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Establishing prevalence of vitamin D deficiency in elective scoliosis surgery may impact clinical outcomes. The objectives of this study were to document vitamin D status of patients with scoliosis preparing for surgical intervention in order to establish frequency of deficiency and determine characteristics influencing levels.Records were queried for patients with scoliosis diagnosis who underwent posterior spinal fusion or initial growing rod placement and had serum vitamin 25 hydroxyvitamin D (D25) recorded in the preoperative period. Demographic data (gender, age, body mass index [BMI], race, scoliosis type, spine surgery procedure, and season of the year) were extracted. Chi-square analysis and multivariate modeling were used to evaluate deficiency status among various demographic categories and determine the demographic factors impacting D25.A total of 217 patients with a mean age of 13.6 ± 3.6 years had vitamin D levels drawn a mean of 38.7 ± 20.6 days prior to surgery. The majority of the sample presented with a diagnosis of idiopathic scoliosis (n = 126), and most patients were scheduled for spinal fusion surgery (n = 192). Nearly 75% of the study population (n = 162) demonstrated D25 values below normal. African Americans presented with greater risk of deficiency (p.0002) compared to Caucasians, as did patients preparing for spinal fusion versus growing rod placement (p.03). Severe hypovitaminosis D was more common in winter than any other season (p.005). Patients with neuromuscular scoliosis demonstrated significantly higher D25 levels over the idiopathic diagnosis type (p.0002). Gender, BMI, and age did not impact D25.Low D25 levels are reported in pediatric patients with scoliosis preparing for corrective spinal surgery. Population subsets most at risk for deficiency in this limited study include African American children, those presenting for spinal fusion surgery, and patients admitted in winter season.

Screening laboratory studies for bleeding disorders are of little predictive value for operative bleeding risk in adults. Predicting perioperative bleeding in pediatric patients is particularly difficult as younger patients often have not had significant hemostatic challenges. This issue is distinctly important for high bleeding risk surgeries, such as major spinal procedures. The aim of this study was to determine if the score of a detailed bleeding questionnaire (BQ) correlated with surgical bleeding in pediatric patients undergoing major spinal surgery. A total of 220 consecutive pediatric patients (mean age 14.2years) undergoing major spinal surgery were administered the BQ preoperatively, as well as having routine screening laboratory studies (i.e., PT, aPTT, PFA) drawn. A retrospective analysis was conducted to determine if there was a correlation between either the results of the BQ and/or laboratory studies with operative outcomes. A BQ score>2 showed a strong positive correlation with intraoperative bleeding based on both univariate and multivariate analyses. In contrast, abnormalities in screening laboratory studies showed no significant correlation with operative bleeding outcomes. Relying on screening laboratory studies alone is inadequate. The BQ used here correlated with increased intraoperative hemorrhage, suggesting this tool may be useful for assessing pediatric surgical bleeding risk, and may also be useful in identifying a subset of patients with a very low bleeding risk that may not require laboratory screening.

BACKGROUND Patients with idiopathic scoliosis, although otherwise healthy, often have significant concerns about their self-image and appearance. In a group of juveniles and adolescents, this can impact adjustment in school, functioning in peer groups, and general sense of well-being. There are limited data to help physicians reliably and precisely identify those who are at higher risk of poor emotional adjustment even after spine deformity correction. The purpose of this study was to determine the predictors of emotional maladjustment in juvenile and adolescent patients after surgical correction of idiopathic scoliosis. METHODS A total of 233 juveniles, mean age 11.26 ± 1.02 (range, 8 to 12) years and 909 adolescents, mean age 14.91 ± 1.61 (range, 13 to 21) years, who underwent surgical correction for idiopathic scoliosis and who were participating in a prospective longitudinal multicenter database, were enrolled in the study. Participants completed the Scoliosis Research Society-22 (SRS-22) questionnaire before surgery and 2 years postoperatively. Radiographs were used to measure Cobb angle and surface measurements were used to determine decompensation and trunk shift. RESULTS Adolescents reported poorer mental health preoperatively (P

STUDY DESIGN: Comparative analysis of 2 groups of patients who underwent surgical treatment of adolescent idiopathic scoliosis (AIS). OBJECTIVE: To compare a segmental pedicle screw only system with a hybrid system for the treatment of Lenke type 1 AIS curves. SUMMARY OF BACKGROUND DATA: Although previous AIS studies have tried to compare various constructs with the all-pedicle screw fixation, all have failed to address important confounding variables, such as skeletal maturity, preoperative flexibility of the curve, and factors associated with a multicenter or multisurgeon analysis. METHODS: The medical records and spinal radiographs of patients with AIS treated surgically by a single surgeon between 2000 and 2009 were retrospectively reviewed. Patients with Lenke type 1 curves and minimum follow-up of 2 years were divided into 2 groups that were meticulously matched: group 1 consisted of patients in whom the all-pedicle screw construct was used, whereas group 2 included patients who were treated with the hybrid hook-screw system. RESULTS: Group 1 included 34 patients and group 2 included 29 patients. At the last follow-up, thoracic curve correction averaged 70.4% for the all-pedicle screw group and 60% for the hybrid group (P = 0.19). The all-pedicle screw group showed a significantly greater increase in thoracic kyphosis than the hybrid group system (P = 0.04). Global sagittal balance showed greater improvement in the all-pedicle screw group during the immediate postoperative that was lost by the last follow-up. The all-pedicle screw system revealed less intraoperative blood loss but greater operating time than the hybrid construct. After controlling for length of follow-up, no statistical difference in any of the radiographical parameters measured was recorded. CONCLUSION: With the exception of global sagittal balance, the pedicle screw system provided better maintenance of its corrective parameters when followed for greater than two years. LEVEL OF EVIDENCE: 3.

