Aims

Scoliosis is a lateral curvature of the spine with associated rotation, often causing distress due to appearance. For some curves, there is good evidence to support the use of a spinal brace, worn for 20 to 24 hours a day to minimize the curve, making it as straight as possible during growth, preventing progression. Compliance can be poor due to appearance and comfort. A night-time brace, worn for eight to 12 hours, can achieve higher levels of curve correction while patients are supine, and could be preferable for patients, but evidence of efficacy is limited. This is the protocol for a randomized controlled trial of ‘full-time bracing’ versus ‘night-time bracing’ in adolescent idiopathic scoliosis (AIS).

Orthopaedic paediatric deformities, globally, are often corrected later than initial identification due to resource constraints (bed availability, investigative modalities, surgical skill set). The study aims to analyse experiences and challenges met with running a flagship scoliosis surgery week in a tertiary public health care facility, with the goal of reducing patient waiting time on the waiting list.

In this retrospective study, patients from an existing deformity correction waiting list were selected for a 5 day scoliosis surgery week. Investigations relevant to clinical findings were carried out and patients were scheduled on a “one patient per day” surgery list. Inclusion criteria was any patient with adolescent idiopathic scoliosis of varying degree that was symptomatic. Exclusion criteria was any other deformity of any age.

Outcomes measured include: Administrative hurdles (obtaining funding, organising ward and ICU beds, getting nursing staff), Surgical challenges (severity of the curve, intraoperative time, approach chosen) and perioperative management (anaesthesia, pain management, cost of equipment) will be looked at to better define the experiences and challenges.

All scheduled surgeries were completed. This meant more cases were carried out than what was done in the last 2 years at the facility combined. Lack of Nursing staff availability and few ICU beds delayed starting cases. Anterior fusion took a shorter surgical time in comparison to posterior and cost far less to carry out owing to deformity severity. Intra and post operative management also varied due to daily changes in theatre staff and a lack of standardized protocols.

Running a scoliosis surgery week helps to lower the waiting time for deformity correction in public health care facilities. Pre organising resources results in more successful outcomes and an increase in the number of cases done over a shorter period.

The August 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: DDH: What can patients expect after open reduction?; Femoral head deformity associated with hip displacement in non-ambulatory cerebral palsy; Bony hip reconstruction for displaced hips in patients with cerebral palsy: is postoperative immobilization indicated?; Opioid re-prescriptions after ACL reconstruction in adolescents are associated with subsequent opioid use disorder; Normative femoral and tibial lengths in a modern population of USA children; Retrospective analysis of associated anomalies in 636 patients with operatively treated congenital scoliosis; Radiological hip shape and patient-reported outcome measures in healed Perthes’ disease; Significantly displaced adolescent posterior sternoclavicular joint injuries.

Scoliosis correction surgery is one of the longest and most complex procedures of all orthopedic surgery. The complication rate is therefore not negligible and is particularly high when the surgery is performed in patients with neuromuscular or connective tissue disease or complex genetic syndromes. In fact, these patients have various comorbidities and organ deficits (respiratory capacity, swallowing / nutrition, heart function, etc.), which can compromise the outcome of the surgery. In these cases, an accurate assessment and preparation for surgery is essential, also making use of external consultants. To make this phase simpler, more effective and homogeneous, a multidisciplinary path of peri-operative optimization is being developed in our Institute, which also includes the possibility of post-operative hospitalization for rehabilitation and recovery. The goal is to improve the basic functional status as much as possible, in order to ensure faster functional recovery and minimize the incidence of peri-operative complications, to be assessed by clinical audit. The path model and the preliminary results on the first patients managed according to the new modality are presented here. The multidisciplinary path involves the execution of the following assessments / interventions: • Pediatric visit with particular attention to the state of the upper airways and the evaluation of chronic or frequent inflammatory states • Cardiological Consultation with Echocardiogram. • Respiratory Function Tests, Blood Gas Analysis and Pneumological Consultation to evaluate indications for preoperative respiratory physiotherapy cycles, Non-Invasive Ventilation (NIV) cycles, Cough Machine. Possible Polysomnography. • Nutrition consultancy to assess the need for nutritional preparation in order to improve muscle trophism. • Consultation of the speech therapist in cases of dysphagia for liquids and / or solids. • Electroencephalogram and Neurological Consultation in epileptic patients. • Physiological consultation in patients already being treated with a cough machine and / or NIV. • Availability of postoperative hospitalization in the rehabilitation center (with skills in respiratory and neurological rehabilitation) for the most complex cases. When all the appropriate assessments have been completed, the anesthetist in charge at our Institute examines the clinical documentation and establishes whether the path can be considered complete and whether the patient is ready for surgery. At the end of the surgery, the patient is admitted to the Post-operative Intensive Care Unit of the Institute. If necessary, a new program of postoperative rehabilitation (respiratory, neuromotor, etc.) is programmed in a specialist reference center. To date, two patients have been referred to the preoperative optimization path: one with Ullrich Congenital Muscular Dystrophy, and one with 6q25 Microdeletion Syndrome. In the first case, the surgery was performed successfully, and the patient was discharged at home. In the second case, after completing the optimization process, the surgery was postponed due to the finding of urethral malformation with the impossibility of bladder catheterization, which made it necessary to proceed with urological surgery first. The preliminary case series presented here is still very limited and does not allow evaluations on the impact of the program on the clinical practice and the complication rate. However, these first experiences made it possible to demonstrate the feasibility of this complex multidisciplinary path in which a network of specialists takes part

