Surgical goals for congenital spinal deformity (CSD) include correction of deformity and prevention of progression without affecting neurological function. CSD has a higher incidence of intraoperative neuromonitoring (IONM) alerts than other scoliosis types and a potential for risk of postoperative neurological deficit. This study investigates incidence, risk factors, and outcomes associated with IONM alerts in surgically treated CSD. A prospectively collected pediatric database was queried for surgically managed patients with CSD. Demographic, surgical, and IONM details were analyzed and neurological outcomes were tracked. One hundred patients were included. Diagnoses were scoliosis, kyphosis, and kyphoscoliosis. Mean dominant-plane curvature was 64°. Hemivertebrae were present in 51 patients. IONM alerts occurred in 19

Adolescent Idiopathic Scoliosis (AIS) patients with a Lenke 5 curve pose a unique challenge due to their distinct alignment characteristics and the ambiguity surrounding whether to include the compensatory thoracic curve in the fusion construct. The aims of this study are to evaluate radiographic, alignment, and patient-reported outcome characteristics of Lenke 5 patients undergoing long vs. short posterior spinal fusion. A total of 277 Lenke 5 AIS patients were classified by surgical approach. Long fusion (LF) was defined as the upper instrumented vertebra (UIV) at levels T5 and above. Short fusion (SF) was defined as UIV at T9 or caudal. Patients were analyzed pre-operatively and at 2-year follow-up. 159 (57

To evaluate the behavior of the unfused lumbar spine 5 years after thoracic fusion (TF) in adolescent idiopathic scoliosis (AIS) patients with open triradiate cartilage (OTRC) compared to patients with closed triradiate cartilage (CTRC). A multicenter AIS database was queried for patients who underwent posterior TF (lowest instrumented vertebra L1 or cephalad) for a primarily thoracic curve (i.e., Lenke 1–3), with a B or C lumbar modifier. Patients were grouped by skeletal maturity into OTRC and CTRC (Risser 4 or 5) cohorts and compared for radiographic outcomes, inclinometer measurements, and SRS-22 scores. Radiographic measures included thoracic curve magnitude (TCM), thoracic kyphosis, lumbar curve magnitude (LCM), lumbar apical vertebral translation (AVT), coronal balance, and adding on. Generalized estimating equation models were utilized to estimate and evaluate differences in means. The OTRC group included 33 patients (mean age 11.9 years). The CTRC group included 131 patients (mean age 15.3 years). LCM decreased from preoperative to the first postoperative visits in both CTRC and OTRC groups, with no further change at 1-year and 5-year postoperative in both groups. Lumbar AVT improved from 1-year to 5-year postoperative in both groups. Coronal balance deteriorated immediately postoperatively in both groups but improved by 1 year and remained stable through 5 years. In all postoperative periods, there was no difference between OTRC and CTRC groups in LCM, lumbar AVT, coronal balance, and SRS-22 scores. Thoracic and lumbar rotation via inclinometer improved comparably in both groups. The OTRC group had a higher rate of distal adding-on (48.5

Background:. Longitudinal pulmonary outcomes after surgical treatment of early-onset scoliosis (EOS) are not well reported. This study aims to evaluate change in serial pulmonary function in children with EOS after surgery. Methods:. A retrospective review was performed at a single academic hospital. All patients who had surgical treatment of EOS and repeated pulmonary function test (PFT) data were included. Pulmonary function test (PFT) measures included forced vital capacity (FVC), FVC % of predicted norms (FVC%), forced expiratory volume in 1 second (FEV1), and FEV1% of predicted norms (FEV1%). To determine whether PFT changed postsurgery, a random-effects mixed model was used. Predicted marginal means of PFT measures were calculated, and Bonferroni adjusted p-values were reported. Spearman correlation was used to analyze the relationship between radiographic measures and PFTs. Results:. Fifty-one patients with EOS were included (mean age 7.2 years at index surgery). The index distraction-based growth-friendly construct was 31 (60.8%) vertical expandable prosthetic titanium rib implants, 9 (17.6%) traditional growing rods, and 11 (21.6%) magnetically controlled growing rods; 23 patients (45%) underwent final fusion. The median duration from the first to the most recent PFT was 44 months. The random-effects model showed no significant change in FVC, FVC%, and FEV1 over time since surgery. When changes in PFTs were analyzed by scoliosis etiology, there was no significant change in PFT measures after surgical treatment with any etiology except in congenital scoliosis where both FVC% and FEV1% significantly decreased during growth-friendly treatment and fusion compared with before surgery. T1-T12 length significantly correlated moderately with FVC (rho = 0.46, p < 0.0001), but not FVC%. Major curve Cobb angle did not significantly correlate with PFT measures. Conclusions:. Growth-friendly EOS surgery did not improve pulmonary function, but at best prevented further pulmonary decline, except in children with congenital scoliosis who had worsening function over time. Level of Evidence:. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Selective thoracic fusion (STF) is a surgical approach to adolescent idiopathic scoliosis designed to limit fusion and preserve lumbar motion by instrumentation, correction, and fusion of the thoracic curve and accepting spontaneous correction of the lumbar curve. This strategy is primarily applied to Lenke type 1C and 2C curves, but also Lenke type 3, 4, and 6 curves. When scoliosis classification guidelines recommend thoracic and lumbar curve inclusion, STF should be considered to allow a patient to maintain lumbar motion and disc function. However, when incorrectly indicated or when limited thoracic correction is obtained, outcomes are suboptimal. It is important to understand which patients to offer STF to and how to optimize their results.

