Background: Pediatric spinal deformity surgery can involve significant perioperative blood loss, and allogeneic blood transfusion has been linked to an increased risk of adverse events. This study aimed to quantify adverse events associated with allogeneic blood transfusion in pediatric idiopathic scoliosis surgery. Study design/setting: Retrospective observational cohort study. Methods: The National Surgical Quality Improvement Program (NSQIP) Pediatric database (2016-2022) was queried. Patients <18 years undergoing posterior arthrodesis with 7 or more surgical levels for idiopathic scoliosis were included. The primary outcome was a composite 30-day adverse event outcome. Chi-square tests were used to compare the rates of adverse events associated with allogeneic blood transfusion. A multivariable logistic regression analysis was performed to assess the association between allogeneic blood transfusion and the occurrence of adverse events. Results: A total of 23,106 patients were included in this study, of which 12.3% received allogeneic transfusion. The rate of the composite 30-day adverse event outcome was 1.1%. Patients that received allogeneic transfusion had a higher rate of 30-day adverse event (2.5% vs 0.9%; X2 ​= ​62.5, P ​< ​.001). Allogeneic transfusion was associated with a higher rate of renal failure, cardiac arrest, venous thromboembolism, deep wound infection/dehiscence, sepsis/septic shock, pneumonia, and unplanned reintubation. In a multivariable logistic regression analysis, allogeneic transfusion was associated with higher odds of the composite 30-day adverse event outcome (odds ratio [OR]: 2.09, P ​< ​.001). Conclusions: In this large national pediatric registry cohort, allogeneic transfusion was associated with higher odds of 30-day adverse events after posterior spinal fusion for idiopathic scoliosis. Further prospective and center-level studies are needed to clarify transfusion thresholds, blood management strategies, and potential contributors to adverse outcomes. Key Concepts: (1) In 23,106 pediatric idiopathic scoliosis patients from the American College of Surgeons National Surgical Quality Improvement Program, 12.3% received allogeneic transfusion and the overall 30-day composite adverse event rate was 1.1%. (2) Patients who received allogeneic transfusion had a significantly higher rate of composite 30-day adverse events compared to those who did not (2.5% vs 0.9%, P ​< ​.001). (3) Allogeneic transfusion was associated with higher rates of specific complications, including renal failure, cardiac arrest, venous thromboembolism, unplanned reintubation, deep wound infection/dehiscence, sepsis/septic shock, pneumonia, and 30-day mortality. (4) On multivariable logistic regression, allogeneic transfusion independently increased the odds of composite adverse events (OR: 2.09, 95% CI: 1.37-3.19, P ​< ​.001). Level of Evidence: Level III

Aims:Spinal casting is accepted as a surgical delay strategy in the management of early onset scoliosis (EOS). There is no consensus on protocol to optimize outcomes. This study compares the five-year outcomes of intermittent casting (IC) with continuous casting (CC) strategies, focusing on deformity control. Methods:This was a progression-free survival analysis informed by retrospective chart review of all EOS patients who had spinal casting between January 2002 and August 2025. IC was defined as two to three casts applied over six months, followed by bracing and single repeat casts if progression was noted. CC was defined as the repeat application of casts every 12 to 16 weeks, over a period > one year. Patients with < 12-month follow-up or with congenital aetiology were excluded. The primary outcome was curve progression > 5° or transition to surgery. Kaplan-Meier analysis with log-rank test compared the efficacy of each strategy to halt curve progression or delay surgery. Cox proportional hazards model was used to estimate the adjusted hazard ratio (aHR) between strategies. In-cast correction and complications related to casting were recorded. Results:Overall, 59% (n = 30) underwent IC and 41% (n = 21) CC. Groups were similar at baseline in sex, age, aetiology, and index curve magnitude (mean 64° (SD 15°)). The five-year progression-free survival rate was 47% (95% CI 33.7 to 66.0), which did not differ by casting strategy (p = 0.095). In-cast correction was stable with CC, whereas less correction was achieved over time with IC (p = 0.004). The adjusted risk of progression decreased with greater correction in first cast (aHR 0.48, 95% CI 0.28 to 0.83, p = 0.009) and increased with larger index curve magnitudes (aHR 3.01, 95% CI 1.48 to 6.12, p = 0.002). Each group had one complication. Conclusion:There is not a distinct advantage with a CC strategy over an IC strategy with both offering deformity control and meaningful delays in surgery for EOS patients. The long-term implications of ongoing in-cast correction seen with CC are yet to be determined.

