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To investigate the risk and predictive factors of junctional issues after conversion from Traditional growing rod (TGR) to definitive spinal fusion in Early-onset scoliosis (EOS). Retrospective review of a multicenter EOS database. TGR patients who received final fusion with at least two-year follow-up were included. Proximal (PJA) and Distal junctional angles (DJA) on pre-final fusion, post-final fusion (within one year of surgery), and at latest follow-up were measured on lateral upright spinal radiographs. Differences in values among designated time points and predictive factors of junctional issues were evaluated statistically. Forty-six of 251 patients (28 females, 18 males and mean age at final fusion: 12 ± 2 [9–17] years) met the inclusion criteria. Mean follow-up between first postoperative measurement and latest follow-up was 49 ± 22 (24–112) months. No statistical differences in PJA and DJA values were available at pre-fusion, first post-fusion, or latest follow-up (p = 0.827, p = 0.076). Fifty percent of patients had extension of TGR instrumentation at fusion, either proximal or distal. No factor including sex and etiology, lumbar lordosis, thoracic kyphosis, major curve magnitude, PJA, and DJA at pre-fusion was found to be a predictive issue for extension of index TGR instrumentation, except the history of at least one implant-related complication during the period from index surgery to the definitive fusion. PJA and DJA remained stable when transitioning from TGR to final posterior spinal fusion. But 50% of patients had extension of construction at fusion, either proximal or distal.

Determine the efficacy of intraoperative traction (IOT) on curve correction in AIS. A prospective, multicenter, longitudinal database identified patients with major thoracic AIS (Lenke 1–4) treated with surgery using IOT and follow-up of 2 years. These cases were matched to comparable cases treated without traction (non-IOT). All patients were treated with single-stage posterior only surgery with pedicle screw constructs. Perioperative, radiographic and clinical outcome data at 2 years post-op were compared between the groups. 104 cases treated with IOT were matched to 104 treated without IOT. Operating room time was significantly greater in the IOT group (339 vs. 306 min, p = 70° (IOT 72% vs. non-IOT 64%, p = 0.04). IOT was associated with a significant reduction in 2D T5–T12 kyphosis measurements (IOT − 6.5° vs non-IOT + 0.48°, p

Retrospective review of a prospectively collected multicenter database. To identify risk factors for early and late readmission of surgically treated patients with adolescent idiopathic scoliosis (AIS). Specific risk factors associated with readmission in patients with AIS remain poorly understood. Patients with AIS who were operatively treated from 19 centers specializing in the treatment of pediatric spinal deformity were studied. Data from a minimum 2 years of clinical follow-up and any readmission were available for analysis. Characteristics of patients with no readmission, early readmission ( 90 days) were evaluated. Both univariate and multivariate analyses of risk factors for readmission were performed. 2049 patients were included in our cohort, with 1.6% requiring early readmission and 3.3% late readmission. In the multivariate analysis, greater preoperative coronal imbalance was associated with early readmission. Longer operative time was associated with late readmission. Finally, greater preoperative pain (SRS-22 pain scale) was associated with both early and late readmission. GI complications accounted for a higher proportion of early readmissions than previously reported in the literature. Preoperative counseling of patients with higher levels of pain and coronal imbalance and the implementation of a thorough postoperative bowel regimen may help optimize patient outcomes. 3.

Decreasing radiation exposure is important for scoliosis patients who require serial imaging. Microdose protocol stereoradiography is now increasingly utilized. Previous studies have reported similar reliability of concurrent Sanders skeletal maturity staging based on standard low-dose stereoradiography and standard hand radiographs. The purpose of our study was to investigate the reliability and radiation exposure of concurrent Sanders staging using microdose protocol compared to a standard protocol for adolescent idiopathic scoliosis. We hypothesized that surgeon-performed Sanders staging would have similar reliability when comparing microdose and standard-dose imaging protocols. A randomized survey of 30 hand images using standard protocol spinal stereoradiography and an equal number from microdose protocol were distributed to six experienced pediatric orthopaedic spine surgeons. Images were graded by each surgeon according to the Sanders skeletal maturity grading system. Items were again randomized and graded after a 2-week interval. Fleiss’ weighted kappa for inter and intraobserver reliability was calculated and an unpaired t test was used to test for significance. Interobserver reliability for all modalities was in the strong to almost perfect agreement (average weighted κ > 0.8) range. For the microdose protocol, κ was 0.82 and 0.84 for each separate round of grading. Standard low-dose protocol κ was 0.83 and 0.79. Intraobserver κ was 0.86 for microdose and 0.82 for standard. Average radiation for microdose was significantly less radiation (82.6%) than standard stereoradiography (0.3 ± 0.1 mGy vs. 1.9 ± 0.4 mGy, p

Purpose The complex three-dimensional spinal deformity in AIS consists of rotated, lordotic apical areas and neutral junctional zones that modify the spine’s sagittal profile. Recently, three specific patterns of thoracic sagittal ‘malalignment’ were described for severe AIS. The aim of this study is to define whether specific patterns of pathological sagittal alignment are already present in mild AIS. Methods Lateral spinal radiographs of 192 mild (10°–20°) and 253 severe (> 45°) AIS patients and 156 controls were derived from an international consortium. Kyphosis characteristics (T4–T12 thoracic kyphosis, T10–L2 angle, C7 slope, location of the apex of kyphosis and of the inflection point) and sagittal curve types according to Abelin-Genevois were systematically compared between the three cohorts. Results Even in mild thoracic AIS, already 49% of the curves presented sagittal malalignment, mostly thoracic hypokyphosis, whereas only 13% of the (thoraco) lumbar curves and 6% of the nonscoliosis adolescents were hypokyphotic. In severe AIS, 63% had a sagittal malalignment. Hypokyphosis + thoracolumbar kyphosis occurred more frequently in high-PI and primary lumbar curves, whereas cervicothoracic kyphosis occurred more in double thoracic curves. Conclusions Pathological sagittal patterns are often already present in curves 10°–20°, whereas those are rare in non-scoliotic adolescents. This suggests that sagittal ‘malalignment’ patterns are an integral part of the early pathogenesis of AIS.

The advantage of considering the three-dimensional curve patterns, including the patterns of the vertebral position and alignment, in classification of adolescent idiopathic scoliosis (AIS) patients and whether such classification system relates to the surgical outcomes are not fully determined. A total of 371 AIS patients who received posterior spinal fusion surgery with 2-year follow-up were included retrospectively and consecutively. The 3D positions and orientations of the T1–L5 vertebrae were calculated from the 3D reconstructions of the spines at pre-operative and 2-year follow-up, a total of 102 variables per patient. A probabilistic clustering method was used to cluster the pre-operative and 2-year follow-up 3D spinal curve patterns separately. The distributions of the Lenke types and 3D pre-operative clusters in the post-operative clusters were determined. A total of nine pre-operative clusters including, four right thoracic types, three left thoracolumbar/lumbar types, one low apex right thoracic/thoracolumbar, and one left thoracic/right lumbar were determined. Three post-operative 3D curve patterns were Type 1 with higher residual proximal Cobb angle, Type 2 with lower T5–T12 kyphosis and highest pelvic incidence-lordosis mismatch, and Type 3 with larger lumbar curve magnitude and rotation compared to the other two groups. More than 50% of patients in each of the 3D pre-operative clusters had the same post-operative group. We developed a 3D classification of the AIS patients before and two-year after spinal fusion surgery. The link between the pre- and post-operative clusters lends itself to application of this classification system in developing predictive models of the AIS surgical outcomes.

