Publications by authors named "Peter O Newton"

264 Publications

Early and late hospital readmissions in adolescent idiopathic scoliosis.

Spine Deform 2021 May 3. Epub 2021 May 3.

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

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

Objectives: To identify risk factors for early and late readmission of surgically treated patients with adolescent idiopathic scoliosis (AIS). Specific risk factors associated with readmission in patients with AIS remain poorly understood.

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

Results: 2049 patients were included in our cohort, with 1.6% requiring early readmission and 3.3% late readmission. In the multivariate analysis, greater preoperative coronal imbalance was associated with early readmission. Longer operative time was associated with late readmission. Finally, greater preoperative pain (SRS-22 pain scale) was associated with both early and late readmission. GI complications accounted for a higher proportion of early readmissions than previously reported in the literature.

Conclusions: Preoperative counseling of patients with higher levels of pain and coronal imbalance and the implementation of a thorough postoperative bowel regimen may help optimize patient outcomes.

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

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

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

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

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

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

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

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

The influence of 3D curve severity on paraspinal muscle fatty infiltration in patients with adolescent idiopathic scoliosis.

Spine Deform 2021 Mar 9. Epub 2021 Mar 9.

Department of Orthopaedic Surgery, University of California, 9500 Gilman Drive (MC0863), La Jolla, San Diego, CA, 92093, USA.

Purpose: In a sex-inclusive cohort of patients with adolescent idiopathic scoliosis (AIS): (1) assess the relationship between 3D curve severity, curve flexibility, and paraspinal muscle fatty infiltration, and (2) describe three-dimensional (3D) fatty infiltration of the paraspinal muscles.

Methods: Fat signal fraction of the paravertebral muscles was measured in pre-operative magnetic resonance images (MRIs) of males and females with AIS at the apex, ± 1, and ± 2 levels from the apex of the curve (n = 62). In a subset of patients with biplanar erect radiographic imaging (n = 35), 3D measures of deformity (axial rotation of the apical vertebrae, thoracic kyphosis, and coronal Cobb angle) were measured.

Results: Contrary to previous studies, no relationship between coronal Cobb angle and fatty infiltration was found. However, axial apical rotation and sagittal Cobb angle were found to be significant predictors of paravertebral fatty infiltration (R = 0.196-0.222). Curve concavity, female sex, and proximity to the curve apex were found to be the strongest predictors of fatty infiltration. Greater fatty infiltration of the paravertebral muscles was found on the concave side of the curve (15-24% vs. 11-13%), with increasing fatty infiltration toward the apex of the curve. Fatty infiltration was protected on the convex side of the curve, with no differences in the amount of fatty infiltration across levels.

Conclusion: These findings highlight that coronal curve severity and flexibility are not the primary influencing factors for the degree of paraspinal fatty infiltration in patients with AIS. This may have implications for nonsurgical rehabilitation strategies such as bracing and physical therapy.

Level Of Evidence: II.
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http://dx.doi.org/10.1007/s43390-021-00318-2DOI Listing
March 2021

Randomized controlled trial of energy healing effects on pain and anxiety in AIS posterior surgery: a pilot study.

Spine Deform 2021 Mar 8. Epub 2021 Mar 8.

Rady Children's Hospital, 3020 Children's Way, MC 5063, San Diego, CA, 92123, USA.

Objectives: Energy healing (EH) is a part of the diverse group of Complementary and Alternative Medicines (CAM). The purpose of this study was to evaluate the effects of EH therapy prior to and following posterior surgical correction for adolescent idiopathic scoliosis (AIS) compared to controls.

Methods: Patients were prospectively randomized to one of two groups: standard operative care for surgery (controls) vs. standard care with the addition of three EH sessions. The outcomes included visual analog scales (VAS) for pain and anxiety (0-10), days until conversion to oral pain medication, and length of hospital stay. For the experimental group, VAS was assessed pre- and post-EH session.

Results: Fifty patients were enrolled-28 controls and 22 EH patients. The controls had a median of 12 levels fused vs. 11 in the EH group (p = 0.04). Pre-operative thoracic and lumbar curve magnitudes were similar (p > 0.05). Overall VAS pain scores increased from pre- to post-operative (p < 0.001), whereas the VAS anxiety scores decreased immediately post-operative (p < 0.001). The control and pre-EH assessments were statistically similar. Significant decreases in VAS pain and anxiety scores from pre to post-EH assessment were noted for the EH group. Both groups transitioned to oral pain medication a median of 2 days post-operative (p = 0.11). The median days to discharge was four in the controls and three in the EH group (p = 0.07).

Conclusion: In this pilot study, EH therapy resulted in a decrease in patient's pre-operative anxiety. Offering this CAM modality may enhance the wellbeing of the patient and their overall recovery when undergoing posterior surgical correction for AIS.

Level Of Evidence: Therapeutic Level II.
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http://dx.doi.org/10.1007/s43390-021-00317-3DOI Listing
March 2021

Changes in peri-apical vertebral body and intervertebral disc shape in both the sagittal and coronal planes correlate with scoliosis severity: a 3D study of 397 patients.

