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Background context Revision adult spinal deformity surgery (RASDS) is a particularly high-risk intervention. Purpose The aim was to assess complication rates in RASDS by surgeon and hospital operative volume. Study design/setting This was a retrospective analysis of prospectively collected data. Patient sample Based on a Nationwide Inpatient Sample (NIS) database (2001–2010), patients aged older than 21 years (International Classification of Diseases, Ninth Revision, Clinical Modification) with spine arthrodesis for scoliosis were included. For longitudinal analysis, the 2008-2011 New York State Inpatient Database (NY SID) was queried. Outcome measures The outcome measures included complication rate after RASDS. Methods Cases were identified as primary or revision surgery with or without osteotomy performed. Annual surgeon and hospital volumes were stratified into quartiles via identifier codes. Case complexity was determined using a novel operative complexity index, based on available NIS operative parameters: levels fused, approach, osteotomy, and revision status. The primary end point was morbidity during the hospital stay. New York State Inpatient Database analysis allowed for identification of rate of reoperation for infection or pseudarthrosis/implant failure. One-way analysis of variance was used to assess continuous measures, chi-square for categorical measures. Results Of 139,150 adult spinal deformity surgery (ASDS) cases, 4,888 revision with hospital identifiers and 1,978 with surgeon identifiers were identified. Higher-volume surgeons performed more revision cases and cases requiring osteotomy. With increasing hospital volume, complication rate for RASDS decreased (9.7% vs. 12.9% at highest- vs. lowest-volume centers, p< .001). The highest-volume surgeons showed significant decreases in the rate of major complications for RASDS (8.8% vs. 10.7% for lowest-volume surgeons, p< .001). A similar trend was observed for ASDS cases requiring osteotomy. Multiple logistic regression analysis showed that the highest-volume hospitals and surgeons showed a reduced odds ratio for all complications compared with lowest-volume hospitals. For the NY SID, 528 RASDS cases indicated reoperation rates for infection and pseudarthrosis/implant failure after RASDS were increased for the lowest-volume hospitals and surgeons. Conclusions Perioperative complication rate associated with RASDS is lower when patients are treated by high-volume surgeons at high-volume centers. As complex cases requiring osteotomy and combined approaches are more frequent at high-volume centers, an operative complexity index helps predict the likelihood of volume-dependent complication rates. Future interhospital and intersurgeon comparisons should account for these case characteristics so that similar case complexity is compared in these analyses. [ABSTRACT FROM AUTHOR]

Comparative effectiveness research provides information on the benefits and complications of specific treatments and can guide spine surgeons to best-quality practices. Although orthopedic implants comprise more than 25% of the perioperative costs for adolescent idiopathic scoliosis (AIS), there are few high-level studies comparing the various implant types, patterns, and number. Numerous studies have shown the superiority of all pedicle–screw constructs over hook-and-hybrid constructs. A wide variety of pedicle screw numbers, densities, and configurations are used in clinical practice. Many small studies indicate no significant difference in clinical outcomes between low-implant density and high-implant density constructs for the surgical treatment of moderate AIS, but these are likely underpowered. More work is needed to determine the appropriate number and distribution of implants for specific curve patterns to optimize the surgical care of AIS patients. [ABSTRACT FROM AUTHOR]

Abstract: Background context: Thoracic pedicle screw (TPS) constructs have improved curve correction measurements compared with hook and hybrid constructs in the treatment of adolescent idiopathic scoliosis (AIS), but the optimal implant density, or the number of screws per level, remains unknown in the treatment of flexible thoracic curves. Purpose: To determine how implant density affects clinical outcome, radiographic outcome, and cost in the treatment of Lenke Curve Type I AIS. Study design: A retrospective clinical study. Patient sample: Ninety-one consecutive AIS patients with Lenke Type I curves who underwent surgical correction with a minimum follow-up of 24 months. Outcome measures: Radiographic outcomes included assessment of preoperative and 2-year postoperative thoracic Cobb angle, T5–T12 kyphosis, and curve flexibility. We also assessed SRS-22 outcome measures and thoracic angle of trunk rotation (ATR) before surgery and at the 2-year postoperative time point. The cost of each construct was also evaluated. Methods: Bivariate analysis was conducted between implant