Purpose There are distinct differences in strategy amongst experienced surgeons from different ‘scoliosis schools’ around the world. This study aims to test the hypothesis that, due to the 3-D nature of AIS, different strategies can lead to different coronal, axial and sagittal curve correction. Methods Consecutive patients who underwent posterior scoliosis surgery for primary thoracic AIS were compared between three major scoliosis centres (n = 193). Patients were treated according to the local surgical expertise: Two centres perform primarily an axial apical derotation manoeuvre (centre 1: high implant density, convex rod first, centre 2: low implant density, concave rod first), whereas centre 3 performs posteromedial apical translation without active derotation. Pre- and postoperative shape of the main thoracic curve was analyzed using coronal curve angle, apical rotation and sagittal alignment parameters (pelvic incidence and tilt, T1–T12, T4-T12 and T10-L2 regional kyphosis angles, C7 slope and the level of the inflection point). In addition, the proximal junctional angle at follow-up was compared. Results Pre-operative coronal curve magnitudes were similar between the 3 cohorts and improved 75%, 70% and 59%, from pre- to postoperative, respectively (P P Conclusion Curve correction by derotation may lead to thoracolumbar lordosis and therefore higher risk for proximal junctional kyphosis. Focus on sagittal plane by posteromedial translation, however, results in more residual coronal and axial deformity.

Prospective cerebral palsy (CP) registry review. (1) Evaluate the incidence/risk factors of gastrointestinal (GI) complications in CP patients after spinal fusion (SF); and (2) investigate the validity of the modified Clavien–Dindo–Sink classification. Perioperative GI complications result in increased length of stay (LOS) and patient morbidity/mortality. However, none have analyzed the outcomes of GI complications using an objective classification system. A prospective/multicenter CP database identified 425 children (mean, 14.4 ± 2.9 years; range, 7.9–21 years) who underwent SF. GI complications were categorized using the modified Clavien–Dindo–Sink classification. Grades I–II were minor complications and grades III–V major. Patients with and without GI complications were compared. 87 GI complications developed in 69 patients (16.2%): 39 minor (57%) and 30 major (43%). Most common were pancreatitis (n = 45) and ileus (n = 22). Patients with preoperative G-tubes had 2.2 × odds of developing a GI complication compared to oral-only feeders (OR 2.2; 95% CI 0.98–4.78; p = 0.006). Similarly, combined G-tube/oral feeders had 6.7 × odds compared to oral-only (OR 6.7; 95% CI 3.10–14.66; p

Surgical treatment of Adolescent Idiopathic Scoliosis (AIS) involves healthy individuals with spinal deformity. Parents are responsible for surgical consent on behalf of their children, a burden which causes trepidation and concern. Therefore, explanation of operative risk is a critical component of informed consent and parent decision-making. We set out to quantify parental risk aversion (RA). RA questionnaires were administered preoperatively to parents of 58 AIS patients undergoing spinal fusion (SF). RA is the likelihood of a parent to consent to their child’s SF (1- least likely, 10- most) with increasing allotments of data about potential complications at each stage (S1-complication named, S2-explained, S3-incidence given, S4-all information). A statistically significant mean difference in answers for each stage was assessed using paired sample t test or Wilcoxon rank t test. Normality was assessed by performing Shapiro–Wilk test. AIS patients (age 14.2 years, 85% female, major curve 61°) were included. Mean scores for each of the stages were 4.4 ± 3.1, 4.9 ± 3.1, 6.5 ± 3.0, 6.6 ± 3.0, respectively. Highest and lowest RA were reported for death and infection, respectively. The greatest increase in likelihood to proceed with surgery was seen after education on malposition of implants and on death, 2.6 and 2.5, respectively (p

Prospective multicenter international observational study. To investigate incidence of new neurologic deficit (NND) and the long-term recovery patterns following complex pediatric spine deformity surgery. The SRS MM idiopathic kyphoscoliosis(5 patients); congenital scoliosis (7 patients); congenital kyphoscoliosis (4 patients); congenital kyphosis (6 patients), other kyphosis (1 patient) and syndromic (1 patient). 1 patient was lost to follow-up (f/u) after discharge; 1 had chronic deficits at the first post-operative erect visit (from discharge to 9 months f/u) and was subsequently lost to follow-up; 2 patients were improving at 1-year f/u but lost to subsequent f/u. 16 patients had normal neurologic function by the time of the first post-operative erect visit, 21 patients at 1-year f/u and 21 patients at the 2-year f/u. 2 patients (0.69%) had improved NND at 2-year mark. A significant proportion of patients with complex spine deformity experience NND. However, significant improvement in neurologic function can be expected over time as seen in this study without additional surgical intervention in most cases. Congenital deformities accounted for 63% of the patients experiencing NND.

Retrospective review of prospective multi-center cohort. To investigate the impact of thoracoplasty on pulmonary function at 2-year follow-up among complex pediatric spine deformity patients. Complex pediatric spine deformities may be associated with significant rib prominence causing body image concerns. Surgical correction of spine deformity may include thoracoplasty to correct the rotational prominence. Some surgeons refrain from performing thoracoplasty due to its purported negative effect on pulmonary function. There is paucity of literature on the effect of thoracoplasty on pulmonary function at 2-year follow-up in pediatric patients with complex spine deformity. We reviewed data of 312 patients (> 100°, with or without vertebral column resection (VCR)) or ( 0.05). Group 1 had significantly lower body mass index (BMI) compared to Group 2 (18.4 kg m−2 ± 2.8 vs. 19.9 kg m−2 ± 4.8, p = 0.0351). The average baseline coronal and sagittal Cobbs were larger for Group 1 relative to Group 2 (p 0.05). The rate of pre-op utilization of halo gravity traction (HGT) was 52.5% vs. 26.7% (p = 0.008), at an average duration of 103 days vs. 47 days, p = 0.0001. The rate of surgical osteotomies was similar in both groups. Estimated blood volume (EBV) loss was greater in Group 1 (63.1% vs. 43.1%, p = 0.0012). Post-op coronal and sagittal Cobb correction was similar in both groups. The incidence of post-op pulmonary complication was similar in both groups (8.2% vs. 8.9%, p = 0.899). Baseline and 2-year follow-up PFT did not differ significantly between and within the groups. Vertebral column resection (VCR) did not negatively affect PFT in both groups. Despite higher curve magnitudes in patients undergoing surgical correction and thoracoplasty for complex pediatric spine deformity, our findings revealed that thoracoplasty does not negatively affect pulmonary function at 2-year follow-up.