Spine Deform 2021 Feb 19. Epub 2021 Feb 19.

Department of Orthopaedics, University of California, 3020 Children's Way, MC 5062, San Diego, CA, 92123, USA.

Purpose: To evaluate associations between vertebrae and disc shape asymmetry and adolescent idiopathic scoliosis (AIS) curve severity.

Methods: Analysis included normal screening referrals and patients with right, main thoracic AIS who underwent upright, biplanar radiographs with 3D reconstruction at a single institution from 2010 to 2015. Peri-apical anterior, posterior, right, and left vertebral body heights (aVBH, pVBH, rVBH, lVBH) and intervertebral disc heights (DH) were measured, and ratios of these measurements were calculated in sagittal and coronal planes. Correlations were performed between curve severity and height measurements. Sagittal and coronal plane components of these measurements were compared between normal controls with coronal curve measurements < 11° and patients with moderate (11°-49°) and severe curves (≥ 50°), with tolerance intervals established for the normal controls.

Results: The analysis included a total of 397 patients. Patients with AIS had coronal curve measurements ranging from 11° to 101°. Greater coronal curve severity strongly correlated with smaller pVBH relative to aVBH and moderately correlated with smaller pDH relative to aDH (r = - 0.643, r = - 0.305, respectively). aVBH was greater for larger curves; pVBH remained stable. Scoliosis severity strongly correlated with right relative to left VBH and DH ratios (r = 0.919, r = 0.865 respectively). In comparison of normal controls to severe curves, severe curves had significantly greater aVBH and aDH, while pVBH was not significantly different and pDH was significantly less. Nearly half (46.9%) of the severe curves were below the range of normal for PA vertebral height ratio.

Conclusion: In right, main thoracic AIS, greater main thoracic curve severity is associated with greater sagittal and coronal plane asymmetry of both the vertebral bodies and the discs. Severity more strongly correlates with vertebral changes in symmetry than with disc changes, though both are present.
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http://dx.doi.org/10.1007/s43390-021-00293-8DOI Listing
February 2021

The Clavicle Continues to Grow During Adolescence and Early Adulthood.

HSS J 2020 Dec 26;16(Suppl 2):372-377. Epub 2020 Apr 26.

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

Background: As more adults undergo surgical fixation of clavicle fractures with improved outcomes, interest is renewed in managing clavicle fractures in adolescents. The medial clavicular physis does not fuse until 23 to 25 years of age, but studies report minimal clavicular growth during adolescence-studies that employed cross-sectional methodologies, which cannot not capture growth in patients over time. The assumption that clavicle length at each stage is uniform, as is the final overall length, may not be accurate if the age groups studied comprise various ethnicities, socioeconomic status, or height.

Questions/purposes: We sought to quantify longitudinal clavicular growth on serial radiographs in adolescents and young adults. Our hypothesis was that substantial clavicular growth would be seen beyond the age of 12 years.

Methods: We conducted a longitudinal case series of non-syndromic patients in a single orthopedic clinic and analyzed serial radiographic images of the clavicles. For ethical reasons, only patients with non-neuromuscular scoliosis and kyphosis (in whom the existing standard of care includes serial thoracic radiographs) were considered for inclusion. Patients ages 10 to 25 years old were included in the study if three or more serial thoracic radiographs over a minimum 5 years were available that captured the entire length of at least one non-rotated clavicle. Three types of radiographs were included for analysis: digital low-dose-radiation stereoradiographic (EOS Imaging, Paris, France), non-EOS digital, and non-EOS printed. The overall longitudinal growth, yearly growth, and the yearly growth percentage were calculated for each clavicle.

Results: Fifty-seven patients (22 male and 35 female) met the inclusion criteria. In male patients, at ages 12 to 15 years, the clavicular growth was 4.9 mm/year, or 4%/year; at ages 16 to 19 years, growth was 3.2 mm/year, or 2.4%/year; and at ages 20 to 25 years, growth was 1.7 mm/year, or 1.1%/year. In female patients, at ages 12 to 15 years, growth was 4.7 mm/year, or 4%/year; at 16 to 19 years, growth was 2.2 mm/year, or 1.7%/year; and at ages 20 to 25 years, growth was 0.2 mm/year or 0.1%/year. We could not detect the age of terminal growth in either sex because growth was ongoing in most patients in the oldest group.

Conclusion: We found substantial clavicular growth potential after age 18 years, when growth is thought to be nearly finished, as well as remodeling potential even up to age 25 years. Further research is needed, but our findings suggest that strategies for managing clavicle fracture in adults may not be applied universally to adolescents and young adults.
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http://dx.doi.org/10.1007/s11420-020-09754-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7749897PMC
December 2020

Long-term Patient Perception Following Surgery for Adolescent Idiopathic Scoliosis if Dissatisfied at 2-year Follow-up.

Spine (Phila Pa 1976) 2021 Apr;46(8):507-511

Rady Children's Hospital, San Diego, CA.

Study Design: Longitudinal.

Objectives: To evaluate whether the rate of patients who report low health-related quality of life (HRQOL) scores at 2 years following surgical correction of adolescent idiopathic scoliosis (AIS) improves by 5 years postoperatively.