density and the following factors: percent correction of the major curve, ATR, and change in kyphosis. The correlation between curve flexibility and percent correction of the major curve was determined. Patients were then divided into two groups: the low-density (LD) TPS group defined by implant density below the mean number of screws per level for the entire cohort (less than 1.3 screws per level) and the high-density (HD) TPS group defined by implant density above the mean number of screws per level (more than 1.3 screws per level). Independent sample t tests were used to compare demographic data as well as radiographic and clinical outcomes at baseline and at follow-up between the two groups. Results: Sixty-one female and 30 male patients met inclusion criteria. No significant correlations were found between implant density and the following parameters: percent correction of the major curve (p=.25), ATR (p=.75), and change in T5–T12 kyphosis (p=.40). No correlation was found between curve flexibility and percent correction of the major curve (p=.54). The LD group consisted of 57 patients, whereas the HD group had 34 patients. There were no differences between the HD group and the LD group in regard to major curve correction, change in T5–T12 kyphosis, or change in ATR. Total implant costs were significantly higher in the HD group ($13,272 vs. $10,819; p<.01). The SRS-22 image domain and overall score improved at 2 years within both groups, but there were no group differences in any of the SRS-22 domains or the overall score. Conclusions: We identified no clinical, radiographic, perioperative, or complication-related advantage of constructs with higher TPS implant density in this patient cohort with flexible idiopathic scoliosis. Cost was significantly higher with HD constructs in comparison with LD constructs. Optimal implant density chosen by the surgeon should rely on a number of factors including curve magnitude and rigidity, bone density, and desired correction. [Copyright &y& Elsevier]

Abstract: Background context: Anterior fusion through an open thoracotomy restores kyphosis more reliably than posterior techniques in patients with thoracic adolescent idiopathic scoliosis (AIS). Video-assisted thoracoscopic spinal fusion and instrumentation (VATS) minimizes the morbidity, from soft tissue and muscle dissection that accompanies traditional open thoracotomy. To our knowledge, there has not been a comprehensive analysis of VATS with respect to radiographic and clinical outcomes in the sagittal plane. Purpose: To measure the radiographic and clinical outcomes after VATS with emphasis on the sagittal plane. Study design/setting: A retrospective, radiographic review of 26 consecutive patients with Lenke type-I AIS who underwent VATS. Methods: Radiographs of 26 consecutive patients with Lenke type-I AIS curves operated by a single surgeon were retrospectively reviewed after VATS. Sagittal and coronal parameters were compared with reported data for open anterior and posterior procedures. Results: There was an increase in kyphosis from baseline to final follow-up by 6.6° (25%) from T2 to T12 (p<.0001), 8.7° (50%) from T5 to T12 (p<.0001), and 8° (54%) in the instrumented segment (p<.0001). Junctional kyphosis did not occur. No differences were detected in sagittal measurements between the first postoperative erect and the final radiographs. Patients experienced significant improvements from baseline to 2 years in Scoliosis Research Society-22 Health-Related Quality-of-Life Outcome Questionnaire scores (p<.0001). Conclusions: Video-assisted thoracoscopic spinal fusion and instrumentation, in agreement with results reported for open anterior instrumentation, reliably restores or increases thoracic kyphosis while preserving junctional alignment in thoracic AIS. [Copyright &y& Elsevier]

Abstract: Background: Range of motion (ROM) has been shown to influence clinical outcomes of total disc replacement (TDR). While the parallax effect in image acquisition has been shown in the literature to influence the accuracy of a variety of measurements, this concept has not been investigated in the assessment of ROM analysis following TDR. We performed an evaluation of the influence of radiograph beam angle on “by hand” and on “gold standard” flexion-extension ROM measurements in lumbar total disc replacement. The purpose of this study is to determine (1) the influence of X-ray beam angle on index level angle (ILA) measurements in lumbar TDR using the keel method, and (2) whether the out-of-plane radiographic beam effects cause a difference between true and calculated range of motion. Methods: Eight blinded orthopaedic surgeons used the keel method to calculate ROM measurements from radiographs of a flexible Sawbones model (Pacific Research Laboratories, Inc., Vashon, Washington) implanted with a ProDisc-L device (Synthes Spine, West Chester, Pennsylvania). Radiographs were obtained at beam angles of 0°, 5°, 10°, and 15° in the sagittal plane from the