Publications by authors named "Michael G Vitale"

131 Publications

Cross-Cultural Adaptation and Validation of the Persian Version of the 24-Item Early-Onset Scoliosis Questionnaire.

Asian Spine J 2021 May 4. Epub 2021 May 4.

Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Irving Medical Center, Columbia University, New York, NY, USA.

Study Design: Cross-sectional study.

Purpose: To translate and culturally adapt the original English version of the 24-item Early-Onset Scoliosis Questionnaire (EOSQ-24) to the Persian language as well as assess its reliability and validity.

Overview Of Literature: Early-onset scoliosis (EOS) patients with progressive curves require active treatments, such as serial elongation- derotation-flexion casting, bracing, and surgery, which are stressful and expensive. In order to evaluate the impact of EOS and its treatment strategies, it is important to consider the patients and their parents' quality of life as the clinical and radiological parameters. The EOSQ-24 is a parent-based measure that evaluates the health-related quality of life of patients with EOS and their caregivers/parents. Similar to other widely used questionnaires, EOSQ-24 needs to be translated into other languages to make it usable in populations from different cultures and societies.

Methods: We evaluated the translation and back translation of the EOSQ-24 and made the required revisions as per the analysis performed by the expert committee and an international guideline to adapt it for use in this study. Thereafter, we recruited 100 EOS patients in order to evaluate its reliability and validity. The reliability was assessed with internal consistency. Convergent validity was assessed by comparing the scores of the EOSQ-24 and the 22-item Scoliosis Research Society Questionnaire (SRS-22r). Finally, the known groups validity was assessed as per patient's sex, curve magnitude, and treatment type.

Results: The Persian EOSQ-24 demonstrated very good internal consistency (Cronbach's α=0.88). All the items had an acceptable corrected item-total correlation (>0.3). Further, the EOSQ-24 and the SRS-22r scores (p <0.001) were significantly correlated. The EOSQ-24 could discriminate patients with different curve magnitudes.

Conclusions: The Persian EOSQ-24 can serve as a disease-specific instrument with strong validity and reliability in the evaluation of EOS patients. Its applicability in other Persian-speaking countries and regions of the world needs to be investigated further.
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http://dx.doi.org/10.31616/asj.2020.0483DOI Listing
May 2021

Power versus manual pedicle tract preparation: a multi-center study of early adopters.

Spine Deform 2021 Apr 23. Epub 2021 Apr 23.

Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA.

Study Design: Retrospective cohort, multicenter. A single surgeon study demonstrated that pedicle tract preparation with power tools was associated with lower fluoroscopy times and revision rates compared to manual tools, while maintaining patient safety.

Objective: Our purpose was to determine the safety of power-assisted pedicle tract preparation by early adopters of this technology.

Methods: Retrospective review comparing patients that underwent posterior spinal fusion by seven pediatric spine surgeons at six institutions between January 1, 2008 and August 31, 2019. The manual pedicle tract preparation used a pedicle awl. Power tract preparation used a flexible 2.0-2.4 mm drill bit, followed by a larger drill bit or a reamer. All screws were inserted with power technique.

Results: In the manual tract preparation group, 9424 screws were placed in 585 cases. In the power tract preparation group, 22,209 screws were placed in 1367 cases. Seven patients (7/1952; 0.36%; 95% CI: 0.14-0.74%) had 11 mal-positioned screws (11/31,633; 0.03%; 95% CI: 0.017-0.062%). Seven screws (7/9424; 0.07%; 95% CI: 0.030-0.15%) were in the manual cohort and four (4/22,209; 0.02%; 95% CI: 0.0049-0.046%) were in the power cohort. There were significantly more revisions per screw in the manual cohort (p = 0.02). However, there were not significantly more revisions per patient in the manual cohort (manual: 0.5%, 3/585 vs. power: 0.3%, 4/1,367; p = 0.43). Of these seven, three patients (3/585; 0.5%; 95% CI: 0.1-1.5%) experienced neurologic injury or neuro-monitoring changes requiring screw removal in the manual cohort, and 1 patient (1/1,367, 0.07%; 95% CI: 0.002-0.4%) in the power cohort (p = 0.08). Three additional patients underwent revision in the power cohort: 1 for an asymptomatic lateral breech, 1 for a spinal headache/medial breech that developed after an MVA, and 1 for an iliac vein injury during pedicle tract preparation.

Conclusion: This is the first multi-center study examining power pedicle preparation. Overall, 99.9% of pedicle screws placed with power pedicle preparation did not have complications or revision. Equivalent patient safety was demonstrated compared to manual technique.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s43390-021-00347-xDOI Listing
April 2021

Completion of a formal physiotherapeutic scoliosis-specific exercise training program for adolescent idiopathic scoliosis increases patient compliance to home exercise programs.

Spine Deform 2021 May 23;9(3):691-696. Epub 2020 Nov 23.

Columbia University Medical Center, 3959 Broadway-8 North, New York, NY, 10032, USA.

Introduction: Physiotherapeutic Scoliosis-Specific Exercise (PSSE) is a conservative approach for management of adolescent idiopathic scoliosis (AIS). Although there is Level I evidence for the efficacy of PSSE, compliance in the teenage population remains in question. The purpose of this study is to investigate the association between completion of formal PSSE training and compliance to prescribed home exercise programs (HEP).

Methods: Patients with AIS evaluated at our institution between 2013 and 2015 with a minimum of one PSSE session were enrolled. A chart review and questionnaire completed by caregivers was utilized to assess HEP compliance following the final PSSE session at 1 week, 3 months, 1 year, and 2 years. Patients were divided into two groups, those completing formal training (10 or more PSSE sessions), and those who did not complete formal training (fewer than 10 sessions).

Results: 81 patients were identified (mean age of 13.1 years; major curve of 31.3°). Patients who completed training demonstrated 50% compliance at 1 week (vs. 25.6% for non-completers, Odds Ratio (OR): 2.9, p = 0.027), 41.2% at 3 months (vs. 18.9% for non-completers, OR: 3.0, p = 0.044), 23.5% at 1 year (vs. 13.5% for non-completers, OR: 2.0, p = 0.281), and 25.7% at 2 years (vs. 13.5% for non-completers, OR: 2.2, p = 0.197). The mean HEP duration (minutes) in patients who completed training was higher at 1 week (80.8 vs. 48, p = 0.010), 3 months (64.6 vs. 23.7, p ≤ 0.001), 1 year (35.3 vs. 22.7, p = 0.270), and 2 years (34.3 vs. 18.9, p = 0.140).

Conclusion: Patients who completed PSSE training maintained higher HEP compliance.
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http://dx.doi.org/10.1007/s43390-020-00253-8DOI Listing
May 2021

Health Care Lobbying, Political Action Committees, and Spine Surgery.

Spine (Phila Pa 1976) 2020 Dec;45(24):1736-1742

Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY.

Study Design: Retrospective review.

Objective: The aim of this study was to analyze the political contributions and strategies of the Political Action Committee (PACs) lobbying for the political interests of spine surgeons.

Summary Of Background Data: In 2016, a presidential election year, $514,224,628 was spent on health care lobbying. Only 16% ($85,061,148) was on behalf of health professionals providing care. Below we chronicle the overlapping contributions between the three different physician-based Political Action Committee (PAC) lobbying entities as it relates specifically to spine surgery.

Methods: Data were abstracted for the PACs of the American Association of Neurological Surgeons (AANS), American Association of Orthopedic Surgeons (AAOS), and the North American Spine Society (NASS). These data were obtained using OpenSecrets (opensecrets.org), and the Federal Election Commission (fec.gov) website. All data points were collected biannually from 2006 to 2018 and statistically analyzed as appropriate.