Thoracolumbar fractures in children are relatively uncommon and should be regarded as a separate entity from those in adults. While percutaneous pedicle fixation has emerged as an effective alternative to open fixation in adults with unstable thoracolumbar fractures, this technique is rarely applied in children. We report a 6-year-old girl with an L3 chance fracture, which was treated via short-segment percutaneous pedicle fixation. We also discussed the technical challenges and caveats of this surgical technique in young children. While potentially more challenging, percutaneous pedicle fixation is feasible in young children with thoracolumbar fractures. Specific differences between the developing and mature spine in regard to anatomical and biomechanical characteristics, including ligamentous laxity and intrinsic elasticity, should be taken into consideration. Future studies are needed to compare outcomes of minimally invasive spinal techniques to open surgery in children.

Study design Observational. Objectives To report on the rate of major complications following spinal fusion and instrumentation to treat spinal deformity in patients with cerebral palsy (CP). Summary of background data Understanding the risk of major complications following the surgical treatment of spine deformities in patients with CP is critical. Methods A prospectively collected, multicenter database of patients with CP who had surgical correction of their spinal deformity (scoliosis or kyphosis) was reviewed for all major complications. Patients with ≥ 2 year follow-up or who died ≤ 2 years of surgery were included. A complication was defined as major if it resulted in reoperation, re-admission to the hospital, prolongation of the hospital stay, was considered life-threatening, or resulted in residual disability. Overall complication and revision rates were calculated for the perioperative (Peri-op; occurring ≤ 90 days postoperative) and delayed postoperative (Delayed; > 90 days) time periods. Results Two hundred and fifty-seven patients met inclusion. Seventy-eight (30%) patients had a major complication, 18 (7%) had > 1. There were 92 (36%) major complications; 64 (24.9%) occurred Peri-op. The most common Peri-op complications were wound (n = 16, 6.2%) and pulmonary issues (n = 28, 10.9%), specifically deep infections (n = 12, 4.7%) and prolonged ventilator support (n = 21, 8.2%). Delayed complications (n = 28, 10.9%) were primarily deep infections (n = 8, 3.1%) and instrumentation-related (n = 6, 2.3%). There were 42 additional surgeries for an overall unplanned return to the operating room rate of 16% (Peri-op: 8.6%, Delayed: 7.8%). Thirty-six (14.0%) reoperations were spine related surgeries (wound or instrumentation-related). Eleven (4.3%) patients died between 3 months to 5.6 years postoperatively; 4 occurred ≤ 1 year of surgery. Two deaths were directly related to the spinal deformity surgery. Conclusion Spinal deformity surgery in CP patients with greater than 2 years of follow-up have a postoperative major complication rate of 36% with a spine-related reoperation rate of 14.0%. Level of evidence Therapeutic-IV.

Prospective cohort review. To compare two AIS databases to determine if a performance improvement-based surgeon group has different outcomes compared to a national database. The American College of Surgeon’s National Quality Improvement Program (ACS-NSQIP) and a surgeon study group (SG) collect prospective data on AIS surgery outcomes. NSQIP offers open enrollment to all institutions, and SG membership is limited to 15 high-volume institutions, with a major initiative to improve surgeon performance. While both provide important outcome benchmarks, they may reflect outcomes that are not relatable nationwide. The ASC-NSQIP Pediatric Spine Fusion and SG database were queried for AIS 30- and 90-day complication data for 2014 and 2015. Prospective enrollment and a dedicated site coordinator with rigorous data quality assurance protocols existed for both registries. Outcomes were compared between groups with respect to superficial and deep surgical site infections (SSI), neurologic injury, readmission, and reoperation. There were a total of 2927 AIS patients included in the ASC-NSQIP data and 721 in the SG database. Total complication rate was 9.4% NSQIP and 3.6% SG. At 90 days, there were fewer surgical site infections reported by SG than ASC-NSQIP (0.6% vs. 1.6%, p = 0.03). Similarly, there were less spinal cord injuries (0.8% vs 1.5%, p = 0.006), 30-day readmissions (0.8% vs. 2.6%, p = 0.002), and 30-day reoperations (0.6% vs. 1.7%, p = 0.02) in the SG cohort. Comparison of these two data sets suggests a range of complications and readmission rates, with the SG demonstrating lower values. These results are likely multi-factorial with the performance improvement initiative of the SG playing a role. Understanding the rate and ultimate risk factors for readmission and complications from big data sources has the potential to further drive quality improvement. III.

AIS patients and their parents will have distinct perspectives regarding the impact of AIS on patients’ lives. Current outcome assessment tools for AIS do not fully assess patient-specific disease impact and fail to distinguish between patient and parent perspectives. Patient Generated Index (PGI) has been used in other disease states to assess individual experiences. This study assesses PGI in operative AIS patients and their parents. Level 1, prospective multi-center study. 44 AIS patient and parent pairs completed the PGI questionnaire comprised of three stages (S1, S2, S3) and decision regret (DR). S1 asks for five areas of the patient’s life most affected by AIS and a 6th encompassing all other areas of their lives affected, S2 focuses on the magnitude of effect, S3 identifies desire to improve affected areas and DR if the surgery did not improve the specific area. S1 free responses were organized into 14 domains. Descriptive statistics were reported for stage scores; free-response format of PGI and DR limited ability for paired sample t test analysis. Mean age at surgery was 14.3 years, 84% female, and mean major curve magnitude was 61°. The three most common patient-reported concerns prior to surgery were (in descending order): sports, general function, and general fitness. However, the three most common parent-reported concerns were (in descending order): general function, sports, and appearance. Patients reported self-esteem and parents reported physical appearance as the most affected domain (S2). Patients reported pain and self-esteem and parents reported sleep and self-esteem as main operative aspirations (S3). Decision regret was the highest for uncertainty of future health in patients and sleep in parents. AIS patients and their parents reported different concerns and DR regarding surgical treatment. PGI provides insight into patient and parent views toward the disease as well as treatment aspirations.