Summary Of Background Data: HRQOL scores are dependent upon a number of factors and even in instances of good surgical correction of a spinal deformity, are not guaranteed to be high postoperatively. Understanding how a low HRQOL score varies over the postoperative period can help surgeons more effectively counsel patients and temper expectations.

Methods: A multicenter database was reviewed for patients with both 2 and 5-year follow-up after spinal fusion and instrumentation for AIS. From a cohort of 916 patients, 52 patients with low HRQOL scores at their 2-year follow-up were identified and reevaluated at 5-year follow-up. A low HRQOL outcome was defined as having SRS-22 domain or total scores less than 2 standard deviations below the mean score. Reoperations were also evaluated to determine if they were associated with HRQOL scores.

Results: Of those patients with low SRS-22 HRQOL scores at 2 years postoperatively, improvements were seen in all SRS-22 domains and total scores at the 5-year time point. The greatest change was seen in the satisfaction category where 41 patients showed improvement. The rate of reoperations during this period did not significantly impact patient-reported outcomes.

Conclusions: Having a low HRQOL score 2 years after surgery for AIS does not guarantee a low score 5 years after surgery. Promisingly, most patients demonstrate some improvement in all domains for patient-reported SRS-22 scores at 5-year compared to 2-year follow-up. Understanding the longer term postoperative evolution in patient-reported outcomes may help surgeons to effectively manage and counsel patients who are dissatisfied in the short term.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003828DOI Listing
April 2021

Intraoperative neuromonitoring practice patterns in spinal deformity surgery: a global survey of the Scoliosis Research Society.

Spine Deform 2021 Mar 23;9(2):315-325. Epub 2020 Nov 23.

Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey.

Purpose: Although multimodal IONM has reached a widespread use, several unresolved issues have remained in clinical practice. The aim was to determine differences in approaches to form a basis for taking actions to improve patient safety globally.

Methods: A survey comprising 19 questions in four sections (demographics, setup, routine practices and reaction to alerts) was distributed to the membership of the SRS.

Results: Of the estimated 1300 members, 205 (~ 15%) completed the survey. Respondent demographics reflected SRS member distribution. Most of the respondents had > 10 years of experience. TcMEP and SSEP were available to > 95%. Less than 5% reported that a MD/PhD with neurophysiology background routinely examines patients preoperatively, while 19% would consult if requested. After an uneventful case, 36% reported that they would decrease sedation and check motor function if the patient was to be transferred to ICU intubated. Reactions to dropped signals that recovered or did not fully recover varied between attempting the same correction to aborting the surgery with no rods and returning another day, with or without implant removal. After a decrease of signals, 85.7% use steroids of varied doses. Of the respondents, 53.7% reported using the consensus-created checklist by Vitale et al. Approximately, 14% reported never using the wake-up test while others use it for various conditions.

Conclusion: The responses of 205 experienced SRS members from different regions of the world showed that surgeons had different approaches in their routine IONM practices and in the handling of alerts. This survey indicates the need for additional studies to identify best practices.
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http://dx.doi.org/10.1007/s43390-020-00246-7DOI Listing
March 2021

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

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

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

Design: Prospective cerebral palsy (CP) registry review.

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

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

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

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

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

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

Predictors of spontaneous lumbar curve correction in thoracic-only fusions: 3D analysis in AIS.

Spine Deform 2021 Mar 17;9(2):461-469. Epub 2020 Nov 17.

Department of Orthopaedics, University of California, San Diego, CA, USA.

Purpose: To evaluate how 3D parameters of the instrumented thoracic spine relate to the uninstrumented lumbar spine following thoracic-only fusion (TOF) for adolescent idiopathic scoliosis (AIS) and determine the factors predictive of lumbar correction.

Methods: A multi-center retrospective review was conducted of AIS patients with Lenke 1-4 B or C curves undergoing fusion of their thoracic spine only with minimum 2-year follow-up and 3D spine reconstructions from biplanar radiography. Pre-operative to 2-year post-operative differences were evaluated. Pearson's correlations were used to identify 3D coronal, sagittal and axial relationships at 2 years post-operative. Multivariate linear regression was used to identify variables most predictive of lumbar curve correction.

Results: Eighty-four AIS patients met inclusion (54 B modifiers, 30 C modifiers). Average pre-operative thoracic and lumbar curves were 54 ± 9° and 41 ± 7° and corrected to 19 ± 7° and 21 ± 7°, respectively. 3D T5-T12 thoracic kyphosis increased from 6 ± 13° to 26 ± 8°. Thoracic and lumbar apical rotation decreased from - 14 ± 6° to -5 ± 6° and 13 ± 5° to 11 ± 6°, respectively. Thoracic curve correction correlated with lumbar curve correction (r = 0.67, p = 0.001) and decreased LIV tilt correlated with smaller residual lumbar curve magnitude (r = 0.63, p < 0.001). Increasing 3D kyphosis of the instrumented segment correlated with increased percentage lumbar curve correction (r = 0.29, p = 0.009). Multivariate linear regression showed LIV tilt and thoracic curve magnitude as the most predictive variables of post-operative residual lumbar curve magnitude, and percent correction of the thoracic curve and change in 3D instrumented kyphosis as most predictive of percent correction of the lumbar curve.