Results: In 2016, the AAOS PAC contributed $2,648,218, the AANS PAC $348,091, and the NASS PAC $183,612. After accounting for respective group size, the AAOS spent >2.34 times that of the AANS. Orthopedists were 3.84 times (95% confidence interval 3.42-4.3) more likely to donate to their PAC than neurosurgeons (P < 0.001) during the 2016 election. The majority of contributions among the three different lobbyist organizations were to federal candidates, followed by fundraising committees, and finally to the national party. Eighty-eight percent of AANS donations went to Republican candidates, whereas AAOS and NASS were 63% and 67%, respectively. From 2008 to 2016, the AAOS PAC had a highest political contributions spend per active member of parent organization ($126.39) as compared to AANS ($80.52) and NASS ($17.81). The AAOS had five surgeons for every donor to the AAOS PAC, whereas the AANS had 14 surgeons and NASS 38 members per each donor. The AANS had a higher percentage of Republican donations with 78.9% of donations going to Republicans as compared to 61.8% of AAOS contributions and 67.9% of NASS contributions.

Conclusion: Spine surgery is unique in that three different physician-based lobbyist organizations seek to influence legislative priorities with the AAOS having the most substantial fiscal impact and greatest participation. Choreography of donation strategies is essential to maximize physician voice at the policy level.

Level Of Evidence: 5.
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http://dx.doi.org/10.1097/BRS.0000000000003693DOI Listing
December 2020

Spinal Deformity Surgery in Pediatric Patients With Cerebral Palsy: A National-Level Analysis of Inpatient and Postdischarge Outcomes.

Global Spine J 2020 Sep 23:2192568220960075. Epub 2020 Sep 23.

Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA.

Study Design: Retrospective cohort.

Objective: To provide a national-level assessment of the short-term outcomes after spinal deformity surgery in pediatric patients with cerebral palsy.

Methods: A national, prospectively collected database was queried to identify pediatric (≤18 years) patients with cerebral palsy, who underwent spinal fusion surgery from 2012 to 2017. Separate multivariate analyses were performed for the primary outcomes of interest including extended length of stay (>75th percentile, >8 days), and readmissions within 90 days after the index admission.

Results: A total of 2856 patients were reviewed. The mean age ± standard deviation was 12.8 ± 2.9 years, and 49.4% of patients were female. The majority of patients underwent a posterior spinal fusion (97.0%) involving ≥8 levels (79.9%) at a teaching hospital (96.6%). Top medical complications (24.5%) included acute respiratory failure requiring mechanical ventilation (11.4%), paralytic ileus (8.2%), and urinary tract infections (4.6%). Top surgical complications (40.7%) included blood transfusion (35.6%), wound complication (4.9%), and mechanical complication (2.7%). The hospital cost for patients with a length of hospital stay >8 days ($113 669) was nearly double than that of those with a shorter length of stay ($68 411). The 90-day readmission rate was 17.6% (mean days to readmission: 30.2). The most common reason for readmission included wound dehiscence (21.1%), surgical site infection (19.1%), other infection (18.9%), dehydration (16.9%), feeding issues (14.5%), and acute respiratory failure (13.1%). Notable independent predictors for 90-day readmissions included preexisting pulmonary disease (odds ratio [OR] 1.5), obesity (OR 3.4), cachexia (OR 27), nonteaching hospital (OR 3.5), inpatient return to operating room (OR 1.9), and length of stay >8 days (OR 1.5).

Conclusions: Efforts focused on optimizing the perioperative pulmonary, hematological, and nutritional status as well as reducing wound complications appear to be the most important for improving clinical outcomes.
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http://dx.doi.org/10.1177/2192568220960075DOI Listing
September 2020

Complications in the treatment of EOS: Is there a difference between rib vs. spine-based proximal anchors?

Spine Deform 2021 Jan 21;9(1):247-253. Epub 2020 Sep 21.

Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY, 10032, USA.

Introduction: Currently, there is significant equipoise regarding the selection and placement of growing spinal instrumentation when treating patients with early-onset scoliosis (EOS). The primary purpose of this study was to compare complications following surgery in patients receiving rib-based versus spine-based proximal anchors as a part of posterior growing instrumentation in the management of EOS.

Methods: Retrospective cohort study. Inclusion criteria required: age 3-10 years old, diagnosis of EOS, treatment with a growing construct that utilized rib- or spine-based proximal anchors, and a major coronal curve larger than 40 degrees. The primary outcome analyzed was postoperative complications. Secondary outcomes included coronal major curve correction and patient reported outcomes measured by the Early-Onset Scoliosis 24-item Questionnaire (EOSQ-24). Subjects were categorized into rib- or spine-based proximal fixation groups for comparison.

Results: Of 104 patients included in the study, 76 (73.1%) were treated with rib-based constructs and 28 (26.9%) were treated with spine-based constructs. 24 (31.6%) patients with rib-based constructs and 9 (32.1%) patients with spine-based constructs experienced at least one implant related complication (p = 0.956). Rod fracture was observed more often in spine-based groups than rib-based groups for both patients with congenital/idiopathic EOS (rib: 0 (0%) vs. spine: 3 (13.6%), p = 0.009) and neuromuscular/syndromic EOS (rib: 0 (0%) vs. spine: 2 (33.3%), p = 0.002). Furthermore, surgical site infection was found to be more frequent in rib-based than spine-based groups for neuromuscular/syndromic patients (rib: (13) 27.15 vs. spine: (1) 4.5%, p = 0.029). The most commonly reported complication was device migration. In patients with rib-based constructs, 2 (12.5%) patients with ≥ 5 anchors and 13 (21.7%) patients with < 5 anchors experienced device migration (p = 0.413). In patients with spine-based constructs, 1 (11.1%) patient with ≥ 5 anchors and 4 (21.1%) patients with < 5 anchors experienced device migration (p = 0.064). Spine-based anchors had significantly higher% correction (42.0%) compared to rib-based anchors (20.6%) (p = 0.003) at the most recent follow-up. There were no significant differences in the change of patient reported outcomes as measured by the EOSQ-24 between patients who received rib or spine-based anchors.

Discussion: The number of patients with at least one implant related complication was similar between the rib- and spine-based groups. Having 5 or more proximal anchors appeared protective against proximal device migration; however, this result was not statistically significant. Spine-based anchors had better overall correction than rib-based anchors. There were no differences in the change in patient reported outcomes between spine- and rib-based cohorts.
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http://dx.doi.org/10.1007/s43390-020-00200-7DOI Listing
January 2021

Reliability and validity of the simplified Chinese version of the Early Onset Scoliosis-24-Item Questionnaire (EOSQ-24).

Transl Pediatr 2020 Aug;9(4):513-521

Department of Orthopaedics, Peking University Third Hospital, 49 Huayuan North Road, Beijing, China.

Background: It is important to use standard assessment tools to quantify the impact of early-onset scoliosis (EOS) on the health-related quality of life of these children and their caregivers. In this study we aimed to translate and validate the simplified Chinese version of the Early Onset Scoliosis Questionnaire-24 (EOSQ-24) in order to assess the health-related quality of life (HRQoL) and caregiver burden among patients with EOS from mainland China.

Methods: EOSQ-24 was forward-and-backward translated according to standard protocols, culturally adapted, and administered to patients fulfilling specific inclusion criteria and recruited between February and December 2015. Response distribution was assessed by their median and standard deviation. Floor and ceiling effects were calculated. Reliability was established using Cronbach's α and discriminative validity was determined using the Mann-Whitney U test and the Kruskal-Wallis test.

Results: A total of 63 children and their parents participated in this study. Most responses were left skewed towards normal physical and psychosocial well-being. No floor effect was observed but ceiling effect was found in questions regarding pain and pulmonary function. Cronbach's α for all questions and all domains was 0.950, and 0.927, respectively. EOSQ-24 scores were negatively correlated with curve severity and ambulatory status. Based on these preliminary results, EOSQ-24 could be used to distinguish patients in these regards.