Purpose:The purpose of this study is to estimate the prevalence and incidence of treatment-range adolescent idiopathic scoliosis (≥20°) over 10-years in Ontario youth 10-17 years of age, by validating a population-based health administrative data algorithm for case ascertainment. Patients and Methods:Algorithms were developed using a combination of health administrative data: diagnostic, fee and/or specialty codes from physician billing data over various look-back periods. Algorithms' ability to distinguish between youth with scoliosis, confirmed by a tertiary-care spine specialist (AIS+; n = 2732), and a provincially derived comparator group without (AIS-; n = 49,049) were evaluated using sensitivity, specificity, positive and negative predictive values with their 95% confidence intervals. The top performing algorithm was used to estimate sex- and age-standardized prevalence and incidence between 2012 and 21. Annual rate ratios were calculated using a negative binomial regression model, adjusted for age, sex, and age-sex interaction. Significance was accepted at p < 0.05. Results:The AIS+ cohort had a median curve magnitude of 35° (interquartile range: 25.5-45.5). Of the 93 algorithms tested, the top was "2 physician billing codes for scoliosis in 2 years" with sensitivity: 83.1% (95% CI, 81.6-84.5%), specificity: 99.3% (95% CI, 99.2-99.3%), positive predictive value: 86.3% (95% CI, 85.0-87.6%), negative predictive value: 99.1% (95% CI, 99.0-99.1%). Annual prevalence estimates averaged 513.3/100 000 and incidence 128.2/100 000. There was a modest annual increase in the adjusted rate ratios: 1% for prevalence, 2% for incidence. Rates were highest for females at 13-years and males at 15-years of age, with rates 65% lower for males. Conclusion:The selected health administrative data algorithm demonstrated excellent diagnostic accuracy in identifying radiographically confirmed, treatment-range adolescent idiopathic scoliosis in 10-17-year-old youth. This is an efficient and scalable method for clinically meaningful population-level cohort creation that will facilitate surveillance of scoliosis diagnostic and treatment trends and longitudinal outcome research.

Aims This study aims to determine the reliability, accuracy, and usability of a new health application that uses AI to estimate major coronal curve magnitude in patients with adolescent idiopathic scoliosis (AIS) from 3D surface topography (ST) captured on a smartphone video scan. Methods This is a prospective validation study. AIS patients, aged ten to 18 years, with coronal curve magnitudes ≤ 45° were recruited at a tertiary care spine clinic. A single trained researcher performed scans twice, six months apart, during participants’ routine clinical and radiological assessment. Participants were asked to complete a scan once a month between clinic visits, starting the day of recruitment. Agreement was calculated by comparing scan curve magnitude predictions to the reference standard: a three-foot standing spine radiograph measured by blinded spine clinicians. Inter-rater reliability was assessed by comparing in-clinic to home scan predictions. Measures of diagnostic accuracy to determine the app’s ability to screen for coronal deformity > 25° and its ability to detect progression > 5° over a six-month period were determined. Successful compared with failed scans were recorded. Results Among participants (n = 63), 59 patients (94%) had at least one successful in-clinic scan and 32 patients (51%) had at least one successful home scan. Agreement with the reference standard was moderate for in-clinic scans (intraclass correlation coefficient (ICC) 0.535) and poor for home scans (ICC 0.402). Inter-rater reliability between in-clinic and home scans was poor (ICC 0.168). The app had an accuracy of 70% when discriminating between curve magnitudes ± 25° and detecting curve progression > 5°. A larger proportion of scans failed at-home (30%) compared with in-clinic (16%). Conclusion Conceptually, the app shows potential as an accessible screening tool for scoliosis. However, the accuracy and reliability suggest it is not yet a reasonable replacement for radiographs and in-person clinical evaluation. Cite this article: Bone Jt Open 2026;7(4):473–481.