Body mass index (BMI), is a nutritional index based on standing height and weight. Children with early onset scoliosis (EOS) have shorter height due to their spine curvature. In these patients’ pulmonary function tests, which are also based off height, arm span is standardly used as a surrogate for height to allow for normative comparisons. Arm span has not been used for nutritional assessments in children with EOS. We used both arm span and measured height to calculate BMI, and BMI as a percent of predicted published norms (BMI

BACKGROUND:For patients with adolescent idiopathic scoliosis (AIS), full-time scoliosis braces are effective in preventing curve progression but are a source of stress for patients and families. Nighttime hypercorrective braces have minimal impact on daily life, but there is little evidence to guide prescription. It is not known how providers with expertise in scoliosis incorporate nighttime bracing into their routine clinical practice. The aim of this study is to assess provider perspectives and recommendations regarding the use of nighttime and full-time scoliosis bracing for patients with AIS. METHODS:Providers engaged in nonoperative scoliosis management were invited to complete an online survey that included 12 scoliosis case scenarios. For each case scenario, respondents were asked to indicate their bracing recommendation and their willingness to randomize each case into a hypothetical clinical trial. The survey also queried respondents' use of nighttime and full-time bracing in their practice. Descriptive statistics were used to summarize findings; a linear mixed effects model was used to determine patient characteristics related to bracing recommendations and willingness to randomize. RESULTS:A total of 214 respondents completed the survey; most had been in practice for >15 years (58%) and dedicate the majority of their practice to pediatric spine (57%). Just over half (54%) currently prescribe nighttime braces. Across case scenarios, most respondents recommended full-time bracing (70% to 92%); recommendations varied by curve type, curve magnitude, and skeletal maturity. For providers who use nighttime braces, the most important factors that led providers to prescribe nighttime over full-time braces were patient willingness to wear the brace (58%), skeletal maturity (57%), and curve type (56%). CONCLUSIONS:Most providers preferred to prescribe full-time over nighttime braces. Providers were more willing to recommend a nighttime brace for patients with lumbar/thoracolumbar curves and those who were at lower risk for curve progression (ie, more skeletally mature and smaller curve magnitudes). Ultimately, results provide insights into current practice and will inform eligibility criteria and feasibility for a future study comparing nighttime and full-time braces. LEVEL OF EVIDENCE:Expert opinion.