device center. Calculations were compared to measurements obtained by a validated digitized software method (Quantitative Motion Analysis, QMA, Medical Metrics, Inc., Houston, Texas). Inter- and intraobserver precision and accuracy were determined. Results: Compared with QMA, the radiographic keel method had an average error of 3.7°. No significant effect of variation in beam angle on interobserver precision (N=16, P =.92) or accuracy (N=16, P =0.86) or intraobserver precision (N=8, P =.09) or accuracy (N=8, P =0.07) of ROM measurements was identified. Repeat testing with QMA also revealed no effect of parallax and resulted in nearly identical ROM measurements. Conclusions: Accuracy and precision of the keel method to determine ROM from index level angle measurements after TDR was not affected by increases in X-ray beam angles up to 15̊ from the device center. Clinical Relevance: Our study demonstrates that range of motion measurements are not influenced by parallax effect when using the keel method to determine index level angle measurements in lumbar total disc replacement. [Copyright &y& Elsevier]

Background Context: Sequential anterior/posterior spinal reconstruction for rigid adult spinal deformity has become a standard operative option. Single-staged double anterior/posterior spinal reconstruction for rigid double major curvature has not been reported in the literature to date.Purpose: To report a previously unreported approach for rigid double major curvature of the thoracic and thoracolumbar spine with emphasis on indications and avoiding complications.Study Design: Four cases of sequential double anterior/posterior spinal reconstruction are reported.Methods: Single-staged double anterior spinal reconstruction was performed on four adult patients with rigid thoracic and thoracolumbar scoliosis. Osteotomies were performed by the anterior and posterior approach and followed by posterior instrumentation. A right thoracotomy and left retropleural/retroperitoneal approach was performed for each patient followed by the posterior approach in a single stage.Results: Only one complication occurred, a posterior dural tear, treated without incident. A high level of patient satisfaction and return to activity was noted. Solid arthrodesis with good coronal and sagittal balance occurred in all patients.Conclusions: Single-staged double anterior/posterior spinal reconstruction for rigid adult deformity can be performed safely and effectively with good patient outcome. The procedure should be reserved only for those patients with severe double major curvature of similar magnitude and rigidity. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Surgical techniques in adolescent idiopathic scoliosis (AIS, age=10–18 years) and adult idiopathic scoliosis (ADS, age>18 years) surgery have evolved over the past 10years. PURPOSE To assess trends in complication rates in AIS and ADS patients from the Scoliosis Research Society (SRS) Morbidity and Mortality (M&M) database over 12years (2004–2015). STUDY DESIGN/SETTING Adolescent idiopathic scoliosis and adult idiopathic scoliosis operative complications rates between 2004 and 2015 were obtained from the SRS M&M database. PATIENT SAMPLE A total of 92,868 patients. OUTCOME MEASURES Determine the trends in complication rates for AIS and ADS surgeries. METHODS We reviewed yearly complications rates over 7years (2009–2015) of all AIS patients (<18 years; n=63,574) and ADS (18–30 years; n=27,990) surgeries from one file. A second file contained the demographics, surgical data and types of complications data (2004–2015) of patients who had only complications. There were 1,165 AIS and 139 ADS patients with complications. Neurological deficit, blindness and death rates over 7years (2009–2015), and infection rates over 4years (2012–2015) were analyzed for both populations. In patients with complications data, we analyzed blood loss, number of levels fused, neurological recovery rate, and type of surgeries. Linear regression was used to analyze the trends of changes. P<.05 was considered statistically significant. RESULTS In AIS patients (p=.02), the amount of blood loss was significantly reduced from 957 mL to 750 mL (2009–2015), and in ADS patients, blood loss was also significantly reduced (p=.02) from 1438 mL to 904 mL (2009–2015). The number of levels fused in the AIS patients (p=.02) significantly increased from 11 levels to 11.9 levels (2009–2015), and also in ADS patients (p=.04) from 10.4 levels to 12.7 levels (2009–2015). In AIS (p=.052) and ADS (p=.03) fusion levels increased significantly over 7years for Lenke type 1 curves. In the AIS population, posterior fusion rate (p=.002) significantly increased and anterior fusion rate (p=.001) significantly decreased over the 12-year analysis (2004–2015). In the ADS population, posterior fusion rate (p=.002) increased, and combined surgeries (p=.046) and anterior fusion rates (p=.035) decrease over the 12-year analysis. In the AIS population, death, blindness