Conclusions: The simplified Chinese version of EOSQ-24 is a reliable and valid tool for HRQoL assessment among caregivers (parents) of children with EOS in mainland China. It could potentially be incorporated into routine clinical care in this patient population and as a standard assessment tool for research purposes.
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http://dx.doi.org/10.21037/tp-19-177DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7475316PMC
August 2020

Surgical site infections in pediatric spinal surgery after implementation of a quality assurance program.

Spine Deform 2021 Jan 1;9(1):125-133. Epub 2020 Sep 1.

Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, USA.

Study Design: Retrospective cohort study.

Objective: To assess the effectiveness of two infection-reducing programs in mitigating the incidence of post-operative surgical site infections (SSI) in pediatric patients after spinal deformity surgery at our institution. Infections following spinal deformity surgery are associated with higher morbidity as well as significantly increased healthcare costs. SSI in patients with neuromuscular etiologies is especially high, exceeding 8 percent for myelodysplasia patients and 6 percent for cerebral palsy patients.

Methods: Manual chart review was conducted for 1934 pediatric spine procedures in 1200 patients at our institution between 2008 and 2018. Patients between the ages of 0 and 21 having any spinal surgical procedure including lengthening of growing rods were included.

Results: Institution of two separate infection-reducing programs reduced risk of SSI in this population by 65.4%, when adjusted for age and number of instrumentation levels (risk ratio [RR] = 0.3, 95% confidence interval [CI] = 0.2; 0.6, p = 0.001). Patients undergoing Initial Instrumentation demonstrated 68.8% less risk of SSI compared to those who had other types of surgical procedures, after adjusting for age and the number of level instrumented (RR = 0.3, 95% CI 0.2; .6, p = 0.002). It was observed that the effect of each of these infection-reducing programs diminished with time. This effect was also observed with prior programs implemented at our institution.

Conclusion: The incidence of SSI decreased following the implementation of two infection-reducing programs especially in patients undergoing Initial Instrumentation procedures. However, time-series analysis suggests these programs may have maximal effect immediately following institution that diminishes with time.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1007/s43390-020-00192-4DOI Listing
January 2021

Comparing health-related quality of life and burden of care between early-onset scoliosis patients treated with magnetically controlled growing rods and traditional growing rods: a multicenter study.

Spine Deform 2021 Jan 26;9(1):239-245. Epub 2020 Aug 26.

Columbia University Medical Center, New York, NY, USA.

Study Design: Multicenter retrospective cohort study.

Objectives: To compare pre-operative and post-operative EOSQ-24 scores in magnetically controlled growing rods (MCGR) and traditional growing rod (TGR) patients. Since the introduction of MCGR, early-onset scoliosis patients have been afforded a reduction in the number of surgeries compared to the TGR technique. However, little is known about (health-related quality of life) and burden of care outcomes between these surgical techniques.

Methods: This is a retrospective cohort study using a multicenter registry on patients with EOS undergoing MCGR or TGR between 2008 and 2017. The EOSQ-24 was administered at preoperative and postoperative 2-year assessments. The EOSQ-24 scores were compared between MCGR and TGR as well as preoperatively and postoperatively within each procedure.

Results: 110 patients were analyzed in this study (TGR, N = 32; MCGR, N = 78). There were no significant differences in preoperative age, gender, etiology, main coronal curve or maximum kyphosis between TGR and MCGR groups. Patients with TGR had averaged 3.9 surgical lengthenings and MCGR had averaged 7.7 non-invasive lengthenings by the 2-year follow-up. When changes in preoperative to postoperative scores were compared, MCGR had more improvements in pain, emotion, child satisfaction and parent satisfaction than TGR although there were no statistical significance. When analyzed separately, MCGR cohort had improvement in scores for all four domains and four sub-domains; while, TGR cohort only had improvement in financial burden domain and pulmonary function sub-domain.

Conclusion: Although there was no statistical significance, the improvement in pain, emotion and satisfaction scores was larger in MCGR than TGR. Since these areas can be influenced more by mental well-being than other sub-domains, the results may prove our hypothesis that compared to TGR, MCGR with reduced number of surgeries have better psychosocial effects.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s43390-020-00173-7DOI Listing
January 2021

Impact of growth friendly interventions on spine and pulmonary outcomes of patients with spinal muscular atrophy.

Eur Spine J 2021 Mar 18;30(3):768-774. Epub 2020 Aug 18.

Division of Orthopaedics, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.

Purpose: Patients with spinal muscular atrophy (SMA) are often treated with growth friendly devices such as vertical expandable prosthetic titanium rib(VEPTR) and magnetically controlled growing rods(MCGR) to correct spinal deformity and improve pulmonary function. There is limited data on this topic, and the purpose of this study was to assess the effect of these constructs and the addition of chest wall support (CWS) on spinal deformity, thorax morphology and pulmonary outcomes.

Methods: This is a retrospective analysis of prospectively collected data. We included patients with chest wall deformity and scoliosis secondary to SMA who were treated with growth friendly interventions and had two-year follow-up. Descriptive statistics and univariate analyses were performed.

Results: This study included 66 patients (25% MCGR, 73% VEPTR, 2% unknown). Approximately 23% of constructs included CWS. The average Cobb angle improved from 67° (SD: 27°) to 50° (SD: 26°) at 2 years in patients with CWS (p = 0.02), and from 59° (SD: 20°) to 46° (SD: 15°) at 2 years in patients without CWS (p < 0.01). Hemithorax height improved in patients treated with and without CWS (p = 0.01), but hemithorax width only improved in patients with CWS (p = 0.01). One patient with CWS and two patients without CWS required additional respiratory support at 2 years. The rates of postoperative complications were not significantly different in patients treated with and without CWS (p = 0.31).

Conclusions: Growth friendly constructs improve spinal deformity and may be effective in altering the progression toward respiratory failure in patients with SMA. Patients treated with CWS have significant improvements in thorax morphology compared to patients without CWS.
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http://dx.doi.org/10.1007/s00586-020-06564-8DOI Listing
March 2021

Improvement of Pulmonary Function Measured by Patient-reported Outcomes in Patients With Spinal Muscular Atrophy After Growth-friendly Instrumentation.

J Pediatr Orthop 2021 Jan;41(1):1-5

Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY.

Background: Children with spinal muscular atrophy (SMA) sustain a progressive reduction in pulmonary function (PF) related to both muscular weakness and the concomitant effects of spinal deformity on the thorax. Growth-friendly instrumentation is commonly utilized for younger patients with scoliosis and SMA to halt the progression of spinal curvature, but its effect on PF in these patients has not previously been investigated. Using the change in Early Onset Scoliosis 24-Item Questionnaire (EOSQ-24) PF subdomain scores, the authors will investigate whether PF improves in patients with SMA after a growth-friendly intervention.

Methods: This was a multicenter retrospective cohort study from 2 international registries of patients with SMA undergoing spinal deformity surgery from 2005 to 2015. Data collected were age, sex, degree of major coronal curve, type of growth-friendly construct, forced vital capacity (FVC), and EOSQ-24 scores at the patient's preoperative, 1-year postoperative, and 2-year postoperative visits. Differences in EOSQ-24 PF scores and FVC between baseline and postoperative assessment were examined by paired tests.

Results: A total of 74 patients were identified (mean age, 7.6±2.3 y, major curve 68.1±22.4 degrees, 51.4% female individuals). The mean EOSQ-24 PF scores improved significantly from 70.6 preoperatively to 83.6 at 1 year (P=0.092) and 86.5 at 2 years postoperatively (P=0.020). The scores in patients with rib-based constructs showed steeper increases at 1-year assessments than those in patients with spine-based constructs. The mean paired FVC value decreased from 63.9% predicted preoperatively, to 57.6% predicted at 1 year postoperatively (P=0.035), and 61.9% predicted preoperatively, to 56.3% predicted at 2 years postoperatively (P=0.178).