Objective: Adolescents with idiopathic scoliosis (IS) are often prescribed an orthosis to prevent curve progression and avoid surgery. Standard-of-care scoliosis orthoses are designed for full-time (FT) wear, which can be burdensome for some patients. Nighttime (NT) hypercorrective scoliosis orthoses are another option that has a lower impact on daily life, however, additional research is needed to guide the prescription of NT orthoses. The aim of this study was to assess the willingness of patients with IS and their parents/guardians to enroll in a randomized controlled study on bracing in scoliosis. Methods: A cross-sectional study was conducted to survey adolescents with IS and their parents/guardians. Eligibility criteria for adolescent participants included: (1) diagnosis of IS, (2) no previous orthosis use, (3) currently seeing a provider for their scoliosis, and (4) able to communicate in English. Parent/guardian participants were the parent or guardian of an adolescent participant and were able to communicate in English. Separate online surveys were designed for adolescents and their parents/guardians. Surveys provided information about a hypothetical study and queried respondents about whether they would participate in the study, their willingness to randomize brace treatment, and their preferences for NT or FT bracing. Descriptive statistics were used to summarize survey data. Results: One hundred four adolescent/parent dyads completed the survey (104 adolescents and 103 parents). Most participants (adolescents: 55.8%, parents: 55.3%) indicated an interest in study participation, and approximately one-third of participants (adolescents: 31.8%, parents: 30.1%) reported that they would be willing to randomize to brace type. Most participants (adolescent: 77.0%, parent: 81.6%) preferred the NT brace if they needed brace treatment. Conclusions: High-quality evidence is needed to inform the use of FT and NT scoliosis orthoses. Approximately a third of respondents would enroll in a randomized trial, indicating that multiple collaborative sites will be needed to recruit a sufficient sample into a randomized study on scoliosis bracing. Study findings also demonstrate support from adolescents and their parents/guardians for research on scoliosis bracing.

BACKGROUND AND OBJECTIVES: Adult biomechanical studies suggest a significant reduction in flexion-extension motion after occipitocervical and atlantoaxial fusion. Anecdotal experience in children suggests a lower magnitude of reduction in motion after these procedures, but high-quality quantitative assessments of this motion have not yet been performed. As such, the aim of this study was to determine the magnitude of reduction in cervical spine flexion-extension after O-C2 and C1-2 fusion in pediatric patients. METHODS: The Pediatric Spine Study Group international registry was queried for patients aged 21 years or younger who underwent O-C2 or C1-2 instrumentation and fusion. Patients with cervical spine flexion-extension radiographs preoperatively and ≥6 months postoperatively were included. Flexion, extension, and overall range of motion (ROM) of the cervical spine were measured on radiographs using McGregor line and the inferior endplate of C7. RESULTS: In total, 34 patients were included, with 19 undergoing index O-C2 and 15 undergoing index C1-2 stabilization. The mean age was 9.3 ± 4.5 years with average follow-up of 3.5 ± 2.6 years. The most common etiologies were syndromic (n = 20) and congenital (n = 9). Patients undergoing O-C2 fusion had reduced neck extension (80° vs 69.6°, P = .003) and overall ROM (92.9° vs 80°, P = .002) after stabilization, but no significant reduction in flexion (−12.9° vs −10.4°, P = .324). After C1-2 fusion, there was no significant reduction in overall ROM (85.0° vs 77.5°, P = .079), extension (70.5° vs 63.4°, P = .120), or flexion (−14.6° vs −14.0°, P = .831). CONCLUSION: In this cohort, children undergoing O-C2 stabilization had a 13.9% reduction in flexion-extension motion of the cervical spine, primarily due to a reduction in extension. There may be a smaller reduction in flexion-extension motion after stabilization in children when compared with adult studies. Further studies with video analysis including axial rotation and lateral bending will be necessary to comprehensively quantify cervical spine motion after fusion across the occipitocervical and atlantoaxial junctions.

Advances in operative and recovery protocols such as the rapid recovery pathway (RRP) in the last decade have shortened inpatient stays for adolescent idiopathic scoliosis (AIS). This study aimed to evaluate the impact of these national trends on length of stay (LOS), complication rates, and costs in patients with AIS undergoing posterior spinal fusion (PSF) using a large, nationally representative dataset. A retrospective review of 10,081 patients requiring PSF for AIS was conducted using the Healthcare Cost and Utilization Project’s (HCUP) Kids’ Inpatient Database (KID) in the latest available year prior to the popularity of protocols like RRP (2012) and most recently (2019). Patients and complications were identified via ICD-9 and ICD-10 codes. Multivariate linear and logistic regression analyses were performed to assess the impact of year of surgery while adjusting for demographic variables. Average LOS decreased in 2019 vs. 2012 (3.9 days vs. 5.4 days, p < 0.001), year of surgery (β = –1.4 days, p < 0.001), and absence of complications (β = –2.8 days, p < 0.001) were the largest predictors of LOS. Overall complication rates declined from 12.8