Conclusions: Analysis of 3D data highlights several considerations for AIS patients undergoing TOF. Maximizing thoracic curve correction, leveling the LIV, and to a lesser extent, restoring kyphosis in the instrumented segment are the factors most likely to result in greater correction of the instrumented lumbar curve following thoracic-only fusions in Lenke 1-4 B and C curves.
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http://dx.doi.org/10.1007/s43390-020-00231-0DOI Listing
March 2021

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

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

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

Study Design: Prospective multicenter international observational study.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Three-dimensional analysis of spinal deformity correction in adolescent idiopathic scoliosis: comparison of two distinct techniques.

Childs Nerv Syst 2021 Feb 24;37(2):555-560. Epub 2020 Aug 24.

Department of Orthopaedics, University of California, San Diego, CA, USA.

Purpose: To compare 3D postoperative deformity correction using two distinct commonly utilized techniques for the treatment of adolescent idiopathic scoliosis (AIS).

Methods: AIS patients with major thoracic (Lenke 1-2) curves at two sites who underwent deformity correction via posterior spinal instrumented fusion using one of two distinct techniques were retrospectively reviewed. Patients were matched 1:1 between sites for Lenke type (95% Lenke 1) and follow-up time. The "band site" performed posteromedial translation using thoracic sublaminar bands and 5.5-mm rods. The "screw site" performed spine derotation using differential rod contouring with pedicle screws and 5.5-mm rods. 3D measures of deformity from spinal reconstructions were compared between sites.

Results: Preoperatively, the groups had similar thoracic curve magnitudes (band, 55 ± 12° vs. screw, 52 ± 10°; p > 0.05); the "screw site" had less T5-T12 kyphosis (2 ± 14° vs. 7 ± 12°, p = 0.05) and greater thoracic apical rotation (- 19 ± 7° vs. - 14 ± 8°, p = 0.007). Postoperatively, the "screw site" had greater percent correction (61% vs. 76%, p < 0.001) and kyphosis restoration (p = 0.002). The groups achieved a similar amount of apical derotation (p = 0.9). The "band site" used cobalt chromium rods exclusively; the "screw site" used cobalt chromium (3%) and stainless steel (97%; p < 0.001). The "band site" performed significantly longer fusions.

Conclusions: Significant variations were found between two commonly utilized techniques in AIS surgery, including rod material, correction mechanisms, and fusion levels. Significantly, a greater 3D deformity correction of the coronal and sagittal planes was observed at the "screw site" compared to the "band site", but with no difference in axial plane correction.
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http://dx.doi.org/10.1007/s00381-020-04868-0DOI Listing
February 2021

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

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

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

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

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

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

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

Conclusion: Despite higher curve magnitudes in patients undergoing surgical correction and thoracoplasty for complex pediatric spine deformity, our findings revealed that thoracoplasty does not negatively affect pulmonary function at 2-year follow-up.
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January 2021

Selecting the "Touched Vertebra" as the Lowest Instrumented Vertebra in Patients with Lenke Type-1 and 2 Curves: Radiographic Results After a Minimum 5-Year Follow-up.

J Bone Joint Surg Am 2020 Nov;102(22):1966-1973

Department of Orthopedic Surgery, The Daniel and Jane Och Spine Hospital, Columbia University, New York, NY.

Background: The selection of the lowest instrumented vertebra (LIV) in patients with adolescent idiopathic scoliosis (AIS) is still controversial. Although multiple radiographic methods have been proposed, there is no universally accepted guideline for appropriate selection of the LIV. We developed a simple and reproducible method for selection of the LIV in patients with Lenke type-1 (main thoracic) and 2 (double thoracic) curves and investigated its effectiveness in producing optimal positioning of the LIV at 5 years of follow-up.

Methods: The radiographs for 299 patients with Lenke type-1 or 2 AIS curves that were included in a multicenter database were evaluated after a minimum duration of follow-up of 5 years. The "touched vertebra" (TV) was selected on preoperative radiographs by 2 independent examiners. The LIV on postoperative radiographs was compared with the preoperative TV. The final LIV position in relation to the center sacral vertical line (CSVL) was assessed. The CSVL-LIV distance and coronal balance in patients who had fusion to the TV were compared with those in patients who had fusion cephalad and caudad to the TV. The sagittal plane was also reviewed.

Results: In 86.6% of patients, the LIV was selected at or immediately adjacent to the TV. Among patients with an "A" lumbar modifier, those who had fusion cephalad to the TV had a significantly greater CSVL-LIV distance than those who had fusion to the TV (p = 0.006) or caudad to the TV (p = 0.002). In the groups with "B" (p = 0.424) and "C" (p = 0.326) lumbar modifiers, there were no differences among the TV groups.