Conclusions: Patients with SMA who received growth-friendly instrumentation did experience improvements in PF as measured by EOSQ-24 assessing the caregivers' perception. Given the uncertain reliability of PFTs in this young population, EOSQ-24 is an important tool for measuring improvements in health-related quality of life.

Level Of Evidence: Level III-retrospective study.
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http://dx.doi.org/10.1097/BPO.0000000000001656DOI Listing
January 2021

Variability in stable sagittal vertebra (SSV) during full-length biplanar xrays can affect the choice of fusion levels in patients with adolescent idiopathic scoliosis (AIS).

Spine Deform 2020 Dec 14;8(6):1261-1267. Epub 2020 Jul 14.

Department of Pediatric Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center, ATTN: Michael Vitale, 3959 Broadway, CHONY 8-N, New York, NY, 10032-3784, USA.

Purpose: Surgical planning for Adolescent Idiopathic Scoliosis (AIS) relies on the coronal and sagittal plane to determine the lowest instrumented vertebra (LIV). Failure to include the stable sagittal vertebra (SSV) within the construct can increase the incidence of postoperative distal junctional kyphosis (DJK). The purpose of this study is to assess the variability of SSV within patients and to identify positional parameters that may lead to its change.

Methods: This is a case-control study of AIS patients with changes in SSV throughout serial radiographs. Radiographic sagittal parameters and hand positioning for the patients with changes in SSV were compared to patients with stable SSV. Additionally, a subgroup analysis was conducted to compare the positional parameters of only the patients with changes in SSV.

Results: 46 patients with a mean age of 15 ± 1.8 years old at the time of surgery were included in this study. 33/76 (43.4%) image pairs were found to have a change in SSV. Positional parameters associated with the more distally measured SSV were found to have a more negative sagittal vertebral axis (p = 0.001), more positive pelvic shift (p = 0.023), and more negative Global Sagittal Axis (p = 0.001) when compared to the more proximally measured SSV.

Conclusion: Significant variability exists in the determination of SSV in AIS patients undergoing serial radiographs. Positional parameters associated with the proximal and distally measured SSV also have variability which indicates that posture has a significant impact on this measure. Surgeons need to be aware of SSV variability during preoperative planning and must consider multiple parameters for the determination of LIV.

Level Of Evidence: 3.
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http://dx.doi.org/10.1007/s43390-020-00166-6DOI Listing
December 2020

The Association Between the Utilization of Traction and Postoperative Complications Following Growing Rod Instrumentation for Early-onset Scoliosis.

J Pediatr Orthop 2020 Oct;40(9):e798-e804

Department of Orthopaedic Surgery, Columbia University.

Background: Preoperative and/or intraoperative traction have been proposed as adjunctive methods to limit complications associated with growth-friendly instrumentation for early-onset scoliosis (EOS). By gradually correcting the deformity before instrumentation, traction can, theoretically, allow for better overall correction without the complications associated with the immediate intraoperative correction. The purpose of this multicenter study was to investigate the association between preoperative/intraoperative traction and complications following growth-friendly instrumentation for EOS.

Methods: Patients with EOS who underwent growth rod instrumentation before 2017 were identified from 2 registries. Patients were divided into 2 groups: preoperative traction group versus no preoperative traction group. A subgroup analysis was done to compare intraoperative traction only versus no traction. Data was collected on any postoperative complication from implantation to up to 2 years postimplantation.

Results: Of 381 patients identified, 57 (15%) and 69 (18%) patients received preoperative and intraoperative traction, respectively. After adjusting for etiology and degree of kyphosis, there was no evidence to suggest that preoperative halo traction reduced the risk of any complication following surgical intervention. Although not statistically significant, a subgroup analysis of patients with severe curves demonstrated a trend toward a markedly reduced hardware failure rate in patients undergoing preoperative halo traction [preoperative traction: 1 (3.1%) vs. no preoperative traction: 11 (14.7%), P=0.083]. Nonidiopathic, hyperkyphotic patients treated with intraoperative traction were 61% less likely to experience any postoperative complication (P=0.067) and were 74% (P=0.091) less likely to experience an unplanned return to the operating room when compared with patients treated without traction.

Conclusions: This multicenter study with a large sample size provides the best evidence to date of the association between the use of traction and postoperative complications. Our results justify the need for future Level I studies aimed at characterizing the complete benefit and risk profile for the use of traction in surgical intervention for EOS.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BPO.0000000000001628DOI Listing
October 2020

Is rod diameter associated with the rate of rod fracture in patients treated with magnetically controlled growing rods?

Spine Deform 2020 Dec 19;8(6):1375-1384. Epub 2020 Jun 19.

Department of Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center, ATTN: Hiroko Matsumoto, 3959 Broadway, HONY 8-N, New York, NY, 10032-3784, USA.

Introduction: Few risk factors for fracture in magnetically controlled growing rods (MCGR) have been identified. We hypothesize an increased rate of rod fracture in small diameter rods compared to large diameter rods in patients with early-onset scoliosis (EOS). The purpose of this study was to determine the association between the diameter of MCGR constructs and the rate of rod fracture.

Methods: Patients with EOS who underwent MCGR implantation-primary or conversion-from 2013 to 2018 were identified from two registries including 40 centers. Rod diameter sizes greater than 5.0 mm or less than or equal to 5.0 mm were defined as "Large" and "Small" rods, respectively. Only dual-rod constructs were included. The primary outcome measure collected was rod fracture at any point in treatment up to the most recent follow-up. Cox regression was utilized for unequal follow-up to compare rate of breakage at the last follow-up between cohorts.

Results: 527 patients with 1,054 rods were included. 552 (52.4%) rods had a diameter of less than or equal to 5.0 mm and 461 (43.7%) rods had a diameter of greater than 5.0 mm. 41 (3.9%) rods were missing a recorded rod diameter and were not included in the analysis to determine the association between the rate of fracture and rod diameter. 20 (1.9%) total rod fractures occurred: 9 (1.6%) rods with diameters of ≤ 5.0 mm, 10 (2.2%) rods with diameters of > 5.0 mm, and 1 uncategorized rod (p = 0.529). No difference in the rate of rod fracture or survival distribution was found between rod diameters of > 5.0 mm and ≤ 5.0 mm even after stratification by ambulatory status, major coronal curve, weight, or location of anchors.

Discussion: Rod fracture appears to be a rare event in dual MCGR constructs and rod diameter does not seem to be associated with the incidence or rate of rod fracture. Surgeons may consider other criteria for selecting rod diameter in their patients such as patient size, amount of surgical correction, single vs. dual constructs, and risk of hardware prominence.
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http://dx.doi.org/10.1007/s43390-020-00161-xDOI Listing
December 2020

Neurophysiological monitoring of spinal cord function during spinal deformity surgery: 2020 SRS neuromonitoring information statement.

Spine Deform 2020 08 25;8(4):591-596. Epub 2020 May 25.

Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands.

The Scoliosis Research Society has developed an updated information statement on intraoperative neurophysiological monitoring of spinal cord function during spinal deformity surgery. The statement reviews the risks of spinal cord compromise associated with spinal deformity surgery; the statement then discusses the various modalities that are available to monitor the spinal cord, including somatosensory-evoked potentials, motor-evoked potentials, and electromyographic (EMG) options. Anesthesia considerations, the importance of a thoughtful team approach to successful monitoring, and the utility of checklists are also discussed. Finally, the statement expresses the opinion that utilization of intraoperative neurophysiological spinal cord monitoring in spinal deformity surgery is the standard of care when the spinal cord is at risk.
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http://dx.doi.org/10.1007/s43390-020-00140-2DOI Listing
August 2020

It is not just about the frontal plane: sagittal parameters impact curve progression in AIS patients undergoing brace treatment.