Aims Spinal casting is accepted as a surgical delay strategy in the management of early onset scoliosis (EOS). There is no consensus on protocol to optimize outcomes. This study compares the five-year outcomes of intermittent casting (IC) with continuous casting (CC) strategies, focusing on deformity control. Methods This was a progression-free survival analysis informed by retrospective chart review of all EOS patients who had spinal casting between January 2002 and August 2025. IC was defined as two to three casts applied over six months, followed by bracing and single repeat casts if progression was noted. CC was defined as the repeat application of casts every 12 to 16 weeks, over a period > one year. Patients with < 12-month follow-up or with congenital aetiology were excluded. The primary outcome was curve progression > 5° or transition to surgery. Kaplan-Meier analysis with log-rank test compared the efficacy of each strategy to halt curve progression or delay surgery. Cox proportional hazards model was used to estimate the adjusted hazard ratio (aHR) between strategies. In-cast correction and complications related to casting were recorded. Results Overall, 59% (n = 30) underwent IC and 41% (n = 21) CC. Groups were similar at baseline in sex, age, aetiology, and index curve magnitude (mean 64° (SD 15°)). The five-year progression-free survival rate was 47% (95% CI 33.7 to 66.0), which did not differ by casting strategy (p = 0.095). In-cast correction was stable with CC, whereas less correction was achieved over time with IC (p = 0.004). The adjusted risk of progression decreased with greater correction in first cast (aHR 0.48, 95% CI 0.28 to 0.83, p = 0.009) and increased with larger index curve magnitudes (aHR 3.01, 95% CI 1.48 to 6.12, p = 0.002). Each group had one complication. Conclusion There is not a distinct advantage with a CC strategy over an IC strategy with both offering deformity control and meaningful delays in surgery for EOS patients. The long-term implications of ongoing in-cast correction seen with CC are yet to be determined. Cite this article: Bone Jt Open 2026;7(5):593–600.

Aims:This study aims to determine the reliability, accuracy, and usability of a new health application that uses AI to estimate major coronal curve magnitude in patients with adolescent idiopathic scoliosis (AIS) from 3D surface topography (ST) captured on a smartphone video scan. Methods:This is a prospective validation study. AIS patients, aged ten to 18 years, with coronal curve magnitudes ≤ 45° were recruited at a tertiary care spine clinic. A single trained researcher performed scans twice, six months apart, during participants' routine clinical and radiological assessment. Participants were asked to complete a scan once a month between clinic visits, starting the day of recruitment. Agreement was calculated by comparing scan curve magnitude predictions to the reference standard: a three-foot standing spine radiograph measured by blinded spine clinicians. Inter-rater reliability was assessed by comparing in-clinic to home scan predictions. Measures of diagnostic accuracy to determine the app's ability to screen for coronal deformity > 25° and its ability to detect progression > 5° over a six-month period were determined. Successful compared with failed scans were recorded. Results:Among participants (n = 63), 59 patients (94%) had at least one successful in-clinic scan and 32 patients (51%) had at least one successful home scan. Agreement with the reference standard was moderate for in-clinic scans (intraclass correlation coefficient (ICC) 0.535) and poor for home scans (ICC 0.402). Inter-rater reliability between in-clinic and home scans was poor (ICC 0.168). The app had an accuracy of 70% when discriminating between curve magnitudes ± 25° and detecting curve progression > 5°. A larger proportion of scans failed at-home (30%) compared with in-clinic (16%). Conclusion:Conceptually, the app shows potential as an accessible screening tool for scoliosis. However, the accuracy and reliability suggest it is not yet a reasonable replacement for radiographs and in-person clinical evaluation.

Background:Children with neuromuscular scoliosis undergoing scoliosis surgery face substantial rates of complications. To mitigate surgical risks such as blood loss in pediatric patients with neuromuscular scoliosis, this study focuses on enabling instrumentation planning for their abnormal vertebral and pelvic anatomy and osteopenia. This study assessed the feasibility of an "ultralow-dose" CT (ULD CT) protocol without sedation in pediatric patients with neuromuscular scoliosis who often have comorbid movement disorders. Our prospective quality improvement study aims: (1) to determine if ULD CT without sedation is feasible in this patient group; (2) to quantify the radiation dose from ULD CT and compare it with preoperative spine radiographs (XR); and (3) to assess if ULD CT allows accurate anatomical assessment and intraoperative navigation given the prevalence of movement disorders.Methods:Children with neuromuscular scoliosis underwent spine XR and ULD CT scans. Chart reviews assessed disease etiology and comorbidities. Radiation dose was quantified through Monte-Carlo simulations giving dose indices and effective dose, with statistical analysis done using a paired student's t-test (alpha=0.05). CT image quality was assessed for its use in preoperative planning and intraoperative navigation.Results:Fourteen patients (5 males, 9 females, average age 14 +/- 3 y) participated. One patient needed sedation due to autism spectrum disorder and global developmental delay. The radiation dose for spine XR was 0.5 +/- 0.2 mSv, and ULD CT was 0.6 +/- 0.1 mSv. There was no statistically significant difference in radiation doses between methods. All ULD CT scans had adequate quality for preoperative assessment of pedicle diameter and orientation, obstacles impeding pedicle entry, S2 Alar-Iliac screw orientation, and intraoperative navigation.Conclusions:ULD CT without sedation is feasible for children with neuromuscular scoliosis. Radiation doses were comparable to standard radiographs. ULD CT provided accurate anatomical assessments and supported intraoperative navigation, proving beneficial despite movement disorders in these patients.Level of Evidence:Level 2-Development of diagnostic criteria on basis of consecutive patients (with universally applied reference widely accepted standard).