Conclusions: We recommend the TV rule as a third modifier in the Lenke AIS classification system. Selecting the TV as the LIV in patients with Lenke type-1 and 2 curves provides acceptable positioning of the LIV at long-term follow-up. The position of the LIV was not different when fusion was performed caudad to the TV but came at the expense of fewer motion segments. Patients with lumbar modifier "A" who had fusion cephalad to the TV had greater translation of the LIV, putting these patients at risk for poor long-term outcomes.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.19.01485DOI Listing
November 2020

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

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

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

Study Design: Observational.

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

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

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

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

Level Of Evidence: Therapeutic-IV.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7384279PMC
December 2020

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

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

Rady Children's Hospital, Encinitas, USA.

Study Design: Prospective cohort review.

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

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

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

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

Level Of Evidence: III.
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December 2020

Three-dimensional analysis of the sagittal profile in surgically treated Lenke 5 curves in adolescent idiopathic scoliosis.

Spine Deform 2020 12 23;8(6):1287-1294. Epub 2020 Jul 23.

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

Study Design: Retrospective.

Objectives: To determine how the pre- and postoperative three-dimensional (3D) sagittal profiles of Lenke 5 curves in idiopathic scoliosis patients compare to unaffected controls. Prior research evaluating the sagittal plane of Lenke 5 (thoracolumbar/lumbar) curves in 2D suggests that the major curve is hypolordotic.

Methods: Patients with Lenke 5 curves treated with thoracolumbar/lumbar posterior fusion who had biplanar radiography (with 3D reconstruction) preoperatively (Pre) and 2+ years postoperatively (PO2Y) were included. A cohort of similarly aged controls (C) without spinal pathology was identified. The following 3D sagittal measurements were compared both pre- and postoperatively to controls: T1-T10, T10-L3, L3-S1, and pelvic incidence (PI). Kyphosis is designated by positive values, and lordosis by negative values.

Results: Nineteen Lenke 5 patients and 125 controls were included. Preoperatively, Lenke 5 patients were hypokyphotic relative to controls from T1 to T10 (30° ± 13° vs. 42° ± 9°, p < 0.001) and hyperlordotic from T10 to L3 (- 26° ± 15° vs. - 13° ± 12°, p < 0.001). Lenke 5 spines were less lordotic from L3 to S1 (- 41° ± 9° vs. - 47° ± 7°, p = 0.004). PI was similar between groups (Lenke 5 Pre: 48° ± 13°, C: 46° ± 10°, p = 0.49). Postoperatively, the area of principal deformity (T10-L3) remained hyperlordotic (PO2Y: - 23° ± 10° vs. C: - 13° ± 12°, p < 0.001). The proximal and distal uninstrumented segments demonstrated spontaneous sagittal correction, becoming similar to controls: T1-T10 (PO2Y: 41° ± 12° vs. C: 42° ± 9°, p = 0.421) and L3-S1 (PO2Y: - 48° ± 9° vs. C: - 47° ± 7°, p = 0.56).

Conclusion: When measured in 3D, Lenke 5 curves were more lordotic than controls in the periapical region of the major coronal curve. Posterior correction improved sagittal alignment, including spontaneous sagittal correction of the unfused segments. However, ~ 10° of hyperlordosis persisted in the instrumented/fused T12-L3 segment. Intraoperative correction strategies should take this preoperative increase in 3D sagittal deformity into account during rod contouring as well as compression/distraction to restore more normal sagittal alignment.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s43390-020-00168-4DOI Listing
December 2020

The Relationship Between 3-dimensional Spinal Alignment, Thoracic Volume, and Pulmonary Function in Surgical Correction of Adolescent Idiopathic Scoliosis: A 5-year Follow-up Study.

Spine (Phila Pa 1976) 2020 Jul;45(14):983-992

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

Study Design: Retrospective review of a prospective multicenter database.

Objective: The aim of this study was to study the effects of thoracic kyphosis (TK) restoration in adolescent idiopathic scoliosis (AIS) Type 1 and 2 curves on postoperative thoracic volume (TV) and pulmonary function.

Summary Of Background Data: Surgical correction of AIS is advocated to preserve or improve pulmonary function, prevent progressive deformity and pain, and improve self-appearance. Restoration of sagittal and 3D alignment, particularly TK, has become increasingly emphasized in efforts to improve pulmonary function, TVs, sagittal balance, and prevent adjacent-segment degeneration and deformity.

Methods: AIS patients 10 to 21years undergoing surgical correction of Lenke Type 1 and 2 curves with baseline, 1-erect-postoperative, and 5-year (5Y) postoperative visits including stereoradiographic assessment and pulmonary function tests (PFTs) were included. 3D-radiographic analysis was performed to assess spinal-alignment, chest-wall, and rib-cage dimensions at each time point. Outcome variables were analyzed between time points with one-way analysis of variance and between variables with linear regression analysis.