Spine Deform 2020 10 27;8(5):921-929. Epub 2020 Apr 27.

Department of Pediatric Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA.

Study Design: Retrospective cohort study.

Objectives: The purpose of this study was to explore the association between pre-brace and in-brace sagittal parameters and curve progression. To date, there has been no published research focused on spinopelvic sagittal parameters and bracing outcomes in AIS. We hypothesize that sagittal spinopelvic parameters are associated with curve progression at 2 years.

Methods: This study included AIS patients with a pre-brace (PB) major curve between 20° and 45°. The outcome was defined as > 10° curve progression or surgery within 2 years of brace initiation. Spinopelvic parameters included C7-Central Sacral Vertebral Line shift (C7-CSVL), thoracic trunk shift, lumbar lordosis (LL), pelvic incidence (PI), T2-T12 thoracic kyphosis (TK) pelvic incidence-lumbar lordosis (PI-LL) mismatch, sagittal vertical axis (SVA), and pelvic tilt (PT).

Results: Of 50 patients included in this review, [70% Rigo (RCSO) and 30% Boston (BSO)], 16 (32%) patients demonstrated progression (23% of patients with RCSO vs 53% with BSO; p = 0.034). In patients with more than 30% major coronal curve correction (CCC), 23% had progression. 45% of patients progressed when they achieved ≤ 30% correction (p = 0.108). Among PB sagittal parameters and adjusting for coronal curve, patients with an abnormal PB SVA had 3.1 times increased risk of treatment failure compared with patients who had a normal PB SVA. Patients with PB hypo-LL had a 2.8 times increased risk of treatment failure compared with patients who had normal or hyper-LL. Among IB sagittal parameters, patients who had a normal PB PI-LL had a 3.9 times increased risk of treatment failure when they became mismatched in-brace (IB). Patients who had normal pre-brace kyphosis who became hypo-kyphotic IB had an 8.4 times increased risk of treatment failure compared with patients who maintained normal TK or became hyper-kyphotic.

Conclusion: These data suggest that we should pay careful attention to sagittal parameters prior to and during brace treatment as braces can control these parameters.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1007/s43390-020-00122-4DOI Listing
October 2020

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

Spine Deform 2020 10 6;8(5):1093-1097. Epub 2020 Apr 6.

Department of Pediatric Orthopaedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center, ATTN: Michael Vitale, 3959 Broadway, CHONY 8-N, New York, NY, 10032-3784, USA.

Purpose: Many children with spinal muscular atrophy (SMA) develop progressive spinal deformity, worsening already compromised pulmonary function and global spinal balance. Early results demonstrate that intrathecal administration of nusinersen, a recent FDA-approved drug, improves motor function and ventilator-free survival, necessitating preservation of intrathecal access when considering PSIF. The purpose of this study is to assess medium-term outcomes of a specialized approach for posterior spinal instrumentation and fusion (PSIF) to preserve intrathecal access in patients with SMA.

Methods: A retrospective review of patients with SMA undergoing PSIF at a single tertiary academic medical center during a 3-year period was completed. To facilitate intrathecal drug administration, the traditional approach to PSIF was modified to "skip" one or more intervertebral levels at the thoracolumbar junction. Clinical notes and radiographs were reviewed for postoperative outcomes including major coronal curve correction and complications, including loss of correction, hardware failure and surgical revision.

Results: Eight patients were identified, with a mean age of 12.7 ± 1.6 years and follow-up of 4 years. These patients had a mean preoperative major coronal curve of 56.4°, with mean curve correction of 35.2°. At follow-up, no patients experienced rod breakage, loss of correction, or postoperative chronic pain. Only one patient required revision surgery due to bony overgrowth at the skipped level after three and a half years.

Conclusion: Implementing the skip construct approach for PSIF in patients with SMA allows for scoliosis correction without compromising intrathecal drug delivery. Follow-up at 4 years reveals no adverse clinical events, hardware failure or loss of correction.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s43390-020-00107-3DOI Listing
October 2020

Risk Factors Associated with Surgical Site Infection in Pediatric Patients Undergoing Spinal Deformity Surgery: A Systematic Review and Meta-Analysis.

JBJS Rev 2020 03;8(3):e0163

Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY.

Background: Considerable variation exists in surgical site infection (SSI) prevention practices for pediatric patients undergoing spinal deformity surgery, but the incidence of SSI has been reported to remain high in the United States. The literature reports various risk factors associated with SSI but findings are inconsistent. The purpose of this systematic review and meta-analysis was to assess the published literature investigating associations between various risk factors and SSI in pediatric patients undergoing spinal surgery.

Methods: The systematic review and the meta-analysis were conducted according to Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) guidelines among peer-reviewed journals published in English between January 2000 and April 2019. Studies that involved pediatric patients with spinal deformity undergoing surgical procedures in North America and assessed risk factors for SSI were included. The quality of individual studies was assessed, and weighted risk ratios and mean differences were calculated for each risk factor.

Results: Of 763 potential articles identified, 13 met inclusion criteria; 7 studies were rated as average and 6, as poor quality based on the quality checklist. The meta-analysis demonstrated that the SSI risk increased by the following factors: 2.53 (95% confidence interval [CI], 1.26 to 5.10) for overweight to obese patients compared with patients with normal weight, 2.84 (95% CI, 1.67 to 4.81) for patients with a neuromuscular etiology compared with non-neuromuscular etiology, 1.69 (95% CI, 1.41 to 2.02) for patients with a gastrostomy tube (G-tube) compared with those without, 3.45 (95% CI, 2.08 to 5.72) for nonambulatory patients compared with ambulators, and 3.39 (95% CI, 2.38 to 4.83) for patients with pelvic instrumentation compared with those without. Patients who developed SSI also had 158.38 mL (95% CI, 46.78 to 269.97 mL) greater estimated blood loss compared with those who did not.

Conclusions: Despite the limited quality of the available studies and wide variety of populations and outcome definitions, evidence suggests that overweight to obese status, neuromuscular etiology, use of a G-tube, nonambulatory status, instrumentation to the pelvis, and greater estimated blood loss are risk factors for SSI. The use of a common SSI definition and strong methodology are warranted for future studies.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete list of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.RVW.19.00163DOI Listing
March 2020

Proximal anchor fixation in magnetically controlled growing rods (MCGR): preliminary 2-year results of the impact of anchor location and density.

Spine Deform 2020 08 18;8(4):793-800. Epub 2020 Mar 18.

Department of Orthopaedic Surgery, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.

Study Design: Multicenter, retrospective cohort study.

Objectives: Analyze the impact of MCGR proximal anchor location and density on radiographic outcomes and complications. Magnetically controlled growing rods (MCGRs) reduce the need for repeat operations for lengthening when treating spinal deformity in children. The evidence behind choosing the location and density of proximal anchors comes from the traditional growing rod and rib-based distraction technique literature. Thus, there is much debate regarding the optimal quantity and location of proximal anchors.

Methods: This study included early-onset scoliosis patients treated with MCGR with a minimum 2-year follow-up. Comparisons of 2-year correction in the coronal and sagittal planes, complication rates, and patient-reported outcomes were made based on proximal fixation type, proximal anchor density, and type of case (primary, conversion).

Results: This study included 155 MCGR patients. Spinal deformity correction at 2 years was significantly higher in spine-based than rib-based constructs, in terms of both the major (23.9° vs. 17.1°, p = 0.05) and minor curves (10.0° vs. 4.5°, p = 0.03). Greater proximal anchor density, regardless of location, was also associated with better major curve correction at 2 years (25.0° vs. 18.2°, p < 0.05). There was a trend towards higher risk of device migration with rib-based fixation (13.8% vs. 4.1%, p = 0.06) and rod breakage with spine-based fixation (10.3% vs. 3.4%, p = 0.21). Having 5+ proximal anchors did not significantly decrease the risk of complication, including device migration (8.4% vs. 7.7%).