Children undergoing posterior spinal fusion (PSF) for neuromuscular and syndromic scoliosis were admitted to the paediatric intensive care (PIC) until about 6 years ago, at which time we created a new unit, a hospital floor-based spinal high-dependency unit-plus (SHDU-plus), in response to frequent bed-shortage cancellations. This study compares postoperative management on PIC with HDU-plus for these non-hospital floor suitable children with syndromic and neuromuscular scoliosis undergoing PSF.

Retrospective review of 100 consecutive children with syndromic and neuromuscular scoliosis undergoing PSF between June 2016 and January 2022. Inclusion criteria were: 1) diagnosis of syndromic or neuromuscular scoliosis, 2) underwent PSF, 3) not suitable for immediate postoperative hospital floor-based care. Exclusion criteria were children with significant cardio-respiratory co-morbidity requiring PIC postoperatively.

55 patients were managed postoperatively on PIC and 45 on SHDU-plus. No significant difference between groups was found with respect to age, weight, ASA grade, preoperative Cobb angles, operative duration, number of levels fused and estimated blood loss. 4 patients in the PIC group and 1 in the SHDU-plus group were readmitted back to PIC or HDU following step-down to the hospital floor. Average length of stay was 2 days on PIC and 1 day on SHDU-plus. Average total length of hospital stay was 16.5 days in the PIC group and 10.5 days in the HDU-plus group. 19 (35%) patients developed complications in the PIC group, compared to 18 (40%) in SHDU-plus. Mean specialist unit charge per day was less on SHDU-plus compared with PIC. There were no bed-shortage cancellations in the SHDU-plus group, compared to 11 in the PIC group.

For children with neuromuscular or syndromic scoliosis undergoing PSF and deemed not suitable for post-operative care on the hospital floor, creation of a SHDU-plus was associated with fewer readmissions back to PIC or HDU, shorter hospital stays, an equivalent complication rate, significant cost-saving and fewer cancellations. Level of Evidence: Therapeutic Level III.

Aims

To determine the value of scoliosis surgery, it is necessary to evaluate outcomes in domains that matter to patients. Since randomized trials on adolescent idiopathic scoliosis (AIS) are scarce, prospective cohort studies with comparable outcome measures are important. To enhance comparison, a core set of patient-related outcome measures is available. The aim of this study was to evaluate the outcomes of AIS fusion surgery at two-year follow-up using the core outcomes set.