Results: Thirty-nine patients (37 females, 14.4 ± 2.2 years) were included. 3D-spinal-alignment analyses demonstrated significant reduction in preoperative to first-erect thoracic and lumbar Cobb-angles, an increase in TK:T2-12 (19.67°-39.69°) and TK:T5-12 (9.47°-28.05°), and reduction in apical vertebral rotation (AVR) (P < 0.001 for all). Spinal-alignment remained stable from 1-erect to 5Y. 3D rib-cage analysis demonstrated small reductions in baseline to first-erect depth (145-139 mm), width (235-232 mm), and increase in height (219-230 mm, P < 0.01), but no significant change in volume (5161-5222 cm,P = 0.184). From 1-erect to 5Y, significant increases in depth, width, height, and volume (all P < 0.001) occurred. PFTs showed preoperative to 5Y improvement in first second of Forced Expiratory Volume (FEV1) (2.74-2.98 L, P = 0.005) and forced vital capacity (FVC) (3.23-3.47 L, P = 0.008); however, total lung capacity (TLC) did not change (P = 0.517). Percent-predicted TLC decreased (Pre: 101.3% to 5Y: 89.3%, P < 0.001); however, percent-predicted forced expiratory volume and FVC did not (P = 0.112 and P = 0.068).

Conclusion: Although TK increases, coronal-Cobb and AVR decrease postoperatively; these do not directly influence TV, which increases from 1-erect to 5Y due to growth, corresponding with increases in FEV1 and FVC at 5Y; however, surgical restoration of kyphosis does not directly improve pulmonary function.

Level Of Evidence: 3.
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July 2020

Associations between three-dimensional measurements of the spinal deformity and preoperative SRS-22 scores in patients undergoing surgery for major thoracic adolescent idiopathic scoliosis.

Spine Deform 2020 12 2;8(6):1253-1260. Epub 2020 Jun 2.

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

Study Design: Retrospective study.

Objective: To analyze the relationships between three-dimensional (3D) measurements of spinal deformity and Scoliosis Research Society-22 (SRS-22) scores in preoperative patients with major thoracic adolescent idiopathic scoliosis (AIS). Previous studies reported 2D measurements were not or only weakly correlated with preoperative SRS-22 scores. However, 2D measures do not always accurately represent the 3D deformity.

Methods: A multicenter prospective registry of surgically treated AIS patients was reviewed for patients with right major thoracic AIS (Lenke type 1-4) who underwent biplanar radiography and completed the SRS-22 questionnaire preoperatively. For the 3D measurements, two reference frames were utilized: global (gravity/patient-based) and local (vertebra/disc-based). To obtain regional measurements, the individual segments in the appropriate reference plane were summed between the levels of interest. Patients were divided into two groups for each SRS-22 domain according to their scores: low (< 4) and high (≥ 4) score groups. Group differences and correlations with SRS-22 scores were analyzed with p < 0.01 as the threshold for significance.

Results: There were 405 eligible patients (mean age, 14.4 years). The mean 3D thoracic curve was 59° (45°-115°). The only significant group difference of 3D measurements occurred in the local lumbar lordosis (LL) with a small mean difference (- 3.4°, p = 0.008) in the mental health domain. In the correlation analyses, global and local thoracic kyphosis (TK) and TK/LL ratio demonstrated significant, but weak, correlations with function and total scores (|r|< 0.2, p < 0.01).

Conclusion: 3D measurements of scoliosis severity have only weak associations with preoperative SRS-22 scores, which might indicate a limit to the discriminative capacity of the SRS-22 within surgical range major thoracic AIS curves. Interestingly, the sagittal plane was the principle 3D plane in which significant correlations existed.

Level Of Evidence: II, prognostic.
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December 2020

More severe thoracic idiopathic scoliosis is associated with a greater three-dimensional loss of thoracic kyphosis.

Spine Deform 2020 12 2;8(6):1205-1211. Epub 2020 Jun 2.

Department of Orthopaedics, University of California, San Diego, CA, USA.

Study Design: Retrospective.

Objectives: Utilize three-dimensional (3D) measurements to assess the relationship between thoracic scoliosis severity and thoracic kyphosis in a large, multicenter cohort, and determine impact of 3D measurements on adolescent idiopathic scoliosis (AIS) curve classification. Research has demonstrated differences in two-dimensional (2D) and 3D assessment of the sagittal plane deformity in AIS. A prior smaller, single-institution study demonstrated an association between scoliosis severity and loss of 3D thoracic kyphosis.

Methods: Data included retrospective compilation of prospectively enrolled bracing candidates and prospectively enrolled surgical candidates with thoracic AIS. Analysis included two groups based on thoracic curve magnitude: moderate (20-45°) and severe (> 45°). Imaging was performed using 2D radiographs. 3D thoracic kyphosis was calculated using a 2D to 3D conversion formula. Kyphosis was categorized according to the Lenke classification sagittal plane modifier.

Results: Analysis included 3032 patients. 2D kyphosis was significantly less in the moderate group (21 ± 12 vs 23 ± 14, p = 0.028). However, estimated 3D kyphosis was significantly greater in the moderate group (13 ± 10 vs 5 ± 12, p < 0.001). In the moderate group, the rate of normokyphosis was 78% with 2D measures and 61% with 3D measures of T5-T12 kyphosis. In the severe group, this rate changed from 72 to 32% with use of 2D and 3D measures, respectively. In the moderate group, 16% of patients were classified as hypokyphotic using 2D measures while this rate increased 38% with 3D measures (p < 0.001). In the severe group, this rate changed from 18 to 68% using 2D and 3D measures, respectively (p < 0.001).

