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Study Design: Retrospective review of prospectively collected spinal surgery and transfusion databases. Objectives: To evaluate the efficacy of a care pathway developed at our institution since 2003 with a focus on reducing the need for blood transfusions in children undergoing scoliosis correction surgery. The care pathway includes nurse-led clinics facilitating preoperative hemoglobin optimization, intraoperative cell salvage, the use of tranexamic acid, and a transfusion criteria awareness program. Methods: Retrospective review of our institution’s prospectively recorded spinal surgery and transfusion databases including all cases of scoliosis surgery in patients 18 years and younger between 2001 and 2015. Results: A total of 1039 procedures were included in the analysis. Overall, 24.4% of patients received a transfusion. The proportion of patients transfused was 89.2% in 2001-2003, 39.6% in 2004-2006, 16.5% in 2007-2009, 15.6% in 2010-2012, and 20.1% in 2013-2015. The volume of blood products transfused in those undergoing transfusion was 9.1 units in 2001-2003, 4.8 units in 2004-2006, 5.0 units in 2007-2009, 2.3 units in 2010-2012, and 2.1 units in 2013-2015. A multivariate logistic regression demonstrated adjusted odds ratios for the probability of receiving any transfusion of 5.45 (95% confidence interval 3.62-8.11) for patients with neuromuscular diagnoses and 11.17 (5.02-24.86) for those undergoing combined anterior and posterior surgical approach. Conclusions: We have demonstrated over a 15-year period that the introduction of a multifaceted, multidisciplinary pathway can dramatically and sustainably reduce the need for blood transfusions and their attendant risks in pediatric scoliosis surgery. This data lends weight to the adoption of such a care pathway in pediatric scoliosis surgery.

Background SMA is a severe neuromuscular disorder characterised by progressive muscle atrophy, weakness, paralysis. Scoliosis is a highly prevalent feature and surgery is almost invariably required in ‘sitters’. However, data are limited on post-surgical secondary outcomes (respiratory, motor function, weight gain, skeletal pain, satisfaction). Methods 1. We retrospectively reviewed the notes of 33 patients who never walked/lost the ability to walk (SMA type II/III) and underwent spinal fusion (25), magnetic (4) or traditional (4) growth rods at Great Ormond Street Hospital; 2. We developed a phone interview and run a focus group for families on post-surgical satisfaction. Results The curve was successfully corrected in all patients. Median follow-up before and after surgery was 3.9 (0.9–12.3) and 3.7 (0.4–10.5) years respectively. Mean annual rate of Forced Vital Capacity% decline improved after surgery in SMA II: -2.8 versus -7.4 (p 5% of total weight) needed gastrostomy. Skeletal pain was frequently documented, especially hip pain (13/33) requiring painkillers (8), intra-articular steroids (1), surgical intervention (1). Nine/10 families participating in the phone interview reported major improvements in posture, physical appearance, self-image; all rated the procedure as very successful. However, 7/10 did not report significant improvements in quality of life due to reduced mobility and increased unmet care needs. Five families attended the focus group highlighting positive and negative aspects of their experiences. Conclusion This study provided relevant data and suggestions to improve the current post-operative multidisciplinary approach of scoliosis surgery in children with SMA.