Retrospective cohort study. To determine whether patients who underwent surgical treatment of adolescent idiopathic scoliosis (AIS) in childhood would have an increased C-section risk in adulthood. Although the impact of scoliosis on future pregnancy and child delivery is a common question for patients and parents, there is limited data regarding pregnancy outcomes following childhood treatment of AIS. Between 1975 and 1992, 60 female patients underwent treatment for AIS with bracing, surgery, or observation and had data available regarding obstetrical history in the electronic medical record or in paper charts. In childhood, 28 had nonoperative treatment and 32 had fusion surgery. During the follow-up period, 2 nonoperative patients and 1 operative patient had fusion surgery in adulthood, but after childbearing years. Mean age at latest follow-up was 43 years (CI 38, 48). Meantime to follow-up since childhood treatment was 31 years (CI 26, 35). 29% of nonoperative patients had a C-section with at least one live birth compared to 38% of operative patients (p = 0.464). For surgical patients fused to L3 or lower, 46% required at least one C-section, compared to 32% of patients fused to L2 or higher (p = 0.40). Overall, 33% of the cohort of patients—including those with all scoliosis treatment methods—required at least one C-section, compared to the state weighted C-section rate of 20.5% (p = 0.014). The percentage of patients with operative treatment—including all levels of fusion—requiring at least one C-section was statistically different than the weighted state C-section rate (p = 0.020). In this long-term cohort of 60 US scoliosis patients, childhood operative fusion treatment was associated with a statistically significant increased incidence of C-section compared to the state incidence at both the patient level and the delivery level. III, comparative cohort study

Retrospective review OBJECTIVES: To report the frequency of pretreatment magnetic resonance imaging (MRI) utilization and rates and types of intra-spinal abnormalities identified on MRI in patients with early-onset scoliosis (EOS). MRI can help identify spinal cord abnormalities in patients with EOS.We reviewed data from patients enrolled from 1993-2018 in an international EOS registry. Patients with incomplete/unverifiable data and those with spinal deformities secondary to infection or tumor were excluded, leaving 1343 patients for analysis. Demographic characteristics, pretreatment major curve magnitude, treatment type, and MRI findings were analyzed. Patients were categorized by EOS type (congenital, idiopathic, neuromuscular, syndromic), pretreatment MRI utilization, and presence of intra-spinal abnormality on MRI. Univariate testing and multivariate logistic regression were performed to identify demographic, radiographic, and clinical predictors of MRI utilization and abnormal MRI findings.MRI was used in 836 patients (62%). Pretreatment MRI utilization rates ranged from 42% in neuromuscular EOS to 74% in congenital EOS. Prevalence of abnormal MRI findings was 24% overall, ranging from 13% in patients with idiopathic EOS to 39% in neuromuscular EOS. Compared with white/Caucasian patients, Asian/Asian-American patients had higher odds of MRI utilization and abnormal MRI findings. Treatment type, pretreatment major curve magnitude, age at MRI, and age at treatment were not associated with abnormal MRI findings. Overall, 249 abnormalities were identified in 197 patients. The most common findings were syrinx and tethered cord. Syrinx with Chiari malformation was the most frequent combination of abnormal findings.In the two-thirds of patients who underwent MRI before EOS treatment, findings were abnormal in 24%. EOS type and race/ethnicity were associated with both MRI utilization and abnormal findings. The most frequent abnormalities were syrinx and tethered cord, and the type of abnormalities appeared to differ by EOS type.Prognostic, Level III.

Retrospective review of prospective data.To delineate a curve threshold where further delay of surgery significantly increased the risks for patients with cerebral palsy (CP) scoliosis.Two approaches exist in the management of CP scoliosis: a proactive one where surgery is recommended once there is a risk of progression (Cobb50°) and a reactive one where surgery is recommended after the patient/caregiver may have significant challenges caused by a large deformity.A prospectively collected CP scoliosis surgical registry was queried for patients with minimum two years of follow-up. Three groups were delineated based on the distribution of curve magnitudes:70° (proactive), 70°-90°, and90° (reactive). Radiographic, surgical, and quality of life outcome data were compared between the groups using analysis of variance and chi-square analyses.There were 38 patients in the70° group, 44 in the 70°-90° group, and 42 in the90° group. They were similar in age. The90° group had significantly longer operative time (p.001), a higher percentage of anterior/posterior procedures (31% vs 5%), and a higher infection rate requiring ID (16.7%) than the other groups (70°: 5.3%; 70°-90°: 6.8%; p.05). The percentage blood volume loss was significantly higher in the90° group compared to70°. There were no differences in length of hospitalization or intensive care unit stay. Preoperatively, the Caregiver Priorities and Child Health Index of Life with Disabilities (CPchild) QOL score was significantly higher for the70° group. At two years, the70° and 70°-90° groups reached similar QOL scores, whereas the90° trended toward a lower postoperative QOL.Being proactive (Cobb70°) has no advantage in terms of decreasing risks or improving outcomes compared to curves 70°-90°. However, delaying surgery to a curve greater than 90° increases the risk of infection, blood loss, and the need for anterior/posterior procedures. Ideally, surgery should be recommended for curves less than 90°.

Value in health care is defined as the quotient of outcomes to cost. Both pediatric and adult spinal deformity surgeries are among the most expensive procedures offered today. With high variability in both outcomes and costs in spine surgery today, surgeons will be expected to consider long-term cost effectiveness when comparing treatment options. We summarize various methods by which value can be increased in complex spine surgery, both through the improvement of outcomes and the reduction of cost. These methods center around standardization, team-based and collaborative approaches, rigorous outcomes tracking through dashboards and registries, and continuous process improvement. This manuscript reviews the expert opinion of leading spine specialists on the improvement of safety, quality and improvement of value of pediatric and adult spinal surgery. Without surgeon leadership in this arena, suboptimal solutions may result from the isolated intervention of regulatory bodies or payer groups. The cooperative development of standardized, team-based approaches in complex spine surgery will lead to the high-quality, high-value care for patients.

Study Design Retrospective cross-sectional, longitudinal radiographic analysis. Objective To report the natural history of spinopelvic parameters in achondroplasia. Summary of Background Data Sagittal spinal deformity is common in children with achondroplasia. However, few data exist on their normative spinal parameters. Methods Lateral standing spine radiographs of children with achondroplasia were reviewed. Measurements included thoracic kyphosis, lumbar lordosis (LL), thoracolumbar kyphosis (TLK), pelvic incidence (PI), T1 pelvic angle (TPA), and sagittal balance (SVA). Comparison between age groups and longitudinal analysis of children with minimum five-year radiographic evaluation was performed; evolution of radiographic measurements was assessed. Children who underwent surgical correction of TLK were studied separately to describe changes of sagittal spinal parameters associated with TLK surgical correction. Results In cross-sectional analysis, 745 radiographs (282 children) were measured. During the first three years, TLK decreased and LL and sacral slope increased significantly. After age 3 years, TLK decreased gradually until age 10. Afterwards, TLK decrease became non-significant. PI increased gradually after age 10. In the longitudinal group, 81 children were followed an average of 8.7 (5–19) years between age 4.4 and 13.1 years. TLK decreased; LL and PI increased significantly. TPA and SVA remained within the normal range although changes with growth were statistically significant. In the surgical group, 19 children underwent surgical TLK correction. Apart from TLK correction, no sagittal parameters changed significantly after surgery. These 19 children had higher TLK and lower LL compared with a nonsurgical group at similar average age. Conclusion In children with achondroplasia, TLK improvement occurs primarily before age 3 years; hyperlordosis at the lumbosacral level is the compensatory mechanism. Significant changes in the sagittal spinal parameters occur early in life, suggesting the importance of attention to sagittal malalignment to prevent any possible clinical sequelae of severe hyperlordosis. Level of Evidence Level III, prognostic study.