BACKGROUND:A substantial proportion of adolescent idiopathic scoliosis (AIS) patients present late at initial visit. Before orthopaedic consultation, community radiology is frequently used. Results inform primary care physicians to determine when an orthopaedic referral is indicated and guide the triage decisions in tertiary care. The utility and accuracy of community spine radiology for AIS patients is suboptimal; however, its impact on timely presentation is unknown. This study quantifies the impact of inaccurate measurements of the major coronal curve by community radiologists on late AIS presentation. METHODS:This is a retrospective review of AIS patients seen for initial consultation with community-acquired index imaging. Available index spine x-rays (n=119) were independently remeasured by 2 blinded raters. Agreement in measurements of the major coronal curve using the Cobb method between community radiology and spine specialists was computed, then compared with readings of the reference standard, which were 3-foot standing spine x-rays obtained at initial consultation. Logistic regression was used to estimate the odds of late presentation from the discrepancy in measurements of the major coronal curve between index and reference standard evaluation when images were obtained within 90 days (n=111). Late presentation was defined as those who were likely surgical candidates at initial consultation. Discrepancies were defined as differences in major coronal curve measurements >5 degrees between index and reference standard evaluation. RESULTS:Discrepancies in measurements of the major coronal curve ranged from 6 to 29 degrees (mean=12 deg., SD=6 deg.). Over half (n=28, 56%) of these inaccuracies were differences of 10 degrees or more. Agreement in measurements of the major coronal curve on the index x-ray between community radiologists and spine specialists was moderate (ICC=0.78 95% CI: 0.66-0.86, SEM=6 deg.; ICC=0.74 95% CI: 0.65-0.81, SEM=7 deg.). Comparatively, agreement between spine specialists on both index image and reference standard was excellent (ICC=0.96, 95% CI: 0.89-0.98, SEM=3 deg.; ICC=0.97, 95% CI: 0.95-0.98, SEM=3 deg.). The proportion of AIS patients who presented late was 34%. The odds of late referral increased with inaccuracies in community measurements (OR=3.55, 95% CI: 1.91-6.59). CONCLUSIONS:Inaccuracies in measurements of the major coronal curve by community radiology may impact timely AIS presentation, potentially increasing the number of avoidable spine surgeries due to missed opportunities for nonoperative treatment. LEVEL OF EVIDENCE:Level III.

Brace treatment minimizes the risk of scoliosis curve progression to surgical range. However, many adolescent idiopathic scoliosis (AIS) patients are referred late for specialist consultation and not considered ideal brace candidates. The purpose of this study was to examine socioeconomic and healthcare utilization trends that may be associated with late AIS referral, that ultimately contribute to a higher than necessary surgical burden. All AIS patients, aged 10-18 years, seen for initial consultation within a single tertiary care spine program between January 1, 2014 to December 31, 2021 were linked to provincial health administrative databases. Linked cohort data included: age, sex, body mass index (BMI), Cob angle, and Risser score. Income and material deprivation quintiles based on geographic area of residence and individual-level data pertaining to immigration were proxies for socioeconomic status. Utilization of health services in the 5 years prior to first spine specialist visit were ascertained by billing codes and represented by rate of physician outpatient visits, stratified by specialty, and number of annual health exams. Late referrals were those with a curve magnitude ≥50° or >40° and Risser 2 or less. A comparative analysis was conducted between youth that were/were not referred late. Impact of independent variables on the probability of being referred late was evaluated with significance set at p < 0 .001. In total 2732 AIS patients (2236 female, 82%) were seen in the study period, average age 14.1y (±1.7, range: 10.0-17.9) and mean Cobb angle 37.6° (±14.4, range: 10-95°). The volume of late referrals was 27% (n=728). Late referral was associated with a younger age at presentation (14.2 vs 13.8), less mature Risser score, and fewer physician outpatient visits (16.1 vs 18.7), but not sex (p=0.39), BMI (p=0.79), or immigration status (p=0.70). The probability of being referred late increased with lower income (Q1=0.32 vs Q5=0.23) and higher level of deprivation (Q5=0.34 vs Q1=0.22) and decreased when the primary care physician had a specialty in paediatrics versus family practice or practice in general (0.13 vs 0.35). Youth that had regular annual health exams were least likely to be referred late (0.11 vs 0.32) with a less than average probability for those having 2 or more exams within 5 years. There are disparities in SES indicators and healthcare utilization between AIS patients that are/are not referred late for specialist consultation. Lower SES and healthcare utilization both increase the probability of late AIS referral, particularly when the primary care physician does not have a specialty in paediatrics, or when annual health exams are infrequent. These findings indicate that education targeted at general practitioners, promotion of annual health exams for adolescents, and screening initiatives in lower socioeconomic regions may facilitate timely AIS referral.