and neurological deficits rates were constant over the 7-year analysis (2009–2015), spinal infections rate was constant over 4years of analysis (2012–2015), neurological deficits recovery rate significantly decreased (p=.05). In ADS population, death rate was constant, blindness (p=.04) and neurological deficit (p=.04) rates significantly increased over the 7years of analysis (2009–2015), and spinal infections rate was constant from 2012–2015. CONCLUSIONS Over 12years, the amount of blood loss and anterior surgery rates significantly decreased in both populations. Posterior fusion rates and number of fused levels significantly increased in both populations. Neurological deficit and blindness rates were constant in AIS patients, but significantly increased in the ADS patients. Complications rates in ADS patients increased even with the evolution of surgical techniques compared to AIS population. [ABSTRACT FROM AUTHOR]

Thoracic spinal deformities may reduce chest wall compliance, leading to respiratory complications. The first SARS-CoV-2 (L-variant) strain caused critical respiratory illness, especially in vulnerable patients. This study investigates the association between scoliosis and SARS-CoV-2 (COVID-19) disease course severity. Clinical data of 129 patients treated between March 2020 to June 2021 who received a positive COVID-19 polymerase chain reaction result from Mount Sinai and had a scoliosis ICD-10 code (M41.0–M41.9) was retrospectively analyzed. Degree of coronal plane scoliosis on imaging was confirmed by 2 independent measurers and grouped into no scoliosis (Cobb angle <10°), mild (10°–24°), moderate (25°–39°), and severe (>40°) cohorts. Baseline characteristics were compared, and a multivariable logistic regression controlling for clinically significant comorbidities examined the significance of scoliosis as an independent risk factor for hospitalization, intensive care unit (ICU) admission, acute respiratory distress syndrome (ARDS), mechanical ventilation, and mortality. The no (n = 42), mild (n = 14), moderate (n = 44), and severe scoliosis (n = 29) cohorts differed significantly only in age (P = 0.026). The percentage of patients hospitalized (P = 0.59), admitted to the ICU (P = 0.33), developing ARDS (P = 0.77), requiring mechanical ventilation (P = 1.0), or who expired (P = 0.77) did not significantly differ between cohorts. The scoliosis cohorts did not have a significantly higher likelihood of hospital admission (mild P = 0.19, moderate P = 0.67, severe P = 0.98), ICU admission (P = 0.97, P = 0.94, P = 0.22), ARDS (P = 0.87, P = 0.74, P = 0.94), mechanical ventilation (P = 0.73, P = 0.69, P = 0.70), or mortality (P = 0.74, P = 0.87, P = 0.66) than the no scoliosis cohort. Scoliosis was not an independent risk factor for critical COVID-19 illness. No trends indicated any consistent effect of degree of scoliosis on increased adverse outcome likelihood. [ABSTRACT FROM AUTHOR]

Abstract: Background context: Previous studies of the Scoliosis Research Society (SRS) 22 discriminative validity have lacked sufficiently matched study groups and were limited to a comparison with three or fewer subgroups of disease severity. Purpose: To evaluate the discriminative validity of SRS-22 by assessing the questionnaire''s ability to discriminate among five groups of pretreatment adolescent idiopathic scoliosis (AIS) patients with increasing curve severity. Study design: Retrospective review of prospectively administered surveys. Methods: Two hundred eighty-six SRS-22 questionnaires were issued to two AIS pretreatment patient populations: 67 nonoperative and 219 preoperative. Study subjects were separated into five subgroups depending on the major Cobb angle (nonoperative 0°–19° and 20°–40° and preoperative 41°–50°, 51°–60°, and >60°). Each group (n=31) was matched for age (within 1 year) and sex (23 females and 8 males), resulting in a total of 155 study subjects. Analysis of variance was used to determine statistically significant differences (p<.05) between the five subgroups'' domains and total scores. Results: Significant differences between study groups were found within two of the four domains (pain and image) and the total score. Both nonoperative groups (0°–19° and 20°–40°) demonstrated significantly less pain than the preoperative group (41°–50°) and significantly better self-image than all three preoperative groups. Both nonoperative groups'' total scores were significantly higher than all three preoperative groups'' scores, with the exception of the 20° to 40° subgroup versus the >60° subgroup. No significant differences were found between groups within the same planned treatment category. Conclusions: The SRS-22 questionnaire demonstrated good discriminative validity between small nonoperative curves and larger surgical curves within the pain, image, and total domains. However, SRS-22 lacked the ability to differentiate between small intervals of curve magnitude, suggesting a limitation to the questionnaire''s discriminative capacity. The discriminative validity of the Scoliosis Research Society (SRS) 22 has not been clearly defined. Our analysis of 155 adolescent idiopathic scoliosis patients evaluates the instrument''s discriminative validity among five age- and sex-matched curve-severity subgroups. The SRS-22 questionnaire lacked the ability to differentiate between small intervals of curve magnitude, suggesting a limit to the questionnaire''s discriminative capacity. [Copyright &y& Elsevier]