Study Design Retrospective review of a prospective cohort. Objective To identify patient and surgical factors that alter the length of postoperative intensive care unit (ICU) stays after spinal fusion/instrumentation in patients with neuromuscular scoliosis secondary to cerebral palsy (CP). Summary of Background Data High perioperative complication rates in patients with CP contribute to the practice of utilizing the ICU postoperatively for monitoring. However, this is costly and little is known regarding which patients truly need this increased acuity of care. Methods A prospective, multicenter database was queried for patients with CP who underwent spinal fusion and instrumentation. Patients with an ICU length of stay (LOS) ≤1 day were assumed to not have required postoperative ICU admission. Demographic and surgical characteristics were compared between those with ICU LOS of ≤1 day versus >1 day. A classification and regression tree (CART) analysis was utilized to create a decision algorithm for postoperative ICU admission. Results Three hundred twenty-four patients were identified with a mean ICU LOS of 4.7 days (range 0-47). Sixty-eight patients (21%) had an ICU LOS ≤1 day and 256 patients (79%) had an ICU LOS >1 day. CART analysis demonstrated that the institution where the surgery was performed was the primary predictor with two groups: sites that almost routinely had ICU stay >1 day (92%) and those that were split (50.5% >1 day). In the latter group, an operative time greater than 4 hours was a risk factor for a longer ICU stay. Conclusion Because of their heterogeneous makeup, CP patients should be evaluated individually and their postoperative disposition should not be based on institutional tradition but instead on objective surgical factors. For those patients with surgical times less than 4 hours, discussions should be held regarding the safety of a postoperative disposition to a regular floor. Level of Evidence Level III.

Retrospective review of prospectively collected data.To determine whether adolescent idiopathic scoliosis (AIS) patients with active complications at two-year follow-up demonstrate lower Scoliosis Research Society (SRS-22) questionnaire scores.There is limited evidence as to whether the SRS-22 is sensitive to complications in postoperative AIS patients.Surgical patients with SRS-22 scores completed at two-year follow-up were included. Five groups were created: no complication, minor complication resolved by 2 years, major complication resolved by 2 years, minor complication active, and major complication active at 2 years. Likelihood of reaching a minimal clinically important difference (MCID) for pain (0.20) and self-image (0.98) was evaluated.1,481 patients were identified. Major complications active at two years existed in 2.2% of patients. These patients had the lowest score in all domains and total scores (p.05). If a minor complication was active, scores were impacted for pain, self-image, satisfaction, and total (p.05). No differences were found between no complication and resolved complications. Patients with active major complications were more likely to have a pain score that worsened from pre- to two years reaching MCID (52%) compared to the other four groups (range 18%-29%, odds ratio [OR] 3.6, p.001). They also had a nonsignificant decreased rate of improvement of self-image score at an MCID level (42% vs. range 51%-66%, OR 0.56, p = .10).When timing is considered, the SRS-22 demonstrates the ability to discriminate between patients with and without a complication. Active experience of a major complication impacted SRS-22 scores, in particular, the rate of worsening scores for pain, self-image, function, and total score.Level III.

Severe, early-onset spinal deformity is common in patients with skeletal dysplasia. These deformities often present at young ages and are associated with significant pulmonary dysfunction. The objective of this study is to verify the effectiveness of growth-friendly spinal instrumentation systems in promoting growth in patients with skeletal dysplasia and early-onset kyphoscoliosis.A retrospective, multicenter comparative cohort study was performed. Twenty-three patients identified to have a skeletal dysplasia (SKD) were evaluated for diagnosis, age at treatment, gender, and type of growing rod construct (spine vs. rib constructs). Patients were matched by age and construct type with similarly treated patients with early-onset scoliosis (CON) without skeletal dysplasia. Radiographic parameters including maximum coronal and sagittal Cobb angle with levels, T1-S1 height, and T1-T12 height were measured.T1-T12 (12.8 vs. 15.2 cm, p = .01) and T1-S1 (21.2 vs. 24.5 cm, p = .05) heights were significantly shorter for the SKD group at implantation, and kyphosis tended to be more severe in children with SKD (p = .80 and .07, respectively). Kyphosis did not improve with treatment. Scoliosis improved (p.01), and ΔT1-T12 and ΔT1-S1 significantly increased in both groups (p.01). Complication rates were similar between the two groups; however, patients with SKD had more intraoperative monitoring changes and hardware failures (p.005).Although patients with SKD start with shorter spine lengths, gains in spine length appear to be comparable to other forms of EOS. Neuromonitoring changes and implant failures are more common in the SKD group.The effectiveness of growth-friendly techniques in promoting growth in early-onset spinal deformities in patients with skeletal dysplasia has not been previously studied. We report the first comprehensive review of this topic. Growth-friendly techniques are an appropriate treatment option in this patient population.

Sagittal alignment abnormalities in Scheuermann kyphosis (SK) strongly correlate with quality of life measures. The changes in spinopelvic parameters after posterior spinal fusion have not been adequately studied. This study is to evaluate the reciprocal changes in spinopelvic parameters following surgical correction for SK.Ninety-six operative SK patients (65% male; age 16 years) with minimum 2-year follow-up were identified in the prospective multicenter study. Changes in spinopelvic parameters and the incidence of proximal (PJK) and distal (DJK) junctional kyphosis were assessed as were changes in Scoliosis Research Society-22 (SRS-22) questionnaire scores.Maximum kyphosis improved from 74.4° to 46.1° (p.0001), and lumbar lordosis was reduced by 10° (-63.3° to -53.3°; p .0001) at 2-year postoperation. Pelvic tilt, sacral slope, and sagittal vertical axis remained unchanged. PJK and DJK incidence were 24.2% and 0%, respectively. In patients with PI45°, patients who developed PJK had greater postoperative T2-T12 (54.8° vs. 44.2°, p = .0019), and postoperative maximum kyphosis (56.4° vs. 44.6°, p = .0005) than those without PJK. In patients with PI ≥45°, patients with PJK had less postoperative T5-T12 than those without (23.6° vs. 32.9°, p = .019). Thoracic and lumbar apices migrated closer to the gravity line after surgery (-10.06 to -4.87 mm, p.0001, and 2.28 to 2.10 mm, p = .001, respectively). Apex location was normalized to between T5-T8 in 68.5% of patients with a preoperative apex caudal to T8, whereas 90% of patients with a preoperative apex between T5 and T8 remained unchanged. Changes in thoracic apex location and lumbar apex translation were associated with improvements in the SRS function domain.PJK occurred in 1 in 4 patients, a lower incidence than previously reported perhaps because of improved techniques and planning. Both thoracic and lumbar apices migrated closer to the gravity line, and preoperative apices caudal to T8 normalized in more than two-thirds of patients, resulting in improved postoperative function. Individualizing kyphosis correction to prevent kyphosis and PI mismatch may be protective against PJK.