Introduction. Scoliosis surgery is a life-changing procedure, but not devoid of perioperative complications. Often patients' scoring systems do not cover their real-life needs, including return to pre-surgery activity. Return to school, physical education (PE) is an important indirect marker of recovery. Although anterior spinal fusion (ASF) may have advantages, compared to posterior spinal fusion (PSF), because of motion-saved segments, there is a paucity of literature about post-operative return to school/PE in the compared groups. Aim. To determine the recovery time for patients with scoliosis who underwent anterior spinal fusion (ASF) and posterior spinal fusion (PSF). Design. Prospective cohort. Methods. Patients undergoing Adolescent Idiopathic Scoliosis (AIS) surgery from 2018–2019, were examined. We excluded no-AIS and over 18y patients. The Scoliosis Sports Survey validated questionnaire was administered post-operatively regarding return to school, PE and other physical activities. ASF and PSF groups were subcategorised into: Selective Anterior Thoracic Fusion (SATF), Thoracolumbar Fusion (TLF), Short Posterior Spinal Fusion (SPSF) and Long Posterior Spinal Fusion (LPSF) procedures. Hospital length of stay (HLOS) and ICU LOS were recorded. Results. A total of 81 patients were contacted and 43 responded to the survey. The different procedures, return to school / PE, HLOS / ICU LOS, costoplasty are all analysed as shown below in Table 1. Conclusions. Anterior and posterior fusions had similar return to school rates at 1–3 months. The TLF and 2-stages groups returned to school the quickest, whilst the SATF had the longest return time. PSF patients returned to PE faster than ASF. Costoplasty, did not affect return time to school and PE. Further research assessing shorter fusions benefits should be conducted. For any figures or tables, please contact the authors directly

Seniors make up 16.9 percent of the Canadian population. Furthermore, the number of Canadians who are 65 years or older is increasing at an average rate of 20 percent every 5 years. In 2017, Sing etal reported that there is an increasing number of patients undergoing degenerative scoliosis surgery with the largest increase attributed to patients aged 65–69 years followed by those aged 70–74 years. Therefore, the purpose of this study is to assess the effectiveness of undergoing spinal surgery to correct degenerative spinal scoliosis in the ever-growing number of elderly patients. We hypothesize that age is not an independent prognostic factor of patients' outcomes followings degenerative scoliosis surgery.

A retrospective review of prospectively collected data within the Canadian Spine Outcome and Research Network (CSORN) was conducted. Data was analyzed using IBM-SPSS. ANOVA was used to analyze continuous variables while Chi Square test was used to analyze categorical variables. Significance level was p < 0.05.

There were 165 patients identified from the registry who met the inclusion criteria, 94 patients (57 %) were female. There were 102 (61.8 %) patients who were 65 years or older. The overall average age was 66.6 years (range 35–84, SD 8.6). There were 27 intra-operative complications, 44 peri-operative complications and 18 post operative complications. There was no statistically significant difference between the two age groups with regards to risk of developing intra-operative, perioperative and post operative complications. Patients who underwent degenerative scoliosis surgery reported an average improvement of 2.95±3.32, 3.64±3.50, 16.84±20.44 points on the back-pain scale, leg pain scale and the Oswestry Disability Index (ODI) respectively, there was no statistically significant differences in these measures between the two age groups.

As the number of patients undergoing degenerative scoliosis surgery increases, clinicians will need to determine which factors will significantly impact patients' outcomes following surgery. This study shows that age is not an independent prognostic factor when it comes to patients' outcomes following degenerative scoliosis surgery. In the future, research should examine the impact of age in conjunction with factors such as frailty, comorbidities and functional status on patient outcomes.

Aims

Severe spinal deformity in growing patients often requires surgical management. We describe the incidence of spinal deformity surgery in a National Health Service.

With the identification of literature shortfalls on the techniques employed in intraoperative navigated (ION) spinal surgery, we outline a number of measures which have been synthesised into a coherent operative technique. These include positioning, dissection, management of the reference frame, the grip, the angle of attack, the drill, the template, the pedicle screw, the wire, and navigated intrathecal analgesia. Optimizing techniques to improve accuracy allow an overall reduction of the repetition of the surgical steps with its associated productivity benefits including time, cost, radiation, and safety.

Cite this article: Bone Joint J 2020;102-B(3):371–375.

Aim

Nasal colonization with S.aureus (SA) is a risk factor for developing nosocomial infections in cardiac surgery. However, the risk in orthopedic surgery remains unclear, especially in adolescent idiopathic scoliosis (AIS) surgery were data are missing. This study aims to evaluate the efficacy of a preoperative nasal decontamination program in SA healthy carriers on early surgical site infections (SSI) after AIS posterior surgery in a pediatric universitary Parisian hospital.

Aims

We present the results of correcting a double or triple curve adolescent idiopathic scoliosis using a convex segmental pedicle screw technique.

Background

Accurate insertion of pedicle screws in scoliosis patients is a great challenge for surgeons due to the severe deformity of thoracic and lumbar spine. Meanwhile, mal-position of pedicle screw in scoliosis patients could lead to severe complications. Computer-assisted navigation technique may help improving the accuracy of screw placement and reducing complications. Thus, this meta-analysis of the published researches was conducted concentrating on accuracy of pedicle screw placement and postoperative assessment in scoliosis patients using computer-assisted navigation technique.