Prior adolescent idiopathic scoliosis (AIS) literature has demonstrated that patient satisfaction correlated weakly with individual SRS-22r domains and did not correlate with specific radiographic parameters. The purpose of this study is to demonstrate the effect of residual deformity on patient satisfaction. We hypothesize that in patients with AIS, residual deformity maybe associated with worse satisfaction. Retrospective analysis of a prospective AIS registry. A total of 1,229 Lenke 1 and 2 AIS patients with available radiographic data and SRS scores at the 2-year follow-up were included. Patient satisfaction using the SRS-22r satisfaction domain, categorized into 2 groups: Complete satisfaction (5/5) and incomplete satisfaction/dissatisfaction (<5). A total of 1,229 Lenke 1 and 2 AIS patients with available radiographic data and SRS scores at the 2-year follow-up were included. A score of 5 on the SRS-22r satisfaction domain at 2 years was considered "complete satisfaction," and anything below a score of 5 was considered "incomplete satisfaction/dissatisfaction." Radiographic parameters that were 2 standard deviations below the mean were deemed to have a "residual deformity." Univariate and binary logistic analyses were performed to assess the association of residual deformity with patient satisfaction. At the 2-year follow-up, 689 (60%) patients reported complete satisfaction, while 455 (40%) reported incomplete satisfaction/dissatisfaction. Radiographic factors associated with incomplete satisfaction/dissatisfaction were: residual trunk shift (OR 3.32, p=0.001) and residual major curve (OR 1.7, p=0.036). Patients with residual trunk shift and major curve also had worse SRS-22r self-image domain scores at the 2-year follow-up. Residual differences in shoulder height (p=0.534), T1 tilt angle (p=0.062), Apex to CSVL distance (p=0.969), and percent correction of the major curve (p=0.102) did not reach statistical significance for predicting incomplete satisfaction/dissatisfaction. Residual curve (>34) and truncal shift (>2.2cm) impact patient satisfaction after surgery for AIS. These factors ought to be taken into account during surgical planning. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Brace treatment is the most common nonoperative treatment for the prevention of curve progression in adolescent idiopathic scoliosis. The success reported in level 1 and 2 clinical trials is approximately 75%. The aim of this review was to identify the main risk factors that significantly reduce success rate of brace treatment. A literature search using the MEDLINE and Embase databases was conducted. Studies were included if they identified specific risk factor(s) for curve progression. Studies that looked at nighttime braces, superiority of one type of brace over another, the effect of physical therapy on brace performance, cadaver or nonhuman studies were excluded. A total of 1,022 articles were identified of which 25 met all of the inclusion criteria. Seven risk factors were identified: Poor brace compliance (eight studies), lack of skeletal maturity (six studies), Cobb angle over a certain threshold (six studies), poor in-brace correction (three studies), vertebral rotation (four studies), osteopenia (two studies), and thoracic curve type (two studies). Three risk factors were highly repeated in the literature which identified specific subgroups of patients who have a much higher risk to fail brace treatment and to progress to fusion. This data demonstrates that 60% to 70% of the patients referred to bracing are Risser 0 and 30% to 70% of this group will not wear the brace enough to ensure treatment efficacy. Furthermore, Risser 0 patients who reach the accelerated growth phase with a curve ≥40° are at 70% to 100% risk of curve progression to the fusion surgical threshold despite proper brace wear. Skeletally immature patients with relatively large magnitude scoliosis who are noncompliant are at a higher risk of failing brace treatment. [ABSTRACT FROM AUTHOR]