Aims:Anchor-related complications are the leading cause for unplanned surgery in early-onset scoliosis (EOS). One strategy to reduce unplanned surgery is staging implant insertion. This study compares the outcomes of staged versus unstaged growing rod (GR) insertion, focusing on complication rates. Methods:This retrospective cohort study examined 48 EOS patients who received GR surgery at a single institution (Hospital for Sick Children, Toronto, Canada) between January 2006 and July 2023. Patients were grouped according to staged and unstaged GR insertion. Radiological measurements were obtained preoperatively, post-insertion, and one-year follow-up to determine radiological change between and within each group. Complications were recorded until posterior spinal fusion (PSF) or most recent follow-up if no PSF was performed, and compared between groups. Results:Overall, 24 patients received staged and 24 patients received unstaged dual GR insertion. The mean follow-up time for patients was 53.1 months (SD 33.1). Patients who underwent unstaged insertion had greater Cobb angle correction (46.6% (SD 15.9%) vs 31.5% (SD 13.3%), p < 0.001). There were no significant differences in kyphosis correction (p = 0.118) or thoracic height growth (p = 0.348) between groups. Staged patients experienced a higher complication rate compared to unstaged patients within the first year following insertion (38% vs 12%). Differences in proximal junctional kyphosis (PJK) development between staged (17%) and unstaged (29%) patients were not significant (p = 0.303). The mean insertion-associated length of stay was longer in staged patients (10.7 days (SD 4.2)) compared to unstaged patients (5.8 days (SD 4.0), p < 0.001). Conclusion:Staged and unstaged GR insertion results in acceptable coronal correction and comparable radiological parameters. However, staged insertion may not be superior to unstaged insertion given the increased length of stay and rate of complications associated with the procedure.

Intraoperative neurophysiological monitoring (IONM) is common practice during spine surgery and has been proven to be an accurate and reliable method for early detection of injury to neural structures. Drawbacks, however, include additional set-up time, financial cost, and particular anesthetic considerations. Although critical in high-risk procedures, the necessity of IONM in lower risk procedures, such as growing rod (GR) lengthenings, has not been extensively investigated. The aim of this study is to investigate the role of IONM during GR lengthening surgery. We hypothesize that it is reasonable to perform pediatric lengthening surgery in the absence of IONM. Early onset scoliosis patients treated with GR between 2003 to 2023 who had routine IONM were retrospectively reviewed. Surgeries were categorized into implant placements, lengthenings, hardware exchanges and fusions. Descriptive statistics summarized baseline patient characteristics and surgical details. Neuromonitoring data for all procedures and any record of post-operative neurologic deficit were reviewed. Diagnostic sensitivity and specificity were calculated. For the 62 patients included (mean age 6.62y, 54.8

The impact of curve correction on adolescent idiopathic scoliosis (AIS) patient satisfaction after posterior spinal fusion (PSF), remains unclear. To optimize correction, some surgeons may consider higher risk surgical techniques. To ensure surgical decision-making is made in the best interest of the patient, it is essential to understand the association between patient satisfaction and curve correction. The aim of this study was to determine the patient and surgical factors most related to satisfaction in AIS patients who have undergone PSF, with a particular focus on the impact of curve correction. AIS patients that had completed a pre- and postoperative Scoliosis Research Society (SRS) questionnaire a year or more after surgery were included. The mean differences between pre- and postoperative scores were assessed using paired two-sample t-tests (normally distributed) and the Wilcoxon rank sum test (not normally distributed) and considered with respect to MCID. Associations between SRS-questionnaire scores and covariates were assessed using linear regression models. Of the 95 patients included (mean age 15.1, 86.3% female), 73 had completed sufficient baseline and follow-up items to consider their total SRS score. There was no other difference between these groups. Mean percent correction was 71.7% (45.8-96.8%) and SVA was corrected by an average of -1.16cm (-7.8-6.7cm). Total and all domain SRS scores, except function, showed statistically significant improvement after PSF. Univariate regression revealed associations between complications (p=0.046) and male sex (p=0.020) with decreasing satisfaction scores, and percent correction (p=0.001) and SVA change (p=0.048) with increasing self-image scores. After multivariable adjustment, male sex was associated with reduced satisfaction scores (p=0.030) and increasing percent correction was associated with improvement in self-image scores (p=0.004), with an effect size of 0.021. No relationship between percent correction and satisfaction was found. Improvement in total score, pain, self-image, mental health and satisfaction was statistically significant however, clinical significance was exclusively achieved in pain and self-image domains. Greater correction was only associated with higher self-image scores with our results suggesting 47% correction produces meaningful improvement. These findings suggest cosmesis may be a concern for AIS patients and should be considered during preoperative planning.