The December 2015 Spine Roundup360 looks at: Ketamine in scoliosis surgery; Teriparatide in osteoporotic spinal fractures; Trabecular metal in the spine?; Revision surgery a SPORTing chance?; The course of degenerative lumbar spondylolisthesis; Hip or lumbar spine: a common conundrum

Increasing health care costs, limited resources and increased demand makes cost-effective and cost-efficient delivery of Adolescent Idiopathic Scoliosis (AIS) management paramount. Rising implant costs in deformity surgery have prompted justification of high implant density. The objective of this study was to analyse the costs of thoracoscopic scoliosis surgery, comparing initial learning curve costs with those of the established technique and to the costs involved in posterior instrumented fusion from the literature. 189 consecutive cases from April 2000 to July 2011 were assessed with a minimum of 2 years follow-up using a prospective database covering perioperative factors, clinical and radiological outcomes, complications and patient-reported outcomes. The patients were divided into three groups to allow comparison; 1. A learning curve cohort, 2. An intermediate cohort and 3. A third cohort using our established technique. Hospital finance records and implant manufacturer figures were corrected to 2013 costs. A literature review of AIS management costs and implant density in similar curve types was performed. The mean pre-op Cobb angle was 53°(95%CI 0.4) and was corrected postop to mean 22.9°(CI 0.4). The overall complication rate was 20.6%, primarily in the first cohort, with a rate of 5.6% in the third cohort. The average total costs were $46,732, operating room costs of $10,301 (22.0%) and ICU costs of $4620 (9.8%). The mean number of screws placed was 7.1 (CI 0.04) with a single rod used for each case giving average implant costs of $14,004 (29.9%). Comparison of the three groups revealed higher implant costs as the technique evolved to that in use today, from $13,049 in Group 1 to $14577 in Group 3 (P<0.001). Conversely operating room costs reduced from $10,621 in Group 1 to $7573 (P<0.001) in Group 3. ICU stay was reduced from an average of 1.2 to 0 days. In-patient stay was significantly (P=0.006) lower in Groups 2 and 3 (5.4 days) than Group 1 (5.9 days). Our thoracoscopic anterior scoliosis correction has evolved to include an increase in levels fused and reduction in complication rate. Implant costs have risen, however, there has been a concurrent decrease in those costs generated by operating room use, ICU and in-patient stay with increasing experience. Literature review of equivalent curve types treated posteriorly shows similar perioperative factors but higher implant density, 69–83% compared to the 50% in this study. Thoracoscopic Scoliosis surgery presents a low density, reliable, efficient and effective option for selected curves

Scoliosis surgery has moved towards all posterior correction, as modern implants are perceived to be powerful enough to overcome stiffer and more severe curves. However, shortening of the anterior spinal column remains most effective in creating thoracic kyphosis, and may still have a role in correcting both coronal and sagittal deformities. Furthermore, anterior correction of lumbar and thoracolumbar curves can theoretically reduce the distal fusion level, and may have significant impact on patients' post-operative function. A single surgeon series of 62 patients with idiopathic scoliosis were examined retrospectively. Radiographs and operation notes were examined by 2 spinal surgeons, sagittal and coronal parameters were measured before and after the operation. The patients were divided into 4 groups: 16 anterior and posterior fusions (AP), 16 anterior thoracolumbar fusions (A), 5 anterior thoracic releases and posterior fusions (AR), and 25 posterior fusions only (P). The mean age was 15.3 (range 10 – 20). The mean main thoracic Cobb angle pre-operatively was: 54° (AP), 43° (A), 63° (AR), and 50° (P). The mean thoracolumbar Cobb angle was: 55° (AP) and 51° (A). There was no significant difference in lumbar lordosis. The mean post-operative main thoracic Cobb angle was: 9° (AP), 13° (A), 9° (AR) and 15° (P). There was significant difference between AR and P groups. The mean post-operative thoracolumbar Cobb angle was: 8° (AP) and 6° for (A). There was a significant difference in the post-operative thoracic kyphosis between AP (mean 14°), A (mean 38°), AR (mean 19°) and P (mean 14°). Overall, the lumbar lordosis for all 4 groups reduced from a mean of 67° to 50°, with no significant difference between the groups. The distal level of fusion for A and AP groups were L3 for all cases, whereas 2 cases had to extend to L4 in the P group. Anterior release improved both coronal and sagittal correction when compared to posterior only surgery, however it is of unknown clinical significance. Anterior thoracolumbar fusion with or without posterior spinal fusion appeared to produce adequate coronal correction if fused to L3. No difference was found between all groups in post-operative lumbar lordosis