Background Context: The minimal clinically important difference (MCID) is the smallest change in an outcomes instrument deemed relevant to a patient. MCID values proposed in spine research are limited by poor discriminative abilities to accurately classify patients as "improved" or "not improved." Furthermore, the MCID should not compare relative effectiveness between two groups of patients, though it is frequently used for this. The minimum detectable measurement difference (MDMD) is an alternative to the MCID in outcomes research. The MDMD must be greater than the MCID for the latter to be of value and the MDMD can compare change between groups.Purpose: The purpose of this study was to determine the MDMD for the Scoliosis Research Society-22r (SRS-22r) in adolescent idiopathic scoliosis (AIS) patients treated with surgery.Study Design: Retrospective cohort study from multi-center registry.Patient Sample: Patients treated surgically for AIS.Outcome Measures: Self-reported SRS-22r.Methods: An observational cohort of surgically treated AIS patients was queried for patients with complete baseline, 1-year, and 2-year SRS-22r data. The MDMD was calculated for SRS-22r domain and subscores. Effect size (ES) and standardized response mean were calculated to measure responsiveness of the SRS-22r to change. MDMD values were compared with MCID values. Research grants were received from DePuy Synthes Spine, EOS imaging, K2M, Medtronic, NuVasive, and Zimmer Biomet to Setting Scoliosis Straight Foundation.Results: One thousand two hundred and eighty-one AIS patients (1,034 female, 247 male, mean age 14.6 years) were analyzed. MDMD values were between 0.23 and 0.31. SRS-Pain MDMD was 0.3, greater than the MCID of 0.2. SRS-Activity MDMD was 0.24, greater than the MCID of 0.08. SRS-self-image MDMD was 0.3, less than the MCID of 0.98. Sixty-four percent of those with baseline SRS-self-image>4.0 improved MDMD or more, whereas only 14% improved beyond the MCID. ES and standardized response mean were highest for subscore and self-image.Conclusions: The MDMD can compare the relevance of change in SRS-22r scores between groups of AIS patients. SRS-pain and SRS-activity MDMD values are greater than the MCID and should serve as the threshold for clinically relevant improvement. MDMD may help evaluate change in patients with baseline self-image>4.0. [ABSTRACT FROM AUTHOR]

Background Context: Current metrics to assess patients' health-related quality of life (HRQOL) may not reflect a true change in the patients' specific perception of what is most important to them.Purpose: This study aimed to describe the initial experience of a Patient Generated Index (PGI) in which patients create their own outcome domains.Study Design: This is a single-center prospective study.Patient Sample: Patients with adult spinal deformity (ASD) comprise the study sample.Outcome Measures: Oswestry Disability Index (ODI), Short Form-36 (SF-36 Physical Component Score [PCS] and Mental Component Score [MCS]), Scoliosis Research Society-22r (SRS-22r), and PGI.Methods: Oswestry Disability Index, SF-36, SRS-22r, and PGI were administered preoperatively and postoperatively at 6 weeks, 3 months, 6 months, and 1 and 2 years. PGI correlations with ODI, SF-36, SRS total score, free-text frequency analysis of PGI exact response with text in ODI and SRS-22r questionnaires, and the responsiveness (effect size [ES]) of the HRQOL metrics were analyzed. No funding was used for this study and there are no conflicts of interest.Results: A total of 59 patients with 209 clinical encounters produced 370 PGI written response topics that included affect or emotions, relationships, activities of daily life, personal care, work, and hobbies. Mean preoperative PGI score was 18.6±13.5 (0-71.7 out of 100 [best]), and mean scores significantly improved at every postoperative time point (p<.05). Preoperative PGI scores significantly correlated with preoperative ODI (r=-0.28, p=.03), MCS (r=0.48, p<.01), and SRS total (r=0.57, p<.01). Postoperative PGI scores correlated with all HRQOL measures (p<.0001): ODI (r=-0.65), PCS (r=0.50), MCS (r=0.55), and SRS total (r=0.63). PGI responses exactly matched ODI and SRS-22r text at 47.8% and 35.4%, respectively, and at 63.2% and 58.9%, respectively, for categories. Patient Generated Index ES at a minimum of 1-year follow-up was -2.39, indicating substantial responsiveness (|ES|>0.8). Effect sizes for ODI, SRS-22r total, SF-36 PCS, and SF-36 MCS were 2.16, -2.06, -2.05, and -0.80, respectively.Conclusions: The PGI is easy to administer and offers additional information about the patients' perspective not captured in standard HRQOL metrics. Patient Generated Index scores correlated with all of the standard HRQOL scores and were more responsive than ODI, SF-36, and SRS-22r, suggesting that the PGI may be a step closer to one HRQOL measure that better encompasses concerns and goals of the individual patients. [ABSTRACT FROM AUTHOR]