BACKGROUND:Delayed-onset neurologic changes (DONCs) following spinal deformity surgery are poorly understood and are often devastating. METHODS:A retrospective review of cases from 12 hospitals was performed. The clinical and radiographic parameters of patients who experienced a new DONC after spinal deformity correction were evaluated. RESULTS:Eighteen patients, with a mean preoperative major Cobb angle of 75° ± 24°, were included. The mean age at surgery was 13 ± 2 years, and 6 patients (33%) were male. Seven patients had temporary intraoperative neuromonitoring changes. Fourteen patients (78%) had neurologic changes within 24 hours postoperatively (range, 3 to 24 hours). Of 16 patients with blood pressure data, 8 (50%) had at least 1 documented episode of hypotension surrounding the change in neurologic status. No misaligned implants were seen on axial imaging. Fourteen patients (78%) were treated with vasopressors. Sixteen patients (89%) returned to the operating room, and 11 patients (61%) underwent implant removal. Seven patients (39%) sustained a spinal cord infarct, with only 1 (6%) experiencing recovery beyond an ASIA (American Spinal Injury Association Impairment Scale) score of B. Ten (91%) of the 11 patients without an infarct demonstrated recovery (5 patients with an ASIA score of D and 5 with a score of E). CONCLUSIONS:A DONC is a rare complication of spinal deformity surgery. This study represents the largest documented series of DONCs and highlights the multifactorial and still poorly understood nature of this condition. The primary modifiable risk factor may be hypotension in the postoperative period: 50% of patients had a mean arterial pressure below the 5th percentile for their height, as documented around the time of the neurologic change. Eighty-six percent of patients with a spinal cord infarct had minimal neurologic recovery, whereas nearly all of the patients without an infarct did recover function. The management of this condition may include elevation of blood pressure with temporary implant removal. LEVEL OF EVIDENCE:Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Anterior vertebral body tethering (VBT) is a non-fusion surgical option for skeletally immature patients with idiopathic scoliosis. Prior studies demonstrated compensatory correction of the thoracic curve after lumbar posterior spinal fusion (PSF); however, no studies have examined thoracic curve correction after lumbar VBT. Patients with Lenke 5 + 6 lumbar scoliosis who underwent VBT and at least 2 years’ follow-up were compared to matched lumbar PSF patients. Groups were compared for major lumbar (L) and compensatory thoracic (T) curve correction, coronal/sagittal balance, and complications. 24 AVBT and 24 PSF patients were matched 1:1 for skeletal maturity and curve flexibility. There were no significant differences between VBT and PSF for average pre-operative or 2 year post-operative major L or compensatory T curves. Average final L curve correction was 50

Selecting the lowest instrumented vertebra (LIV) in fusion for adolescent idiopathic scoliosis is potentially the most nuanced decision a surgeon has to make. This article reviews the literature on the range-of-motion loss related to the LIV, ability to return to sports based on LIV, correlation between LIV and disk degeneration, and short-term and long-term clinical outcomes related to LIV.

Intraoperative traction can improve deformity correction during posterior spinal fusion (PSF). This is commonly done with invasive distal femoral or pelvic pins, or traction boots. The novel technique of intraoperative skin traction (ISkinT) avoids risks associated with intraoperative skeletal traction (ISkelT) or hyperlordosis with extended hip position. We aimed to describe ISkinT and assess its safety and efficacy in PSF in non-ambulatory scoliosis. Retrospective review of patients aged 10-21yo who underwent T2-pelvis PSF with ISkinT from 2017 to 2023. Demographics and radiographic measurements were statistically compared to a published cohort that used ISkelT. 42 patients treated with ISkinT were included and compared to 41 patients treated with ISkelT. ISkinT was applied by a cranial attachment and an average of 12