Conclusions: When using the MCGR, proximal spine anchors and greater anchor density impart superior deformity correction but do not significantly impact the risk of device complications. Although rib-based constructs afford less rigidity than spine-based constructs, there is a similar risk of rod breakage and device migration. This study suggests that having 5+ MCGR proximal anchors does not protect against proximal anchor complication.

Level Of Evidence: Level III-therapeutic.
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http://dx.doi.org/10.1007/s43390-020-00102-8DOI Listing
August 2020

Bigger is better: larger thoracic height is associated with increased health related quality of life at skeletal maturity.

Spine Deform 2020 08 11;8(4):771-779. Epub 2020 Mar 11.

Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA.

Study Design: Cross sectional OBJECTIVES: The purpose of this study is to evaluate the association between thoracic height and health-related quality of life (HRQoL) at skeletal maturity in patients with EOS. Current literature suggests a minimum thoracic height of 18 cm to 22 cm to avoid poor pulmonary function and related health outcomes.

Methods: Patients with EOS who reached skeletal maturity from 2005 to 2018 were identified in two registries including 32 centers. Thoracic height from T1 to T12 at skeletal maturity and Early Onset Scoliosis 24 Item Questionnaire (EOSQ-24) scores were collected. The EOSQ-24 domains included HRQoL of patients, parental impact, financial impact and patient and parental satisfaction.

Results: 469 patients (mean age: 14.9, female: 77.4%) were identified. 29% patients were of congenital etiology, 20.3% neuromuscular, 13.6% syndromic, 34.8% idiopathic, and 2.3% other. When patients were grouped by thoracic height at skeletal maturity, all EOSQ-24 domains increased after a threshold of 18 cm. When stratified by etiology, the 18 cm cutoff held for patients with congenital, neuromuscular and syndromic EOS. The cutoff for idiopathic EOS was 20 cm. For all patients, after the threshold was met, HRQoL continued to improve with increases in thoracic height at skeletal maturity. A subset of 169 patients for which arm span measurements were available was also identified and their thoracic heights were normalized. When grouped by the percentage of expected thoracic height attained, EOSQ-24 domains increased after a threshold of 80%.

Conclusions: Once 18 cm of actual thoracic height or 80% of expected thoracic height is achieved, HRQoL continues to improve as thoracic height increases in skeletally mature patients with non-idiopathic EOS. Patients with idiopathic EOS had a higher threshold, possibly due to their larger average size and higher care giver expectations for HRQoL.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1007/s43390-020-00095-4DOI Listing
August 2020

Unplanned return to OR (UPROR) for children with early onset scoliosis (EOS): a comprehensive evaluation of all diagnoses and instrumentation strategies.

Spine Deform 2020 04 6;8(2):295-302. Epub 2020 Feb 6.

The Children's Hospital of Philadelphia, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA.

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

Objectives: Our goal was to study unplanned return to the OR (UPROR, a postoperative complication that could not be treated without an additional anesthetic) as a function of C-EOS diagnosis and implant type. Growing concerns over the impact of multiple anesthetic events on the young brain have focused attention on limiting UPROR in early onset scoliosis (EOS).

Methods: We studied all patients with a diagnosis of EOS who had surgical implantation of growing instrumentation from October 4, 2010, to September 27, 2015, with a minimum 2-year follow-up. Among the complications requiring surgical treatment (revision for implant or anchor failure, infection, or implant removal), we analyzed all UPROR events-those that required a separate anesthetic (could not be treated as part of a planned surgical lengthening) within the first 2 years after initial implantation. UPROR was analyzed by diagnosis, deformity type, and implant strategy using the C-EOS classification.

Results: A total of 369 patients met inclusion criteria. Eighty-five of the 369 (23%) required unplanned trips to the operating room for various reasons. The C-EOS group at highest risk of an unplanned trip to the operating room is the hyperkyphotic neuromuscular (M3+, 14/85) cohort, followed closely by the congenital (C3N, 9/85) and neuromuscular (M3N, 8/85) groups with normal sagittal profiles and Cobb angles between 50° and 90°. Implant strategy was significantly related to risk of UPROR (p = .009; Table 1), with traditional implants (vertically expandable prosthetic titanium rib/traditional growing rod) being less likely to have an UPROR event.

Conclusions: Growing instrumentation to treat EOS, when considered comprehensively, results in a true unplanned reoperation rate within 2 years of implantation of 23% (85/369). UPROR events are more common with certain C-EOS groups (hyperkyphotic neuromuscular deformities) and implant strategies. Families should be counseled that unplanned anesthetics are common with any implant strategy available today.

Level Of Evidence: Level III, therapeutic.
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http://dx.doi.org/10.1007/s43390-019-00024-0DOI Listing
April 2020

Idiopathic Early-onset Scoliosis: Growing Rods Versus Vertically Expandable Prosthetic Titanium Ribs at 5-year Follow-up.

J Pediatr Orthop 2020 Mar;40(3):142-148

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

Background: Distraction-based techniques allow spinal growth until skeletal maturity while preventing curve progression.

Methods: Two multicenter early-onset scoliosis databases were used to identify patients with idiopathic spine abnormalities treated with traditional growing rods (TGR) or vertically expandable titanium ribs (VEPTR). Patients underwent at least 4 lengthenings and had at least 5-year follow-up. Significance was set at P<0.05.

Results: In total, 50 patients treated with TGR and 22 treated with VEPTR were included. Mean (±SD) age at surgery was 5.5 (±2.0) years for the TGR group versus 4.3 (±1.9) years for the VEPTR group (P=0.044); other demographic parameters were similar. VEPTR patients had more procedures (mean 15±4.2) than TGR patients (mean 10±4.0) (P=0.001). Unilateral constructs were present in 18% (4 of 22) of VEPTR and 16% (8 of 50) of TGR patients. Bilateral constructs spanned a mean 2.1 additional surgical levels and exposed patients to 1.6 fewer procedures than unilateral constructs. Curve correction was similar between bilateral and unilateral constructs. TGR patients experienced greater curve correction (50%) than VEPTR patients (27%) (P<0.001) and achieved a greater percentage of thoracic height gain (24%) than VEPTR patients (12%) (P=0.024). At latest follow-up, TGR patients had better maintenance of curve correction, less kyphosis, and 15% greater absolute gain in thoracic height versus VEPTR patients. TGR patients had a lower rate of wound complications (14%) than VEPTR patients (41%) (P=0.011).

Conclusions: In patients with idiopathic early-onset scoliosis, TGRs produced greater initial curve correction, greater thoracic height gains, less kyphosis, and lower incidence of wound complications compared with VEPTR.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BPO.0000000000001202DOI Listing
March 2020

Establishing consensus on the best practice guidelines for the use of bracing in adolescent idiopathic scoliosis.

Spine Deform 2020 08 5;8(4):597-604. Epub 2020 Feb 5.

Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA.

Study Design: Survey.

Objectives: Bracing is the mainstay of conservative treatment in Adolescent Idiopathic Scoliosis (AIS). The purpose of this study was to establish best practice guidelines (BPG) among a multidisciplinary group of international bracing experts including surgeons, physiatrists, physical therapists, and orthotists utilizing formal consensus building techniques. Currently, there is significant variability in the practice of brace treatment for AIS and, therefore, there is a strong need to develop BPG for bracing in AIS.