Conclusions: Increased coronal curve severity was associated with decreased thoracic kyphosis. Hypokyphosis was more pronounced in 3D. 2D radiographs increasingly underestimate kyphosis with increasing coronal severity. Assessment of sagittal alignment from 2D radiographs can be improved with a 2D-3D conversion formula. Findings indicate potential for classification system improvement with use of 3D sagittal plane measurements.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s43390-020-00149-7DOI Listing
December 2020

A 3D Parameter Can Guide Concave Rod Contour for the Correction of Hypokyphosis in Adolescent Idiopathic Scoliosis.

Spine (Phila Pa 1976) 2020 Oct;45(19):E1264-E1271

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

Study Design: Retrospective.

Objective: To evaluate the effect of preoperative rod shape on 3D spinal deformity correction.

Summary Of Background Data: Differential rod contouring is a surgeon-dependent process based on an estimate of 3D deformity correction sought and the flexibility of the spine. An objective measure to this otherwise subjective scoliosis correction technique is lacking.

Methods: A series of adolescent idiopathic scoliosis (AIS) patients with right, thoracic major curves, preoperative rod contour tracings, and EOS imaging was evaluated. All patients underwent posterior spinal fusion with 5.5 mm steel rods contoured prior to insertion. 3D reconstructions were generated pre- and postoperatively using sterEOS software (EOS Imaging) and imported into MATLAB (Mathworks) for analysis. A new measurement of the maximum perpendicular distance from the preinsertion concave rod contour to the preoperative 3D sagittal spinal reconstruction was defined as rod to 3D spine distance (RSD). Linear regressions were used to identify relationships between pre and postoperative parameters, including RSD and 3D thoracic kyphosis.

Results: Ninety-nine patients were included. Average preoperative concave rod angle decreased from (48 ± 10°) preoperatively to 26 ± 6° postoperatively (P < 0.001) for an average flattening of ∼20°. Average convex rod angle increased from 30 ± 6° to 34 ± 5° (P < 0.001). Average preoperative thoracic curve magnitude and apical vertebral rotation were 57 ± 8° and 16 ± 5° and decreased to 11 ± 6° and 5 ± 6° (P < 0.001). Average 2D and 3D thoracic kyphosis increased from 19 ± 14° and 2 ± 12° to 27 ± 6° and 22 ± 5° (P < 0.001). Preoperative RSD strongly correlated with 3D thoracic kyphosis change (P < 0.001, r = 0.796, R = 0.633).

Conclusion: On average, the concave rod flattened ∼20° after connection to the spine. Similarly, kyphosis increased ∼20° following rod insertion. A strong correlation was identified between RSD and 3D thoracic kyphosis restoration. This novel 3D parameter can guide the degree of concave rod bend necessary to achieve a desired increase in thoracic kyphosis in AIS.

Level Of Evidence: 2.
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October 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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August 2020

Anterior Spinal Growth Modulation in Skeletally Immature Patients with Idiopathic Scoliosis: A Comparison with Posterior Spinal Fusion at 2 to 5 Years Postoperatively.

J Bone Joint Surg Am 2020 May;102(9):769-777

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

Background: Anterior vertebral body tethering (AVBT) has been introduced as a means of correcting scoliosis without fusion. The purpose of this study was to compare outcomes for patients with thoracic idiopathic scoliosis between a group of patients who underwent AVBT and a matched cohort of patients treated with posterior spinal fusion and instrumentation (PSF).

Methods: A retrospective study of patients who underwent AVBT and PSF for idiopathic scoliosis was conducted. The inclusion criteria were determined on the basis of the AVBT cohort: primary thoracic idiopathic scoliosis with a curve magnitude between 40° and 67°, Risser stage of ≤1, age of 9 to 15 years, no prior spine surgery, index surgery between 2011 and 2016, and minimum follow-up of 2 years. Demographic, radiographic, clinical, and patient-reported outcomes and revisions were compared between groups.

Results: There were 23 patients in the AVBT cohort and 26 patients in the PSF cohort. The mean follow-up (and standard deviation) was similar between groups: 3.4 ± 1.1 years for the AVBT group and 3.6 ± 1.6 years for the PSF group (p = 0.6). Preoperatively, the groups were similar in all measurements of radiographic and clinical deformity, with mean main thoracic curves of 53° ± 8° for the AVBT group and 54° ± 7° for the PSF group (p = 0.4). At the time of final follow-up, the AVBT cohort had significantly more residual deformity, with a mean thoracic curve of 33° ± 18° compared with 16° ± 6° for the PSF group (p < 0.001). There were 9 revision procedures in the AVBT cohort (with 3 conversions to PSF and 3 more pending) and none in the PSF cohort. Revisions occurred at a mean postoperative time of 2.3 years (range, 1.2 to 3.7 years). Twelve patients (52%) had evidence of broken tethers; of these patients, 4 underwent revision. The post-intervention patient-reported outcomes were similar.