Background context Ethnic disparities have been documented in the incidence and treatment of many diseases. Additionally, race and socioeconomic status (SES) have been shown to affect disease severity and access to care in the recent orthopedic literature. Purpose To assess the role, if any, that race, SES, and health insurance type play in disease severity and treatment decisions in patients with adolescent idiopathic scoliosis. Study design Retrospective chart review. Patient sample Pediatric patients seen in a single surgeon's practice over 6 years (2004–2009). Outcome measures Treatment modality (observation, bracing, or surgery). Methods Data were obtained from 403 patients seen over 6 years (2004–2009). A patient-reported questionnaire was used to collect race, age, family income, and parent marital status data. Race was self-reported as “Asian,” “black or African American,” “Hispanic or Latino,” “white or Caucasian,” or “Other.” Socioeconomic status was determined using family income and type of health insurance as indicators. Major curve magnitude and prescribed initial treatment (observation, brace, or surgery) were assessed from physician records. An independent sample t test was used to detect differences in curve magnitude of the different racial groups. A Pearson chi-square analysis was used to detect group differences for curves in surgical patients, defined as curves greater than 40°, and their initial treatment. Results Patients self-identified with one of the following racial groups: white (N=219), black (N=86), Hispanic (N=44), Asian (N=37), or Other (N=17). Mean curve magnitude was greater in black than in white patients (33° vs. 28°, p<.05). Black patients were more likely to present with curves in the surgical range (34% vs. 24%, p<.05) and were more likely to have surgery as their initial treatment than white patients (34% vs. 19%, p<.05). Black patients had more limited health care plans and lower incomes compared with whites (p<.001). Patients with higher access insurance plans presented at a younger age than patients with more limited access plans, irrespective of race (13.6 vs. 14.1, p<.05). There was no difference in Cobb angle at presentation by income or type of insurance. Conclusions Curve magnitude and percentage of patients with curves in the surgical range were greater in black than in white patients. There was no difference in age on presentation or treatment offered across all racial groups. Black patients were more likely to have surgery as their initial treatment than white patients. While race did have an impact on disease severity in this single surgeon's practice, SES did not. [ABSTRACT FROM AUTHOR]

Background context Spine surgery is usually associated with large amount of blood loss, necessitating blood transfusions. Blood loss-associated morbidity can be because of direct risks, such as hypotension and organ damage, or as a result of blood transfusions. The antifibrinolytic, tranexamic acid (TXA), is a lysine analog that inhibits activation of plasminogen and has shown to be beneficial in reducing surgical blood loss. Purpose To consolidate the findings of randomized controlled trials (RCTs) investigating the use of TXA on surgical bleeding in spine surgery. Study design A metaanalysis. Study sample Randomized controlled trials investigating the effectiveness of intravenous TXA in reducing blood loss in spine surgery, compared with a placebo/no treatment group. Methods MEDLINE, Embase, Cochrane controlled trials register, and Google Scholar were used to identify RCTs published before January 2014 that examined the effectiveness of intravenous TXA on reduction of blood loss and blood transfusions, compared with a placebo/no treatment group in spine surgery. Metaanalysis was performed using RevMan 5. Weighted mean difference with 95% confidence intervals was used to summarize the findings across the trials for continuous outcomes. Dichotomous data were expressed as risk ratios with 95% confidence intervals. A p<.05 was considered statistically significant. Results Eleven RCTs were included for TXA (644 total patients). Tranexamic acid reduced intraoperative, postoperative, and total blood loss by an average of 219 mL ([−322, −116], p<.05), 119 mL ([−141, −98], p<.05), and 202 mL ([−299, −105], p<.05), respectively. Tranexamic acid led to a reduction in proportion of patients who received a blood transfusion (risk ratio 0.67 [0.54, 0.83], p<.05) relative to placebo. There was one myocardial infarction (MI) in the TXA group and one deep vein thrombosis (DVT) in placebo. Conclusions Tranexamic acid reduces surgical bleeding and transfusion requirements in patients undergoing spine surgery. Tranexamic acid does not appear to be associated with an increased incidence of pulmonary embolism, DVT, or MI. [ABSTRACT FROM AUTHOR]