To describe complications and reoperation rates associated with degenerative spinal deformity surgery

A retrospective review of prospectively collected data from a single spinal surgeon in the United Kingdom. A total of 107 patients who underwent surgery, of 5 or more levels, for primary degenerative kyphoscoliosis between 2006 and 2012 were identified. Clinical notes were reviewed and post-operative complications, reoperation rates, length of follow up and mortality were analysed.

A total of 107 patients, average aged 66.5 years (range 52 – 85), with 80% women. 105 patients underwent posterior surgery, two patients required both anterior and posterior surgery. The average number of instrumented levels was 8.3; 10% 5 levels, 15% 6 levels, 11% 7 levels, 14% 8 levels, 15% 9 levels and 35% had fusions of 10 levels and above. 58% included fixation to sacrum or pelvis. 93% had a decompression performed and 30% had an osteotomy. There were 40 complications recorded within the follow-up period. Infection occurred in 7 patients (6.5%). All were successfully managed with debridement, antibiotic therapy and retention of implants. There were 4 dural tears (3.7%). One patient developed a post-operative DVT (0.9%). No patients sustained cord level deficits. Prevalence of mechanical complications requiring re-operation was 26% (28 patients). 5 patients (4.7) required revision surgery for symptomatic pseudarthrosis, 7 patients (6.5%) underwent revision fixation for metal work failure (broken rods/screw pull-out) and 16 patients (14.9%) underwent revision surgery to extend fixation proximally or distally due to adjacent segment disease (symptomatic proximal junction kyphosis 4.7%; osteoporotic fracture 3.7% and junctional/nerve root pain 6.5%). Overall reoperation rate was 32.5% at an average of 1.9 years following primary surgery (range 1 week–6 years). 37% patients remain on regular outpatient review (average 3.8 years following first surgery; range 2–6 years). 52% have been discharged after a mean follow-up of 2.3 years. 11 patients had died since their surgery (10.2%) at an average 4.1 years following their spinal surgery (range 1 –5.9 years).

Overall complication rate was 37.3%. 32.5% of patients were re-operated for infective or mechanical complications. 52% of patients had been discharged at an average of 2.3 years following their surgery. 10.2% of patients had died within 6 years of surgery.

During the last decade or more, the anchors used for instrumentation in scoliosis surgery are predominantly transpedicular screws, according to Suk. The long term radiographical feature of screw fixation after scoliosis surgery is not previously studied.

A consecutive series of 81 cases with AIS operated on with an all screw construct has been studied by means of low dose CT postoperatively and at 2 years postoperatively. There were 67 females and 14 males, with a mean age of 18.3 ± 3 years.

In 26 / 81 (32 %) there were signs of loosing of one or more screws, at a maximum 3 screws. We observed loosened screws in the upper thoracic region in 16 cases, in the thoracolumbar 6 and in lumbar area in 4. Mean pre-op Cobb angle was 56 in cases of loosening and 53 of intact screw fixation (n.s.), the correction rate was 69% in loosened vs 70% among intact screws (n.s.). In males there were signs of loosening in 8/14 (57%) and in females 18/67 (27%). Among cases with loosening, 14% had suboptimal screw positioning postoperatively, in intact cases it was observed in 11% (n.s.). In the whole group there were signs of suboptimal screw positioning 12%. Clinically, 1 case had a loosened L4 screw replaced; and at all 21/26 had no complaints and 5/26 reported minor pain or discomfort. 1/26 had a minor proximal junctional kyphosis about 10°, in 3/26 there was a pull-out of some few mms. With plain radiography loosening could be observed in 11/26 cases; 5 were in the lumbar region.

In a consecutive series of 81 adolescents with idiopathic scoliosis who had underwent scoliosis surgery according to Suk, one third showed, 2 years after the intervention, some minor screw loosening, assessed by low dose CT. One patient had one lumbar screw replaced and only 5 patients reported minor discomfort. Males were more prone to develop screw loosening.