Methods: We utilized the Delphi process and the nominal group technique to establish consensus among a multidisciplinary group of bracing experts. Our previous work identified areas of variability in brace treatment that we targeted for consensus. Following a review of the literature, three iterative surveys were administered. Topics included bracing goals, indications for starting and discontinuing bracing, brace types, brace prescription, radiographs, physical activities, and physiotherapeutic scoliosis-specific exercises. A face-to-face meeting was then conducted that allowed participants to vote for or against inclusion of each item. Agreement of 80% throughout the surveys and face-to-face meeting was considered consensus. Items that did not reach consensus were discussed and revised and repeat voting for consensus was performed.

Results: Of the 38 experts invited to participate, we received responses from 32, 35, and 34 for each survey, respectively. 11 surgeons, 4 physiatrists, 8 physical therapists, 3 orthotists, and 1 research scientist participated in the final face-to-face meeting. Experts reached consensus on 67 items across 10 domains of bracing which were consolidated into the final best practice recommendations.

Conclusions: We believe that adherence to these BPG will lead to fewer sub-optimal outcomes in patients with AIS by reducing the variability in AIS bracing practices, and provide a framework future research.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1007/s43390-020-00060-1DOI Listing
August 2020

Burden of care in families of patients with early onset scoliosis.

J Pediatr Orthop B 2020 Nov;29(6):567-571

Department of Orthopaedic Surgery, Division of Pediatric Orthopaedics, Columbia University Irving Medical Center, New York, New York.

Early onset scoliosis is a complex manifestation of a heterogenous group of disorders, often necessitating multiple medical and surgical interventions to address the spinal deformity and its accompanying comorbidities. Current literature documents decreases in the health-related quality of life of these patients; however, there is a distinct lack of published data examining the burden on their caregivers. The purpose of this study is to compare burden on caregivers of children with early onset scoliosis and those on caregivers of age-matched healthy peers. A multicenter retrospective cohort study was conducted by querying a national registry for patients with early onset scoliosis diagnosed before 10 years old whose caregivers completed the caregiver burden (CB) and financial burden (FB) domains of the Early Onset Scoliosis Questionnaire (EOSQ-24) before their treatment. Scores were compared by etiology and planned treatment. The study identified 503 patients categorized by etiology and eventual treatment type. Overall, FB and CB scores for patients with early onset scoliosis were ≥10% worse than those of their age-matched peers, greater than the minimal clinically important difference for the EOSQ-24 (P < 0.001). Non-idiopathic patients' scores were ≥16% worse than age-matched peers regardless of future treatment (P < 0.001), while scores for idiopathic patients were varied. Idiopathic patients who went on to be observed had similar scores to national norms, but those who were managed either non-operatively (14% worse FB, 7% worse CB; P < 0.001) or operatively (25% worse FB, 27% worse CB; P > 0.05) had caregivers who reported greater burdens compared to those of healthy peers. This study suggests burdens on caregivers of patients with early onset scoliosis of nearly all etiologies are greater than those imposed on caregivers of healthy children, even before the additional stress of treatment is imposed. Level of evidence: II.
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http://dx.doi.org/10.1097/BPB.0000000000000711DOI Listing
November 2020

Results of growth-friendly management of early-onset scoliosis in children with and without skeletal dysplasias: a matched comparison.

Bone Joint J 2019 12;101-B(12):1563-1569

Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA.

Aims: The aim of this study was to compare the surgical and quality-of-life outcomes of children with skeletal dysplasia to those in children with idiopathic early-onset scoliosis (EOS) undergoing growth-friendly management.

Patients And Methods: A retrospective review of two prospective multicentre EOS databases identified 33 children with skeletal dysplasia and EOS (major curve ≥ 30°) who were treated with growth-friendly instrumentation at younger than ten years of age, had a minimum two years of postoperative follow-up, and had undergone three or more lengthening procedures. From the same registries, 33 matched controls with idiopathic EOS were identified. A total of 20 children in both groups were treated with growing rods and 13 children were treated with vertical expandable prosthetic titanium rib (VEPTR) instrumentation.

Results: Mean preoperative major curves were 76° (34° to 115°) in the skeletal dysplasia group and 75° (51° to 113°) in the idiopathic group (p = 0.55), which were corrected at final follow-up to 49° (13° to 113°) and 46° (12° to 112°; p = 0.68), respectively. T1-S1 height increased by a mean of 36 mm (0 to 105) in the skeletal dysplasia group and 38 mm (7 to 104) in the idiopathic group at the index surgery (p = 0.40), and by 21 mm (1 to 68) and 46 mm (7 to 157), respectively, during the distraction period (p = 0.0085). The skeletal dysplasia group had significantly worse scores in the physical function, daily living, financial impact, and parent satisfaction preoperatively, as well as on financial impact and child satisfaction at final follow-up, than the idiopathic group (all p < 0.05). The domains of the 24-Item Early-Onset Scoliosis Questionnaire (EOSQ24) remained at the same level from preoperative to final follow-up in the skeletal dysplasia group (all p > 0.10).

Conclusion: Children with skeletal dysplasia gained significantly less spinal growth during growth-friendly management of their EOS and their health-related quality of life was significantly lower both preoperatively and at final follow-up than in children with idiopathic EOS. Cite this article: 2019;101-B:1563-1569.
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http://dx.doi.org/10.1302/0301-620X.101B12.BJJ-2019-0735.R1DOI Listing
December 2019

Pelvic Obliquity Correction in Distraction-Based Growth Friendly Implants.

Spine Deform 2019 11;7(6):985-991

Children's Spine Study Group, P.O. Box 397, Valley Forge, PA 19481, USA.

Design: Multicenter retrospective review.

Objective: To evaluate radiographic outcomes and complication rates of patients treated with distraction based implants and pelvic fixation with either screws (sacral-alar-iliac [SAI] screws or iliac screws) or hooks (S hook iliac fixation).

Summary Of Background Data: Multiple options exist for pelvic fixation in distraction-based growing rod systems; however, limited comparative data are available.

Methods: Early-onset scoliosis (EOS) patients of all diagnoses with distraction-based implants that had pelvic fixation from 2000 to 2013 were reviewed from two EOS multicenter databases. Patients were divided into two groups by type of pelvic fixation: (1) screw group (SAI screws or iliac screws) or (2) S hooks. Exclusion criteria were as follows: index instrumentation ≥10 years old and follow up <2 years. A total of 153 patients met the inclusion criteria. Mean age at index surgery was 6.1 years (range 1.0-9.9 years) and mean follow-up was 4.9 years.

Results: Pelvic fixation in the 153 patients was as follows: screw group = 42 and S hook group = 111. When comparing patients with >20° of initial pelvic obliquity, the screw group had significantly more correction; mean 26° ± 13° for the screw group versus mean 17° ± 7° in the S hook group (p = .039). There was no significant difference in change in T1-S1 length (40 vs. 39 mm, p = .89) or correction of Cobb angle (30° vs. 24°, p = .24). The total complication rate for the screw group was 14% (6/42) versus 25% (28/111) in the S hook group, though this did not achieve significance (p = .25). The most common complications were device migration (13), implant failure (8), and implant prominence (4) for S hooks and implant failure (3), implant prominence (2), and device migration (1) for the screw group.

Conclusion: In distraction-based growth-friendly constructs, pelvic fixation with screws achieved better correction of pelvic obliquity than S hooks. Complications were almost twice as common with S hooks than screws, though this did not reach statistical significance.
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http://dx.doi.org/10.1016/j.jspd.2019.03.003DOI Listing
November 2019

Posterior Correction Techniques for Adolescent Idiopathic Scoliosis.

J Am Acad Orthop Surg 2020 May;28(9):e363-e373

From the Division of Orthopaedic Surgery, Gillette Children's Specialty Healthcare, St Paul, MN (Dr. Miller), the Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA (Dr. Cahill), the Department of Orthopaedic Surgery, Columbia University Medical Center (Dr. Vitale), and the Department of Orthopedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE (Dr. Shah).