Surgical correction of adolescent idiopathic scoliosis is advocated for severe curves to preserve or improve pulmonary function, prevent progressive deformity and pain, and improve self-appearance. Restoration of sagittal and 3D alignment, in particular thoracic kyphosis (TK), has become increasingly emphasized in efforts to improve pulmonary function, thoracic volumes, provide improved sagittal balance, and prevent adjacent segment degeneration and deformity. To study the effects of thoracic kyphosis restoration in AIS type 1 and 2 curves on postoperative thoracic volume and pulmonary function. Retrospective review of prospective multicenter database. Thirty-nine AIS patients with Type 1 and 2 curves with 5Y postoperative stereo-radiographic data and pulmonary function tests (PFTs). Five-year spinal and rib cage measures and PFTs. A multicenter prospective registry of patients undergoing surgical correction of Type 1- and 2- AIS curves was queried for patients with 5-year postoperative visits including stereoradiographic assessment and PFTs. 3-dimensional (3D) radiographic analysis was performed to assess spinal alignment and chest wall dimensions at preoperative, first erect and 5 year postoperative time points. Variables were analyzed between time points with a one-way ANOVA and post-hoc Tukey analysis, and between variables with linear regression analysis. A total of 39 patients met the inclusion criteria (37F, age 14.4±2.2). 3D spine alignment analyses demonstrated significant reduction in pre-op to 1st erect upper thoracic (41.3° to 11.6°), mid-thoracic (48.6° to 9.55°) and lumbar Cobb angles (19.7° to 8.9°), an increase in TK:T2-12 (20.0° to 39.8°) and TK:T5-12 (9.8 to 28.2°), and reduction in proximal and mid-thoracic apical vertebral rotation (9.5° to 2.1°) from preoperative to 1st erect postoperative (p<0.001 for all). 3D spinal alignment remained stable from 1st erect to 5 years (p>0.05 for all). 3D rib cage analysis demonstrated there was a small reduction in maximal depth (144 mm to 138 mm), maximum width (235 mm to 232 mm), and increase in thoracic height (220 mm to 230 mm, p<0.01 for all), but no significant change in rib cage volume (5136 to 5202 cm3 p=0.184). There was no correlation between change in coronal or sagittal alignment parameters and perioperative change in rib cage volume. From first erect to 5-year a significant increase in max depth (138 mm to 144 mm), width (232 mm to 242 mm), thoracic height (230 mm to 233 mm) and rib cage volume (5202 cm to 5912 cm, p<0.001 for all) occurred. Pulmonary function analysis showed significant improvement in FEV1 (2.73 to 2.98 L, p=0.003) and FVC (3.22 to 3.46 L, p=0.006) from preoperative to 5-year, however, TLC did not change (4.54 to 4.59 L, p=0.517). Percent predicted TLC was reduced (Pre:101.3% to 5Y:89.1%, p<0.001), however, % predicted FEV and FVC did not (89% to 86.4%, p=0.227 & 92.5% to 87.7%, p=0.10 respectively). PFTs at 5-year follow-up correlated most closely with rib cage volume at 5-year follow-up (FEV r=0.643, FVC r=0.800, TLC r=0.73, p<0.001). While thoracic kyphosis increases, coronal Cobb and apical vertebral rotation decrease postoperatively, these do not directly influence chest wall volume. Chest wall volume continues to increase between from first erect to 5 years due to presumed growth, which corresponds with an improvement in FEV1 and FVC at 5 year follow-up. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Prior literature in patients with adult spine deformity has found that poor mental health at baseline is associated with worse postoperative outcomes. The purpose of this study is to demonstrate that adolescent idiopathic scoliosis (AIS) patients with poor mental health at baseline can experience significant improvements with surgery. We hypothesize that in AIS, low SRS-22r mental health scores are largely due to the presence of deformity. The purpose of this study is determine if the correction of the deformity would potentially improve mental health scores. Retrospective review of prospective AIS registry. Adolescents with idiopathic scoliosis. Mental health scores and percent of patients reaching minimum clinically important difference (MCID) at 2 years postoperative. A total of 1,532 (1,261 girls, 271 boys) with available baseline and 2-years follow-up SRS-22r scores were included. Patients with baseline mental health domain scores who were 1 standard deviation below the mean (< 3.3) were classified as "low mental health" score (LMH) group, and patients who were 1 standard deviation above the mean (> 4.7) were classified as "high mental health" score (HMH) group. The remaining patients were classified as "intermediate mental health" score (IMH). A minimal clinically important difference (MCID) of 0.6 was used for SRS-22r for analysis There were 247 patients in the LMH group, 1,015 in the MMH group, and 270 in the HMH group. Compared to baseline, all 3 groups demonstrated significant improvements in the overall SRS-22r scores at the 2-year follow-up: 0.8 ±0.5 in the LMH group, 0.5 ±0.4 in the IMH group, and 0.29 ±0.35 in the HMH group (P<0.001 each). Further, at the 2-year follow-up, 72% of patients in the LMH group, 40% of patients in the IMH group, and 17% of patients in the HMH group reached MCID for SRS-22r. At the 2-year follow-up, there was no significant difference in the final SRS-22r score of the 3 groups. In distinction from adult deformity patients, in the AIS population, alterations in normal body image may results in low mental health at baseline. These patients can experience significant benefit with surgery, and majority of these patients achieve MCID for the SRS-22r at the 2-year follow-up. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]