Adolescent idiopathic scoliosis (AIS) is the most prevalent pediatric spine disorder, developing in the absence of obvious physiological defects. Genome sequencing and functional studies have demonstrated association of musculoskeletal collagen variants and cartilaginous extracellular matrix (ECM) defects in a subset of patients. However, the underlying biological causes of AIS remain poorly understood, limiting treatment options. Using multiple zebrafish AIS models, we demonstrate that reduction-oxidation (redox) imbalances induce cell stress and collagen remodelling within intervertebral segments of the developing spine. Mutant spines are consequently stiffer, as measured by shear wave elastography, and exhibit deformations of intervertebral structures. Remarkably, elevated stiffness and intervertebral ECM phenotypes are detectable prior to scoliosis onset, suggesting a causal relationship, and can be suppressed by antioxidant treatment. Together, our preclinical studies implicate oxidative stress-induced intervertebral deformations in the pathogenesis of AIS and identify elevated spine stiffness and redox imbalance as plausible first-in-kind prognostic biomarkers and therapeutic targets.

OBJECTIVE:Traumatic spinal cord injury (SCI) in children and adolescents is uncommon but represents a substantial source of morbidity. Due in part to its rarity, there are few pediatric-specific studies on this topic. Therefore, the aim of this study was to assess demographics, injury mechanisms, treatment characteristics, and neurological outcomes in a cohort of pediatric patients with traumatic SCI, and to determine patient and injury factors associated with neurological recovery after injury. METHODS:In this retrospective observational cohort study, children and adolescents with traumatic SCI presenting to a quaternary children's hospital from January 2000 to December 2020 were identified. Patients with spinal column injury without evidence of spinal cord involvement, such as fracture and ligamentous injury alone, were excluded. Neurological examinations were abstracted from clinical notes at admission, discharge, and 3- to 4-month and 12-month follow-up time points, and the grade of injury was assessed per the American Spinal Injury Association Impairment Scale (AIS). Univariate logistic regression was used to identify associations between demographic, injury, and treatment variables with improvement of ≥ 1 AIS grade at 12 months. RESULTS:Seventy-five patients (45 male, mean age 10.4 years) with traumatic SCI were included in the analysis. The injury mechanism was most often motor vehicle collision (MVC; n = 35, 46.7%), followed by sports and recreation injuries (n = 23, 30.7%) and falls (n = 9, 12%). There were 36 patients (48%) with concomitant nonspinal injuries, including 24 (32%) with traumatic brain injury. Overall, 15 patients (20%) died in the hospital at a median of 1 day (IQR 1-2 days) after injury, most of which were associated with MVC, concomitant head injury, and/or craniocervical junction (CCJ) dissociation. Surgical intervention was performed for 30 patients (40%). Of the 47 patients with AIS grades A-D who survived to the 1-year follow-up, 34 (72%) improved by ≥ 1 AIS grade and 11 (23%) improved by ≥ 2 AIS grades by 12 months. A higher injury severity score (OR 0.86, 95% CI 0.77-0.93) and spinal cord hemorrhage on MRI (OR 0.09, 95% CI 0.01-0.58) were associated with lower odds of improvement. CONCLUSIONS:Mortality was relatively common after pediatric SCI and was associated with CCJ dissociation or concomitant nonspinal injuries. Among surviving patients who were admitted to the hospital with neurological impairment, a majority experienced improvement by ≥ 1 AIS grade at the 12-month follow-up.

