scoliosis Research Society (SRS)-22, radiographic and clinical parameters were evaluated at preoperative and 2-year time points.

Results: Twenty-six patients were included (mean age 13.6 ± 1.5 years). Preoperative thoracic Cobb measured 52 ± 9°, which improved to 17 ± 4° at 2-year follow-up, resulting in 68 ± 9% correction. The average thoracic kyphosis from T5-T12 did not significantly change (21 ± 10° to 22 ± 5° at 2 years); however, in patients with kyphosis less than 20° preoperatively (avg. 13 ± 5°) kyphosis increased significantly at 2-year follow-up (avg. 20 ± 4°, p<.05). Preoperatively, axial rotation was more than 13° in 21 of 26 cases. At 2-year follow-up, axial rotation remained more than 13° in 4 of 26 cases (p<.01). Rib hump prominence was 17 ± 5° preoperatively, which improved significantly to 10 ± 4° at 2-year follow-up (p<.05). Postoperative SRS domain scores significantly improved in pain (4.3 to 4.7), self-image (3.7 to 4.3), and satisfaction (3.3 to 4.6) (p<.05).

Conclusion: A high degree of coronal correction can be achieved in association with vertebral derotation without sacrificing sagittal plane alignment. High-strength rods aggressively bent to create kyphosis allow both restoration of kyphosis and axial plane derotation in thoracic idiopathic scoliosis.
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http://dx.doi.org/10.1016/j.jspd.2012.06.001DOI Listing
January 2013

Which Lenke 1A curves are at the greatest risk for adding-on... and why?

Spine (Phila Pa 1976) 2012 Jul;37(16):1384-90

Department of Orthopedic Surgery, Shriners Hospital for Children, Los Angeles, CA, USA.

Study Design: Multicenter review of prospectively collected data.

Objective: The purpose of this study was to evaluate the incidence of distal adding-on and associated risk factors in each of the 2 Lenke 1A curve patterns.

Summary Of Background Data: Previous work has demonstrated 2 distinct Lenke 1A curve patterns on the basis of the tilt of L4 (1A-L and 1A-R) that are different in form and treatment.

Methods: A query of a prospective multicenter adolescent idiopathic scoliosis database identified 195 patients with Lenke 1A curves. Patients were grouped on the basis of the direction of the L4 vertebral tilt: 1A-L (left) and 1A-R (right). The incidences as well as clinical and radiographical risk factors for adding-on were identified for each group. Adding-on was defined as an increase in the Cobb angle of at least 5° and distalization of the end vertebra of the thoracic curve or a change in disc angulation of 5° or greater below the lowest instrumented vertebra from the first erect to 2-year postoperative radiographs.

Results: Forty (21%) patients met the criteria for adding-on. The average increase in Cobb angle was 11.9° for those categorized as having adding-on compared with 3.8° in the non-adding-on group. Lenke 1A-R curves were 2.2 times more likely to experience adding-on than 1A-L curves. In the 1A-R curves, patients who added-on were fused at an average of 1.6 levels proximal to the neutral vertebra versus an average of 0.9 levels proximal to the neutral vertebra for the patients who did not add-on (P = 0.023). Patients who added-on were fused at an average of 2.5 levels above stable versus 2.1 levels above stable in those who did not (P = 0.06). Age and skeletal maturity were not identified as risk factors in the 1A-R curves. In 1A-L curves, younger (12.7 vs. 14.7 yr, P = 0.002) and less skeletally mature patients based on Risser grading (70% vs. 14% Risser 0, P = 0.004) were more likely to experience adding-on.

Conclusion: Understanding the difference between Lenke 1A-L and 1A-R curve types may be helpful in preventing the adding-on phenomena postoperatively. To prevent adding-on in 1A-R curves, we recommend fusing distally to 1 level above the neutral vertebra or 1 to 2 levels above the stable vertebra. In 1A-L curves, adding-on may simply be a need to balance some lumbar curve progression in a young, skeletally immature patient.
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http://dx.doi.org/10.1097/BRS.0b013e31824bac7aDOI Listing
July 2012

Multilevel factor analysis and structural equation modeling of daily diary coping data: Modeling trait and state variation.

Multivariate Behav Res 2010 Sep;45(5):767-789

San Diego State University.

The current study used multilevel modeling of daily diary data to model within-person (state) and between-person (trait) components of coping variables. This application included the introduction of multilevel factor analysis (MFA) and a comparison of the predictive ability of these trait/state factors. Daily diary data was collected on a large (n = 366) multiethnic sample over the course of five days. Intraclass correlation coefficient for the derived factors suggested approximately equal amounts of variability in coping usage at the state and trait levels. MFAs showed that Problem-Focused Coping and Social Support emerged as stable factors at both the within-person and between-person levels. Other factors (Minimization, Emotional Rumination, Avoidance, Distraction) were specific to the within-person or between-person levels, but not both. Multilevel structural equation modeling (MSEM) showed that the prediction of daily positive and negative affect differed as a function of outcome and level of coping factor. The Discussion section focuses primarily on a conceptual and methodological understanding of modeling state and trait coping using daily diary data with MFA and MSEM to examine covariation among coping variables and predicting outcomes of interest.
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http://dx.doi.org/10.1080/00273171.2010.519276DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3049912PMC
September 2010

Coping with Daily Stress: The Role of Conscientiousness.

Pers Individ Dif 2011 Jan;50(1):79-83

San Diego State University, USA.

The current study examined how specific coping strategies mediate the relationship between Conscientiousness (C) and positive affect (PA) in a large, multiethnic sample. Using an internet-based daily diary approach, 366 participants (37.6% Caucasian, 30.6% Asian American, 20.7% Hispanic, 9.1% African American) completed measures that assessed daily stressors, coping strategies used to deal with those stressors, and PA over the course of five days. In addition, participants completed a measure of the Five-Factor Model of Personality. Problem-Focused coping partially mediated the relationship between C and PA. Individuals higher in C used more problem-focused coping, which, in turn, was associated with higher PA. The findings of the current study suggest C serves as a protective factor from stress through its influence on coping strategy selection. Other possible mediators in the C-PA relationship are discussed.
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http://dx.doi.org/10.1016/j.paid.2010.08.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2976572PMC
January 2011
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