BACKGROUND:Patients with certain spinal anomalies are at risk for rare but devastating spinal cord injuries under anesthesia. We created a Spine at Risk (SAR) program to evaluate and recommend precautions for such patients, including intraoperative neuromonitoring (IONM) use for the highest-risk patients. We aimed to review all monitored nonspine procedures to determine rate of potential spinal cord injuries avoided in those who would otherwise have been unmonitored.METHODS:We performed a retrospective review of our institutional SAR program from 2011 to 2019 to analyze the number of nonspine anesthetized procedures that were done under IONM, the characteristics of those that had an IONM alert; and the clinical outcomes.RESULTS:Of the 3,453 patients flagged for SAR review, 1121 (33%) received a precaution recommendation, and 359 (10% of all flagged) were given IONM recommendations. Of those, 57 patients (16% of recommendations, 2% of all flagged) had a total of 102 nonspine anesthetized procedures done under IONM. Seven patients had a total of 10 cases with IONM alerts. Two cases were aborted when improved signals could not be obtained after working through a checklist; one of these patients woke with transient neurological deficits. Signals improved to baseline in 7 cases by working through a signal loss checklist. One case was aborted preoperatively when monitorable baseline signals could not be obtained.CONCLUSIONS:In the highest-risk spinal anomaly patients, we monitored an average of 11.7 nonspine cases per year, with a 10% rate of IONM alerts, and no permanent neurological deficits. Although the majority of patients remain safe during procedures, in the most critical patients IONM allowed the team to identify and react to alerts that may have otherwise led to permanent neurological injury. This is the largest series of spinal cord-monitored nonspine pediatric cases. It is important for pediatric orthopedic surgeons to evaluate at-risk patients and recommend IONM where appropriate, to protect both patients and our procedural colleagues.LEVEL OF EVIDENCE:Case series, level IV.

As rapid discharge protocols for pediatric spine fusion shorten stays, gastrointestinal (GI) complications are uncovered and cause delays in discharge. A pre-operative carbohydrate (CHO) drink has been shown to improve perioperative GI symptoms and functional return but has not been examined in pediatric spine patients. We aimed to determine if a preoperative CHO drink is safe in pediatric spine fusion patients, and if it improves their comfort scores and return of bowel function. We prospectively randomized ASA-1 and -2 pediatric spine fusion patients to either a pre-anesthesia carbohydrate drink 2 h prior to surgery or to a control group (standard 8 h NPO), blinded to surgical team. We documented time to return to flatus, bowel movement, GI symptoms, and comfort scores for 72 h post-operatively or until discharge. 62 patients were randomized. There was no significant differences between the groups’ pre-operative characteristics, surgical details, nor post-operative morphine dose equivalents, except for EBL (405 cc control, 340 cc CHO drink, p = 0.044). There were no perioperative complications related to ingestion of the CHO drink. CHO group had a positive trend for earlier return of flatus (21

Proximal junctional kyphosis is an infrequent complication in AIS; however, equipoise remains on the effects of ending a fusion proximally at the C7-T1 junction on the future development of PJK. The purpose of this study was to determine the rate of PJK in patients with AIS who had a UIV of T1 vs those with a UIV of T2 at 5 years of follow-up. A query was performed of a prospective, multi-center AIS database of patients who received a PSF with at least 5 years of follow-up. Patients with a T1 UIV (n = 29) were compared to those with a T2 UIV (n = 58). PJK was defined as a proximal junctional angle (PJA) > 10 degrees. There was no difference between the T1 and T2 UIV cohorts in preoperative T2-T12 kyphosis or pelvic incidence; however preoperatively, T1 UIV patients had a significantly decreased PJA at − 3° ± 4.5° as compared to T2 UIV patients 1.6° ± 6.5° (p = 0.0014). No patients with a T1 UIV experienced PJK at 5-years of follow-up, while 16

A halo has many applications for the treatment of pediatric spine pathology. It is most commonly used with gravity traction for the correction of severe thoracolumbar deformity over the course of several weeks before a staged fusion or growing implant placement. It is also used for preoperative optimization, secure positioning of small skulls for prone spine approach, cervical deformities such as basilar invagination, trauma treatment, or postoperative immobilization with a halo vest. Application of a halo is generally straightforward, but surgeons must be vigilant about complications and risks. Key Concepts (1)Halo placement must be done with an understanding of safe corridors for pin placement and pin torque specific to a patient's bony anatomy, quality, and age.(2)In severe thoracolumbar spinal deformity, halo-gravity traction (HGT) allows for elongation of the spine, correction of deformity, and chest elongation before the second-stage placement of implants.(3)In the cervical spine; HGT can be used to reduce basilar invagination before occipitocervical fusion, C1-2 rotatory subluxation before C1-2 fusion. A halo vest orthosis can be a definitive treatment for atlanto-occipital dislocation without neurologic injury.(4)Complications such as pin site infections and nerve palsies are frequent but most resolve quickly with appropriate management and vigilant monitoring.