Study Design Patients with preoperative spine magnetic resonance imaging (MRI) studies from a prospective multicenter study of operative adolescent Scheuermann kyphosis (SK). Objectives To investigate the usefulness of MRI screening in operative planning for SK surgeries. Summary of Background Data Neural axis abnormalities in operative SK have not been previously studied with MRI screening, despite its use. Methods One orthopedic surgeon and two radiologists evaluated all images retrospectively. Radiographs were evaluated for kyphosis apex and magnitude. MRIs were evaluated for spinal cord abnormalities, epidural lipomatosis, location and number of vertebral wedging, Schmorl nodes and posterior disc herniations, frequency of spondylolysis, etc. The relationship of these pathologies to the kyphosis apex was explored. This group was compared to a surgical SK group without preoperative MRIs. Results Eighty-six patients with MRIs, mean age 16.3 years, 64% male, and a mean preoperative kyphosis of 75.9° were evaluated. There were 17 spinal cord abnormalities. Low-lying conus was found in 2 patients, and syrinx in 15 (no Chiari malformations). Epidural lipomatosis was found in 49 patients, average of 5.7 levels. Anterior vertebral wedging occurred in all (mean 4.7 levels). Posterior disc herniations averaged 5.2 levels/patient and 1.8 levels caudad to the apex. Spondylolysis was reported in 8.1%. Four cases (4.7%) had the operative plan changed as a result of the preoperative MRI: two due to neural compression, one due to disc herniation and one due to a spinal cord draped over the apex. Thirty-one patients did not receive an MRI; there were no significant differences between the two groups. The rate of postoperative neurologic change was 3.5% in the MRI group and 3.2% in the no-MRI group. Conclusions Based on 4.7% of cases requiring a change in the operative plan as a result of preoperative MRI, the authors recommend considering performing screening MRI in operative SK patients.

Is there any relationship between lengthening intervals and rod fracture in traditional growing rod (TGR) surgery? A multicenter EOS database was queried for patients who had: (1) dual growing rods for EOS; (2) minimum 2-year follow-up; (3) a minimum of 2 lengthenings; and (4) revision surgery due to rod fracture. Of 138 patients who met the criteria: 56 patients experienced at least one-rod fracture (RF group) and 82 patients had no rod fractures (NRF group). In addition to each patient’s lengthening intervals, demographics, construct details, and radiographic parameters were compared. RF and NRF patients had a mean pre-op age of 5.7 years (range 1.3–10.7) and 7.3 years (range 1.6–12.8), respectively (p 0.05). RF and NRF patients had statistically similar mean pre-op major curve size and max kyphosis (p = 0.279; p = 0.619, respectively). Stainless steel rods fractured more frequently compared with Titanium rods (SS 49.2 % vs. Ti 38 %; p = 0.004). Rod fracture occurred more in rods smaller than 4 mm (p = 0.011). Lengthening intervals were not statistically different in RF and NRF groups and there was no association between lengthening interval and rod fracture in TGR cases. It was shown that patients who had rod fracture were younger and were more likely to have SS rods with smaller than 4 mm diameter.

Objective The purpose of this study was to assess L4–S1 inter-vertebral coronal motion of the unfused distal segments of the spine in patients with adolescent idiopathic scoliosis (AIS) after instrumented fusion with regards to postoperative time and fusion length, independently. Methods Coronal motion was assessed by standardized radiographs acquired in maximum right and left bending positions. The intervertebral angles were measured via digital radiographic measuring software and the motion from the levels of L4–S1 was summed. The entire cohort was included to evaluate the effect of follow-up time on residual motion. Patients were grouped into early ( 10 years) follow-up groups. A subset of patients (n = 35) with a primary thoracic curve and a nonstructural modifier type “C” lumbar curve were grouped as either selective fusion (lowest instrumented vertebra [LIV] of L1 and above) or longer fusion (LIV of L2 and below) and effect on motion was evaluated. Results The data for 259 patients are included. The distal residual unfused motion (from L4 to S1) remained unchanged across early, midterm, to long-term follow-up. In the selective fusion subset of patients, a significant increase in motion from L4 to S1 was seen in the patients who were fused long versus the selectively fused patients, irrespective of length of follow-up time. Conclusion Motion in the unfused distal lumbar segments did not vary within the >10-year follow-up period. However, in patients with a primary thoracic curve and a nonstructural lumbar curve, the choice to fuse longer versus shorter may have significant consequences. The summed motion from L4 to S1 is 50% greater in patients fused longer compared with those patients with a selective fusion, in which postoperative motion is shared by more unfused segments. The implications of this focal increased motion are unknown, and further research is warranted but can be surmised.

Study Design Retrospective review of a prospectively collected multicenter database of patients with adolescent idiopathic scoliosis (AIS). Objective To determine if Ponte osteotomies improve correction in Lenke 1A and 1B AIS curves treated with pedicle screws. Summary of Background Data There is little data studying the risks and benefits of Ponte osteotomies in AIS. Methods We identified patients with Lenke 1A and 1B curve types treated with pedicle screw constructs and a 2-year follow-up. They were grouped based on whether they did (PO) or did not (NoPO) have Ponte osteotomies. Demographic, surgical, and radiographic data collected preoperatively and at 2 years were statistically analyzed using unpaired Student t test and Fisher exact test. Results One hundred ninety-one patients met the inclusion criteria (mean age of 14.7 ± 2.2 years), and among those, 125 patients (65.4%) had Ponte osteotomies (average of 4.3 ± 1.5 Pontes per patient). The patients treated with Ponte osteotomies had similar clinical and radiographic parameters (major Cobb: PO=51.5°, NoPO=50.8°, p=.6) to the patients who did not have Ponte osteotomies except that they had stiffer and more lordotic curves (Flexibility Index: PO=47.3%, NoPO=54.5%, p=.04; T5–T12 kyphosis: PO=18.7°, NoPO=23.2°, p=.02). At 2 years, the patients treated with Ponte osteotomies had significantly better thoracic Cobb angle correction (Correction Index: PO=67.1%, NoPO=61.8%, p=.01) and an increase in T5–T12 kyphosis (PO = +3.0°, NoPO=−0.4°, p=.045). The Ponte group demonstrated greater rib prominence correction (PO = 53.2%, NoPO=38.4%, p=.02). There were no neurologic events in this cohort. Conclusions Although the use of Ponte osteotomies was not randomized, these data suggest that greater deformity correction in all 3 planes may be possible when Ponte osteotomies are performed for the stiffer and more lordotic Lenke 1A and 1B curves. The clinical significance of these overall small statistical differences remains to be determined. Level of Evidence III.