Despite spinal casting being widely accepted as a conservative management strategy to control severe early-onset scoliosis (EOS) and delay surgical intervention, there is no consensus on the most appropriate protocol to optimize outcomes. At our institution an intermittent cast protocol was used prior to November 2018, with 2-3 casts applied over 6 months, followed by bracing and consideration of a repeat cast if progression was later noted. A continuous cast protocol was introduced after November 2018 with casts worn 12-16 weeks, often for 2-3 years. The objective of this study was to compare the outcomes of intermittent versus continuous spinal casting protocols, focusing on progression-free survival at 4-years. This was a retrospective review of prospectively collected data of all 43 EOS patients managed with spinal casting, at a single institution that had at least 2 cast applications (intermittent) or over 12 months of casting (continuous), initiated between November 2002-April 2022. The Kaplan-Meier method estimated the probability of progression-free survival at 4 years, defined as the time to curve progression beyond index or definitive surgical decision, whichever occurred first. A Cox Proportional Hazards model considered the association between survival and cast protocol, sex, etiology, age at first cast, pre-cast Cobb angle, and percent correction achieved in first cast. The hazard ratio (HR) of each variable was calculated. Comparative analyses considered change in Cobb angle over time, including correction in first- versus most recent cast. Thirty patients underwent intermittent casting (24 female, 14 idiopathic), and 13 continuous casting (7 female, 5 idiopathic). At baseline both groups were similar in sex (p=0.17), etiology (p=0.87), and Cobb angle (63.5° vs 69.1°, p=0.26) but differed on age of cast initiation (3.89 years vs 2.7 years, p Non-idiopathic etiology and curve stiffness decrease the probability of 4-year progression-free survival for severe EOS patients treated with spinal casting. A continuous cast protocol allows for on-going improvement of in-cast Cobb angle however does not demonstrate a survival advantage in the short term. Both protocols effectively delay surgery in severe EOS patients.

Primary care physicians rely on community radiology reports to confirm an Adolescent Idiopathic Scoliosis (AIS) diagnosis prior to spine specialist referral. Accurate reporting of spine x-rays is essential as results guide management. While Cobb angle is known to have excellent reliability, this may be over-reported, specific to orthopaedic specialists and with some studies pre-determining end-vertebrae. The study objectives were 1) to determine the agreement of Cobb angle readings between index evaluation of community spine x-ray and re-evaluation of the same image by tertiary-care clinicians (spine specialist and pediatric radiologist) and 2) to determine if inaccurate measurements were associated with late AIS referrals, defined as those who present as likely surgical candidates on initial presentation. A review of AIS patients (n=170) seen for an initial visit at a tertiary-care pediatric hospital between January-September 2021 was conducted, excluding those seen for second opinion, missing index Cobb angle or with index imaging from the same institution. Community index spine x-rays available on the institution's PACS (n=119) were independently measured by two blinded raters (spine specialist and pediatric radiologist). The agreement in Cobb angle readings between community radiology and tertiary-care clinicians was measured using intraclass correlation coefficient (ICC) and the agreement in the corresponding Scoliosis Research Society management categories was measured using Fleiss’ Kappa statistic (κ). Agreement statistics were calculated for evaluation of the reference standard 3-foot standing spine x-ray in the same cohort. Bland-Altman plots were constructed to compare raters on index image and reference standard. Logistic regression was used to estimate the odds of late referrals from the discrepancy in Cobb angle measurements between community radiology and reference standard when images were within 90 days (n=111). Discrepancies were defined as differences in Cobb angle measurements >5°. An adjusted model included age, imaging location, image quality and referring specialty. Most index x-rays (72.6%) were obtained at a private community clinic. The agreement in Cobb angle on the index x-ray between community radiologist and spine specialist was fair (ICC=0.78 95% CI 0.66-0.86, SEM=6.14°) with moderate agreement in corresponding management (κ=0.58). On the same image, the agreement between community radiologist and pediatric radiologist remains fair (ICC=0.74 95% CI 0.65-0.81, SEM=6.73°) though improved agreement in corresponding management (κ=0.65). Comparatively, the agreement between spine specialist and pediatric radiologist on both index and reference standard was excellent (ICC=0.96, 95% CI 0.89-0.98, SEM=2.57°; ICC=0.97, 95% CI 0.95-0.98, SEM=2.86°) with substantial agreement in corresponding management (κ=0.73; κ=0.71). The proportion of patients with discrepancies in Cobb angle measurements was 45.0% when comparing those with index images within 90 days of the reference standard. The proportion of patients who present late was 34.2%. The odds of late referral increased when there were inaccuracies in community measurements (OR = 3.55 95% CI 1.91-6.59). There are clinically important differences between community radiology and tertiary-care evaluation of spine x-rays. Inaccurate interpretation impacts timely referrals, contributing to missed opportunities for conservative treatment and increased surgical burden.