KEY POINTS Current literature supports the use of serial casting for most progressive early onset spinal deformities as either a definitive or a surgical delay treatment. If and when surgery is required for early onset scoliosis treatment, the most commonly used system is growing rods, but this may change in the future with other viable options undergoing research, including magnetically controlled growing rods, nitinol staples, tethering, and the Shilla procedure. Expansion thoracoplasty is generally recommended for patients with thoracic insufficiency syndrome. Future goals include scoliosis treatment methods that involve less complications and to successfully treat patients with “fusionless” methods.

Introduction We present a case of an incidental finding of dural ectasia in a child diagnosed with Larsen syndrome. Larsen syndrome is a rare inherited disorder of connective tissue characterized by facial dysmorphism, congenital joint dislocations of the hips, knees and elbows, and deformities of the hands and feet. Dural ectasia is as an abnormal expansion of the dural sac surrounding the spinal cord and may result in spinal morphologic changes, instability, and spontaneous dislocation. To the best of our knowledge, the presence of dural ectasia in Larsen syndrome has not previously been reported. Case study A 6-year-old boy diagnosed with Larsen syndrome presented with an upper thoracic curve measuring 74 degrees, a right thoracic curve measuring 65 degrees, and significant cervicothoracic kyphosis with 50% anterior subluxation of C6 on C7 and C7 on T1. Advanced imaging studies showed dural ectasia (evidenced by spinal canal and dural sac expansion), thinning of pedicles and lamina, and C4 and C6 pars defects with cervical foramen enlargement. The patient received growing rod instrumentation (attached to cervical spine fixation) by a combined anterior/posterior surgical approach using intraoperative halo. Complications included intraoperative medial breach (fully resolved), wound dehiscence, 2 instances of bilateral broken rods, and a broken cervical rod. Following 7 lengthening procedures, the patient underwent definitive fusion. Discussion Surgeons should be aware of the potential for dural ectasia in patients with Larsen syndrome. Its presence will cause difficulties in the surgical intervention for spinal deformity. Multiple factors must be considered, and surgical approach and technique will require modification to avoid complications. Although dural ectasia confounds surgical intervention in these patients, surgery still appears to outweigh the risks associated with delayed intervention. The presence of dural ectasia should not preclude surgical decompression and stabilization. This report adds to the body of knowledge on the treatment of Larsen syndrome by demonstrating the potential existence of dural ectasia and highlights the importance of careful and thorough preoperative evaluation and diagnostic imaging.

Preoperative screening for bleeding disorders in pediatric patients is problematic due to children's limited exposures to significant hemostatic challenges and the inherent difficulty in obtaining blood samples from young patients. Overcoming these challenges is of particular importance for surgical procedures that carry a significant bleeding risk, such as spinal surgeries. Many pediatric surgeons, including the Pediatric Orthopedic team at our Institution, rely on an unfocused history and measurement of general markers of hemostasis for preoperative screening. In order to improve preoperative screening of pediatric patients undergoing spinal procedures, we instituted the use of a detailed semi-quantitative questionnaire based on the ISTH Bleeding Assessment Tool (BAT), in combination with evaluation of PT, aPTT, platelet count, and PFA. The BAT gives positive points for a personal or family history of bleeding, and negative points for significant hemostatic challenges that did not result in bleeding complications. It was decided a priori that a BAT score of ≥3 would result in referral to Pediatric Hematology. A total of 212 patients presenting for major spinal surgeries (e.g., spinal fusion, growth rod placement) ranging in age from 3 to 25 years were prospectively evaluated in this fashion. A total of 41 patients (19.3%) had a prolongation of the PT and/or aPTT, none of which had a high BAT score. The majority of the abnormal PT/aPTT values were minimal prolongations that were not reproducible on repeat testing. Prolongation of the PT and/or aPTT revealed 3 patients with mild deficiencies of either factors VII, X, or XI, none of which were felt to be clinically significant. Prolonged PFAs were observed in 32 patients (16%), 1 of which was diagnosed with type I VWD (BAT score = 1), and the other with "possible VWD" based on a borderline VWF antigen level (BAT score = 0). Both were treated with Humate P. The remainder of the patients with a prolonged PFA were determined not to have a significant bleeding disorder after further testing. A total of 15 patients were referred to Hematology based on a high BAT score. Of these, 2 had a history of thrombocytopenia (1 with known DiGeorge syndrome and 1 with Depakote-related thrombocytopenia). Neither required platelet transfusion. One patient with a high BAT score was known to have type I VWD and was treated with Humate P, another was diagnosed with low expression of glycoprotein GP1b and was treated with Humate P and platelet transfusion. The remainder of the patients with high BAT scores were not felt to have a clinically significant bleeding disorder based on a Hematologist's assessment. None of the 212 patients evaluated were felt to have excessive intraoperative bleeding by the surgical team, suggesting that none of the patients had a significant undiagnosed hemostatic defect. Together, these results suggest that reliance on history or screening labs alone may not be sufficient for many pediatric surgery patients. While the PFA identified 2 patients with mild/possible VWD that would have been missed by the BAT, the PFA also had a significant number of apparent false positives. The combination of a BAT and a platelet count, as well as assessment of VWF activity for patients without previous hemostatic system challenges, may provide a more effective screening methodology for institutions with ready access to VWF activity measurement. Disclosures No relevant conflicts of interest to declare.