A prospective, longitudinal cohort was studied to determine the incidence, consequences, and risk factors of major perioperative complications in patients with cerebral palsy (CP) treated with spinal fusion. There is a wide variety of data available on the complications of spine surgery; however, little exists on the perioperative complications in patients with CP. A prospective multicenter dataset of consecutive patients with CP treated with spinal fusion was evaluated. All major perioperative complications were identified and stratified into categories: pulmonary, gastrointestinal, other medical, wound infection, neurological, instrumentation related, and unplanned staged surgery. Univariate and multivariate analyses were performed to identify various risk factors for major perioperative complications. 127 patients were identified with a mean age of 14.3 ± 2.6 years. Overall, 39.4 % of the patients had a major perioperative complication. Occurrence of a complication [no complication (NC), yes complication (YC)] resulted in significantly increased intensive care unit (ICU) (NC = 3.2 days, YC = 7.8 days, p

Retrospective, controlled, clinical study.To define the average values for sagittal spinopelvic parameters including pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS) in Scheuermann's kyphosis (SK); evaluate the differences in spinopelvic parameters among patients with SK and unaffected normal controls; and evaluate the correlation of various sagittal spinopelvic parameters to each other in SK and normal controls.Prospectively collected radiographic data from a study on SK were compared with those from previously published series of unaffected patients. Measures were made according to standard, defined measurement methods. Parameters measured included PT, PI, SS, thoracic kyphosis, lumbar lordosis, and radiographic sagittal alignment. Values were compared using independent-samples t test. Pearson correlation coefficient was used to analyze relationships between variables.A total of 47 patients with SK and 50 control patients, mean age 16.1 and 13.5 years, respectively, were included. In SK, average PI was 42°, average PT was 7°, and average SS was 35°. These values were not different from those of normal controls (PI, 46° [p = .084]; PT, 8° [p = .476]; SS, 37° [p = .162]). Pelvic incidence directly correlated with lordosis in both groups (p.005). T5-12 kyphosis correlated with lordosis in normal controls (p ≤ .05) but not in the SK group. Kyphosis in SK as quantified by greatest measurable Cobb angle did not correlate with PI or lordosis.Sagittal pelvic alignment in patients with SK is not different from that in normal subjects. Furthermore, in SK thoracic kyphosis did not correlate with any distal region of the spine (lumbar or pelvic). Further understanding of the relationship between sagittal spinopelvic alignment in various conditions causing spinal deformity will lead to better treatment of these conditions.

The combined spine and rib cage deformity in scoliosis is best described as a thoracic deformity, and recent advances in imaging have enabled better definition of three-dimensional (3D) deformity of the thorax in scoliosis. However, a comprehensive report that summarizes the published thorax deformity quantification parameter studies is lacking in the orthopaedic literature. An extensive literature review on the quantification of thorax deformity was performed, and a total of 25 thorax deformity parameters were compiled into eight independent categories based on their similarities of deformity assessment. This review serves as the first comprehensive summary of radiographic and CT-based thorax deformity quantification measures. Future work on the complex relationships between spine and ribcage deformity and the relationship with pulmonary function could help improve clinical interventions for scoliosis treatment.

A multicenter, prospective study of consecutively enrolled surgical patients with Scheuermann kyphosis (SK).To evaluate the impact of SK on preoperative pulmonary function and to determine which radiographic criteria may help predict pulmonary impairment.Pulmonary function in SK is not well studied. Previous studies on adolescent idiopathic scoliosis revealed that certain factors, including the magnitude of the thoracic curve and the number of vertebrae involved, significantly affect pulmonary function.A total of 64 patients with SK were evaluated. Absolute and percent predicted forced vital capacity (FVC), forced expiratory volume in 1 second, and total lung capacity were collected preoperatively. Subjects were divided according to kyphosis apex (thoracic or thoracolumbar) and kyphosis magnitude groups, and compared. Correlation analysis was performed to evaluate the impact of gender, age, kyphosis magnitude, and apex on pulmonary function. American Thoracic Society guidelines were used to classify patients according to the severity of pulmonary impairment.Mean age was 16 years (range 13-24 years), with 42 males. The percent predicted forced vital capacity was 95.8%, percent forced expiratory volume in 1 second was 92.5%, and percent total lung capacity was 106.2%. The percent predicted FVC differed significantly between the 71°-80° and 81°-90° groups (105% vs. 83%, respectively; p = .016) and the 71°-80° and greater than 90° groups (105% vs. 73%, respectively; p = .009). For percent predicted TLC, patients with greater than 90° had significantly lower average values than those in the 71°-80° range (79% vs. 115%, respectively; p = .016). Greatest kyphosis showed a fairly weak (r = -.24; p .10) but significant correlation with percent predicted FVC. The percentage of patients with moderate to severe impairment (4%) was lowest in the 71°-80° range, which increased with increasing ranges of kyphosis magnitude: 81°-90° (11%) and greater than 90° (50%).

Study Design Prognostic study and validation using prospective clinical trial data. Objective To derive and validate a model predicting curve progression to ≥45° before skeletal maturity in untreated patients with adolescent idiopathic scoliosis (AIS). Summary of Background Data Studies have linked the natural history of AIS with characteristics such as sex, skeletal maturity, curve magnitude, and pattern. The Simplified Skeletal Maturity Scoring System may be of particular prognostic utility for the study of curve progression. The reliability of the system has been addressed; however, its value as a prognostic marker for the outcomes of AIS has not. The BrAIST trial followed a sample of untreated AIS patients from enrollment to skeletal maturity, providing a rare source of prospective data for prognostic modeling. Methods The development sample included 115 untreated BrAIST participants. Logistic regression was used to predict curve progression to ≥45° (or surgery) before skeletal maturity. Predictors included the Cobb angle, age, sex, curve type, triradiate cartilage, and skeletal maturity stage (SMS). Internal and external validity was evaluated using jackknifed samples of the BrAIST data set and an independent cohort (n = 152). Indices of discrimination and calibration were estimated. A risk classification was created and the accuracy evaluated via the positive (PPV) and negative predictive values (NPV). Results The final model included the SMS, Cobb angle, and curve type. The model demonstrated strong discrimination (c-statistics 0.89–0.91) and calibration in all data sets. The classification system resulted in PPVs of 0.71–0.72 and NPVs of 0.85–0.93. Conclusions This study provides the first rigorously validated model predicting a short-term outcome of untreated AIS. The resultant estimates can serve two important functions: 1) setting benchmarks for comparative effectiveness studies and 2) most importantly, providing clinicians and families with individual risk estimates to guide treatment decisions. Level of Evidence Level 1, prognostic.