Timely diagnosis of Adolescent Idiopathic Scoliosis (AIS) allows for effective management through brace treatment, potentially preventing complex spine surgery. Concerningly, over 25% of patients are late referrals, increasing the rate of surgeries and associated complications that may be avoided with conservative management. Most AIS detection occurs in the community; however, community spine x-rays can be of inadequate quality and inaccurately interpreted. The study objective is to establish the diagnostic accuracy of community spine x-rays for AIS brace candidates. A review of AIS patients seen for initial visit at a tertiary care pediatric hospital between January-September 2021 was conducted, excluding those seen for second opinion, missing index Cobb angle or with index imaging from the same institution (n=170). The index test was the community spine x-ray obtained prior to referral and evaluated by community radiologist. Positive test to detect a brace candidate was dichotomized by Cobb angle (25-40 degrees) as per Scoliosis Research Society. Risser stage was not included in diagnostic criteria given significant missing data in index reports (n=110). Measures of diagnostic accuracy for the index test were determined against the reference standard if images were obtained within 90 days of the reference standard (n=111). The reference standard was the three-foot standing EOS spine x-ray obtained on initial visit and evaluated by orthopedic spine specialists. Sensitivity analyses were conducted on a subsample of data with index test within 60 days of the reference standard (n=67). Late referrals were defined as those who present as likely surgical candidates based on initial orthopedic evaluation. The study cohort was mostly female (76.6%) with an average age of 13.7 years (SD=1.6). The accuracy of the community spine x-ray to detect a brace candidate was 65.8% (95% CI 56.2-74.5). The sensitivity of the index test was 65.4% with a false negative rate of 34.6%. The specificity was 66.1% with a false positive rate of 33.9%. Positive and negative predictive values were 63.0% and 68.4%, respectively. The positive likelihood ratio was 1.99. Out of the total cohort (n=111), there were 38 misdiagnoses, 34 of which were due to underestimation. Of the total number of true brace candidates (n=52), 32.7% were missed because of underestimation (95% CI 21.5-46.2). With index images within 60 days of the reference standard, the accuracy remained 67.2% (95% CI 54.6-78.1). The proportion of missed brace candidates because of underestimation was unchanged when looking at 60-day data (p=0.37). The proportion of late referrals was 34.2%. Inaccuracies in community spine radiology may lead to missed opportunities for conservative treatment. This may be a contributing factor to referral trends thereby increasing rates of avoidable surgeries and costs to the health care system.

PURPOSE:Previous studies have suggested routine preoperative laboratory assessment may be unnecessary or excessive. The primary aim of this study was to determine the association between abnormal preoperative laboratory screening tests on allogeneic transfusion in pediatric patients receiving posterior spinal fusion for idiopathic scoliosis correction. METHODS:The NSQIP Pediatric database for years 2016-2022 was used. Patients who were (1) < 18 years old, (2) received posterior arthrodesis for idiopathic scoliosis correction, and (3) had recorded preoperative laboratory tests were included in this study. Preoperative bloodwork values of interest were hematocrit, albumin, platelet count, international normalized ratio (INR), and partial thromboplastin time (PTT). Descriptive statistics were used to characterize patient demographics, surgical metrics, and preoperative laboratory values. Rate of allogeneic transfusion was stratified by laboratory value cut-offs and compared using G-test. Standardized cut-offs were used to define abnormal values. A multivariable logistic regression analysis was used to assess the impact of abnormal bloodwork values on rate of allogeneic transfusion. RESULTS:There were 6057 patients included in this study. The mean age was 13.8 years. There were 13.6% that received allogeneic transfusion. The mean transfusion volume was 62.1 mL. Patients with abnormal preoperative INR (13.1% vs. 20.0%; p < 0.001), hematocrit < 35 (12.4% vs. 25.9%; p < 0.001), and albumin < 3.4 (13.4% vs. 25.8%; p = 0.004) had higher rates of transfusion. In the multivariable logistic regression analysis, INR > 1.2 (OR 1.4, p = 0.023) and hematocrit < 35 (OR 2.3, p < 0.001) were significantly associated with higher odds of allogeneic transfusion. CONCLUSION:Preoperative INR and hematocrit values can aid in risk stratification for allogeneic transfusion requirements. PTT and platelet count did not significantly impact perioperative transfusion rates or volumes.