Adolescent idiopathic scoliosis represents a complex, three-dimensional deformity of the spine. Posterior spinal fusion is commonly performed in severe cases to avoid the long-term adverse sequelae associated with progressive spinal deformity. The goals of spinal fusion include halting the progression of deformity, optimizing spinal balance, and minimizing complications. Recent advances in short-segment spinal fixation have allowed for improved three-dimensional deformity correction. Preoperative planning and assessment of spinal flexibility is essential for successful deformity correction and optimization of long-term outcomes. Judicious use of releases and/or spinal osteotomies may allow for increased mobility of the spine but are associated with increased surgical time, blood loss, and risk of complications. Appreciation of implant design and material properties is critical for safe application of correction techniques. Although multiple reduction techniques have been described, no single technique is optimal for every patient.
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http://dx.doi.org/10.5435/JAAOS-D-18-00399DOI Listing
May 2020

Outcomes of Primary and Conversion Magnetically Controlled Growth Rods Are Different at Two-Year Follow-up: Results of North American Release.

Spine Deform 2019 09;7(5):829-835

Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA; Le Bonheur Children's Hospital, 848 Adams Ave, Memphis, TN 38103, USA. Electronic address:

Study Design: Multicenter retrospective review.

Objectives: To compare the radiographic outcomes and complication rates in patients with primary and conversion magnetically controlled growing rod (MCGR) implants at one and two years after surgery.

Summary Of Background Data: Many initial early-onset scoliosis (MCGR) implantations in the United States were conversions from other types of growth-friendly systems, and the outcome similarities and differences between primary and conversion MCGR implantation procedures are still relatively unknown.

Methods: Multicenter retrospective review of EOS patients from two multicenter EOS registries identified consecutive EOS patients treated from 2014 to 2017 with a minimum of one-year follow-up. In addition, a subset of these patients who had two-year follow-up were further analyzed.

Results: In total, 383 MCGR patients were identified, of which 272 (71%) were primary (P) and 111 (29%) were conversion (C). Group P patients had significantly greater coronal curves at the time of MCGR implantation and greater initial coronal correction. There was no statistically significant difference in Cobb correction at one year or between follow-up at one and two years. The preimplantation thoracic spine height was identical in both groups, with statistically greater improvement at initial implantation in P than in C patients. Significantly greater height gains were seen in P than in C patients in the one-year follow-up cohort. There was a higher rate of complications in the C group than in the P group; however, the difference was not statistically significant. Overall, most complications were implant-related. No loss of curve correction occurred in either group.

Conclusions: Patients with primary MCGR insertion can be expected to have greater radiographic correction and spine length gain than those with conversion from growth-friendly instrumentation to MCGR, most likely because of increased spine stiffness in conversion patients. The rate of complications, primarily implant-related, remains higher in conversion than in primary insertion patients.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.jspd.2019.01.002DOI Listing
September 2019

Best Practice Guidelines for Surgical Site Infection Prevention With Surgical Treatment of Early Onset Scoliosis.

J Pediatr Orthop 2019 Sep;39(8):e602-e607

Columbia University Medical Center, New York, NY.

Background: Postoperative surgical site infection (SSI) is unfortunately a commonly encountered complication in the surgical treatment of children with Early Onset Scoliosis (EOS). There is documented variation in the treatment of this patient population. Previous work building consensus for the approach to high risk patients (eg, neuromuscular etiology) has been promising. The goal of the current study is to apply similar principles to develop consensus-based guidelines for the treatment of patients with EOS.

Methods: A focus group from 2 multicenter pediatric spine deformity study groups developed a list of statements to be distributed to a larger group of EOS experts. Using the Delphi process, participants were presented with a systematic review of the literature as well as a review of current practices in growth friendly surgery. The first round was conducted using an electronic survey. Results of this survey were then discussed face-to-face and the statements were further refined. A final round was conducted using the Audience Response System, allowing participants to vote for each statement (strongly agree or agree). Agreement >80% or disagreement <20% was considered consensus.

Results: A total of 29 of 57 statements reached consensus. Negative statements (statements of disagreement) were excluded, so the final consensus guidelines included 22 statements. The number of statements from the previously published Best Practice Guidelines (BPG) approved for insertion and lengthening growth friendly procedures were 12 of 14 and 11 of 14, respectively. The high risk BPG therefore does not cover all of the issues specific to the EOS population, and explains why 22 statements reached consensus in the current guideline. Upon completion of the surveys, 100% of the participants agreed to support its publication.

Conclusions: Using the Delphi process several "best practices" were developed for growth friendly surgical treatment of EOS.

Level Of Evidence: Level V.
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http://dx.doi.org/10.1097/BPO.0000000000001079DOI Listing
September 2019

Increased complications without neurological benefit are associated with prophylactic spinal cord untethering prior to scoliosis surgery in children with myelomeningocele.

Childs Nerv Syst 2019 11 2;35(11):2187-2194. Epub 2019 Jul 2.

Division of Pediatric Neurosurgery, Department of Neurological Surgery, Children's Hospital of New York, Columbia-Presbyterian, New York, NY, USA.

Purpose: Children with myelomeningocele (MMC) are at increased risk of developing neuromuscular scoliosis and spinal cord re-tethering (Childs Nerv Syst 12:748-754, 1996; Neurosurg Focus 16:2, 2004; Neurosurg Focus 29:1, 2010). Some centers perform prophylactic untethering on asymptomatic MMC patients prior to scoliosis surgery because of concern that additional traction on the cord may place the patient at greater risk of neurologic deterioration peri-operatively. However, prophylactic untethering may not be justified if it carries increased surgical risks. The purpose of this study was to determine if prophylactic untethering is necessary in asymptomatic children with MMC undergoing scoliosis surgery.

Methods: A multidisciplinary, retrospective cohort study from seven children's hospitals was performed including asymptomatic children with MMC < 21 years old, managed with or without prophylactic untethering prior to scoliosis surgery. Patients were divided into three groups for analysis: (1) untethering at the time of scoliosis surgery (concomitant untethering), (2) untethering within 3 months of scoliosis surgery (prior untethering), and (3) no prophylactic untethering. Baseline data, intra-operative reports, and 90-day post-operative outcomes were analyzed to assess for differences in neurologic outcomes, surgical complications, and overall length of stay.

Results: A total of 208 patients were included for analysis (mean age 9.4 years, 52% girls). No patient in any of the groups exhibited worsened motor or sensory function at 90 days post-operatively. However, comparing the prophylactic untethering groups with the group that was not untethered, there was an increased risk of surgical site infection (SSI) (31.3% concomitant, 28.6% prior untethering vs. 12.3% no untethering; p = 0.0104), return to the OR (43.8% concomitant, 23.8% prior untethering vs. 17.4% no untethering; p = 0.0047), need for blood transfusion (51.6% concomitant, 57.1% prior untethering vs. 33.8% no untethering; p = 0.04), and increased mean length of stay (LOS) (13.4 days concomitant, 10.6 days prior untethering vs. 6.8 days no untethering; p < 0.0001). In multivariable logistic regression analysis, prophylactic untethering was independently associated with increased adjusted relative risks of surgical site infection (aRR = 2.65, 95% CI 1.17-5.02), unplanned re-operation (aRR = 2.17, 95% CI 1.02-4.65), and any complication (aRR = 2.25, 95% CI 1.07-4.74).

Conclusion: In this study, asymptomatic children with myelomeningocele who underwent scoliosis surgery developed no neurologic injuries regardless of prophylactic untethering. However, those who underwent prophylactic untethering were more likely to experience SSIs, return to the OR, need a blood transfusion, and have increased LOS than children not undergoing untethering. Based on these data, prophylactic untethering in asymptomatic MMC patients prior to scoliosis surgery does not provide any neurological benefit and is associated with increased surgical risks.
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http://dx.doi.org/10.1007/s00381-019-04276-zDOI Listing
November 2019