Systematic review of clinical studies.To critically evaluate existing literature to determine whether increased anchor or implant density (screws, wires, and hooks per level fused) results in improved curve correction for adolescent idiopathic scoliosis (AIS) surgery.Wide variability exists in the number of screws used for AIS surgery. High numbers of pedicle screws are increasingly used, but there is limited evidence to support this as best practice.Online English-language databases were searched to identify articles addressing anchor density. Articles were reviewed for anchor type/number, radiographic measures, and patient-reported outcomes.Of 196 references identified, 10 studies totaling 929 patients met the inclusion criteria. Reported mean anchor density varied from 1.06 to 2.0 implants per level fused. Mean percent coronal curve correction varied from 64% to 70%. Two studies (463 patients) analyzed hook, hybrid (combined hooks and screws), and screw constructs as a single cohort. Both found increased correction with high-density constructs (p = .01, p.001), perhaps as a result of the hooks and hybrid constructs. Eight retrospective studies and 1 prospective randomized, controlled trial had predominantly screw constructs (466 patients). Increased anchor density was not associated with improved curve correction. The studies evaluating screw density are significantly underpowered to detect a difference in curve correction.Wide heterogeneity in anchor density exists in the surgical treatment of AIS. Reports evaluating the effects of increased anchor density are mostly retrospective and significantly underpowered to detect a difference in curve correction and patient outcomes. At this time, there is insufficient evidence to show that anchor density affects clinical outcomes in AIS.

Review of prospective database.To report the results of Ponte osteotomy with pedicle screw instrumentation for major thoracic adolescent idiopathic (AIS) curves.Ponte osteotomy for achieving coronal and sagittal correction of major thoracic curves in AIS with pedicle screw instrumentation is a widespread technique, but results have not been well described.Review of 87 consecutive AIS patients with Lenke 1-4 curves who underwent Ponte osteotomies and pedicle screw instrumentation by 2 surgeons at a single institution. Surgical details, blood loss, and complications were recorded. We evaluated coronal and sagittal radiological measurements and Scoliosis Research Society-22 (SRS-22) questionnaire scores over 2-year follow-up.The mean preoperative thoracic coronal Cobb angle was 57° ± 9.7°, fulcrum flexibility was 47.2%, and lateral Cobb angle was 17.8° ± 4°. The mean estimated blood loss (EBL), expressed as percent estimated blood volume, was 35.8 ± 20.5 mL. There was significant improvement in coronal thoracic Cobb angle, percent correction, and apical vertebral translation over 2-year follow-up (p .05). In hypokyphotic curves, there was a significant increase in lateral thoracic T5-T12 kyphosis from 8.1° to 18.3° (p.001). In hyperkyphotic curves, mean lateral thoracic T5-T12 kyphosis improved from 45° to 26° (p.001). Median SRS-22 domains were higher after treatment (p.05). Complications included significant hypotension (1), EBL greater than 75% estimated blood volume (2), and wound infection needing drainage (2). There were neuromonitoring signal changes in 7 patients but no significant neurological complications.In this case series of major thoracic AIS curves treated with segmental pedicle screw instrumentation and Ponte osteotomies, there was an improvement in the coronal and sagittal radiological parameters. A prospective controlled study is needed to determine whether pedicle screw instrumentation and Ponte osteotomies influence outcomes and complications.

To determine the mid-term clinical and radiographic impact of pedicle screw fixation in patients with adolescent idiopathic scoliosis (AIS).A multicenter AIS database was retrospectively queried to identify 99 consecutive patients who underwent posterior spinal fusion using an all pedicle screw construct with a minimum of 5-year follow-up. Radiographic and clinical parameters were reviewed at regular intervals up to 5 years.The mean age was 14.4 ± 2.0 years with 79 % being female. The mean preoperative major curve was 51.7 ± 14.2° with a mean correction of 66 and 64 % at 2 and 5 years (p = 0.16). Pre-op thoracic kyphosis averaged 22.3 ± 12.9° and was 18.4 ± 10.6° at 5 years with no significant change from 2 years (p = 0.33). SRS total and domain scores demonstrated significant improvements at 2 years, which were slightly decreased at 5 years (p = 0.06). SRS scores of self-image (p = 0.99) and satisfaction (p = 0.18) were significantly improved after surgery with minimal change by 5 years. The change in SRS total scores from 2 to 5 years was attributed to differences in SRS scores of pain and mental health (p0.05).Intermediate follow-up of patients with AIS treated with an all pedicle screw construct demonstrates maintenance of their coronal, and sagittal plane correction between 2- and 5-year follow-up. At 5 years, improvements in SRS scores were consistent with 2-year values, except for a decline in pain and mental health scores.

The treatment of pediatric spinal deformity has changed dramatically over the past several decades, and surgeons face new challenges when managing the complications associated with these treatments. Care of the patient can be considered in 3 phases: preoperative evaluation, perioperative period, and postoperative management period. There are opportunities to identify and prevent potential complications during each of these phases of treatment. Comprehensive safety protocols that include the participation of all team members should make surgery safer over time, and the use of postoperative management protocols and multidisciplinary teams to manage complex patients can improve patient outcomes and shorten hospital stays. Surgeons, patients and payers are motivated to continue to improve safety for the pediatric spinal deformity patient, and there will be heightened interest in defining specific measures that positively affect outcomes.

Severe EOS can be treated as effectively with distraction instrumentation in comparison to less severe EOS.

Uterine artery embolization is a safe and effective procedure for the treatment of symptomatic uterine fibroids. Nontarget embolization of adjacent internal iliac artery branches is a reported complication of uterine artery embolization. The following report describes the presentation and management of ulcerations of the labium minora due to nontarget embolization of the internal pudendal artery.

A cross sectional and longitudinal study of 315 children with achondroplasia showed that thoracolumbar kyphosis improves significantly during the first three years of age and hyperlordosis at the lumbosacral level is the compensatory mechanism. Pelvic alignment and hip positioning are directly affected by this mechanism. After three years of age, thoracolumbar kyphosis gradually improves until age ten. While pelvic incidence is stable before age ten, it increases gradually afterwards.

These are the first reported cases of MRI use in humans with MCGR. There were no adverse events observed. MCGR rods lengthened as expected following MRI. MRIs of the cervical spine were able to be interpreted, but MRIs of the thoracolumbar spine could not be interpreted due to MCGR artifact.

In a series of 748 traditional growing rod patients the overall rate of post-op neurological deficit was 0.45%, and the rate of permanent deficit was 0.05%. Neurological events occurred in all types of procedures including routine lengthenings. It is recommended IOM be utilised as a default for all distraction-based surgeries including lengthenings.

Treatment of complex congenital scoliosis with growth friendly instrumentation led to only modest correction of major curves, residual imbalance, minimal gain in spine and thoracic height and a high incidence of complications. It is unknown whether this treatment improves upon the natural history or early fusion.