Conclusions: Both AVBT and PSF resulted in postoperative correction; however, 2-year correction was better maintained in the PSF group. There were no differences in post-intervention patient-reported outcomes. AVBT resulted in less deformity correction and more revision procedures than PSF, but resulted in the delay or prevention of PSF in the majority of patients.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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May 2020

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

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

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

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

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

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

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

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

Level Of Evidence: IV.
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June 2020

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

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

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

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

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

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

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

Level Of Evidence: Therapeutic-IV.
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June 2020

Spinal growth tethering: indications and limits.

Authors:
Peter O Newton

Ann Transl Med 2020 Jan;8(2):27

Rady Children's Specialist of San Diego, San Diego, CA, USA.

The standard of care for progressive spinal deformity that is greater than 45-50 degrees in growing children is deformity correction with spinal fusion and instrumentation. This sacrifice both spinal motion and further spinal growth of the fused region. Idiopathic scoliosis in particular is associated with disproportionate anterior spinal column length compared to the posterior column (hypokyphosis) that is associated with the coronal (scoliosis) and axial plane (rib and lumbar prominence) deformities. In theory, application of compression to the convex and anterior aspects of vertebrae could decrease both anterior and lateral growth via the Hueter-Volkmann principle, while allowing growth on the concave and posterior aspect resulting in spinal realignment created by altered growth. Animal models and preliminary clinical experience suggest spinal growth can be modulated in this way using a flexible tether applied to the convex side of scoliotic vertebral column. Experimental studies suggest disc health is preserved with a flexible tether as disc motion is maintained during the growth period. Anterolateral tethering been performed via a thoracoscopic spinal approach clinically for a number of years and the early clinical outcomes are beginning to appear in the literature. Initial results of anterolateral tethering in growing patients with spinal deformities are encouraging, however the results 3-4 years after the procedure are somewhat mixed. Further research is ongoing and many remain optimistic that improvements in technology and understanding will continue to lead to better patient outcomes.
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http://dx.doi.org/10.21037/atm.2019.12.159DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6995909PMC
January 2020

Non-Fusion Surgical Correction of Thoracic Idiopathic Scoliosis Using a Novel, Braided Vertebral Body Tethering Device: Minimum Follow-up of 4 Years.

JB JS Open Access 2019 Oct-Dec;4(4):e0026. Epub 2019 Dec 12.

National University of Singapore, Singapore.

Anterior vertebral body tethering to effect scoliosis correction in a growing spine has been shown to work with varying degrees of success. This report describes the mid-term results of this technique using a new device composed of a braided ultra-high molecular weight polyethylene (UHMWPE) cord anchored to bone screws applied without segmental compression.

Methods: This was a single-center prospective observational study of an investigational device. Five female patients aged 9 to 12 years with thoracic scoliosis underwent thoracoscopic insertion of the UHMWPE tether. Radiographs and magnetic resonance imaging (MRI) were performed, and the Scoliosis Research Society (SRS)-22 was administered, preoperatively and at regular intervals after surgery, with a minimum of 4 years of follow-up.

Results: All tethering devices spanning the end vertebrae (range, 7 to 8 vertebrae) were implanted successfully. Mean blood loss was 136 mL, and the mean operative time was 205 minutes. The mean preoperative main thoracic Cobb angle was 40.1°. Curve correction of the tethered segment ranged from 0% to 133.3% at 4 years. We observed greater correction in 2 patients with open triradiate cartilage (TRC), achieving full scoliosis correction at 2 years and 121.5% at 4 years. MRI showed improvement in periapical disc wedging morphology and 55% improvement of rotation at 3 years. There were 20 adverse events, of which 16 were mild and 4 were moderate in severity. The 4 moderate events of pneumonia, distal decompensation, curve progression, and overcorrection occurred in 3 patients, 2 of whom required fusion.

Conclusions: Anterior vertebral body tethering resulted in scoliosis deformity correction in the coronal and axial planes, with preservation of curve flexibility. Actual correction by growth modulation was noted only in patients with open TRC, whereas curve stabilization was noted in patients with closed TRC. Overcorrection, curve progression, and distal decompensation are problems with this technique.

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.OA.19.00026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6959921PMC
December 2019

New Paradigms in the Continuum of Spine Care: From Newborns to Elderly Patients.

Instr Course Lect 2019 ;68:289-304

The evaluation and management of spinal disorders is complex and constantly evolving. Back pain and spinal deformity are substantial contributors to hospital and outpatient physician visits even for young patients. With new insights into the etiology, clinical presentation, and evaluation, children can be more accurately diagnosed and treated. Patients with adolescent idiopathic scoliosis may undergo selective fusion to preserve motion segments, and in some cases, vertebral body tethering or other growth-modification techniques may provide correction with motion preservation in this rapidly changing specialty. The understanding of spinopelvic parameters (pelvic incidence, pelvic tilt, sacral slope) and sagittal balance as they relate to clinical health status has provided surgeons with valuable guidance when managing pediatric and adult spinal deformity. An evidence-based approach to the management of spinal disorders across the continuum of ages has the goal of improving the value of care through optimization of outcomes and limitation of costs and complications. There are new paradigms in the management of spinal disorders and evidence-based approaches to the evaluation and management of patients across the ages.
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February 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