Clinical relevance of echocardiogram in patients with cerebral palsy undergoing posterior spinal fusion

BACKGROUND

Spinal deformity is one of the secondary musculoskeletal problems that occur with cerebral palsy (CP). Of the co morbidities associated with CP and spinal deformity, cardiac function is of theoretical concern.

OBJECTIVE

The goal of our study was to determine the clinical relevance of routine preoperative cardiology evaluation via echocardiogram for patients with CP presenting for posterior spine fusion (PSF) surgery.

METHODS

A retrospective chart review was performed of CP patients presenting for scoliosis surgery. The data collected for each patient included: age, sex, height, weight, Cobb angle, and medical history. All patients had a preoperative cardiac evaluation.

RESULTS

Seventy-two patients were included. The mean age was 13.6 ± 3.4 years. Left ventricular systolic function was normal in all patients; the mean shortening fraction was 39.3 ± 6.2%. No patient had more than mild insufficiency of either the semilunar or atrioventricular valve. One patient was diagnosed with aortic root dilation as well as aortic valve insufficiency. All patients had PSF surgery without changes in anesthetic or surgical plans, and no patient experienced complications attributable to a cardiac origin.

CONCLUSION

The results suggest that routine preoperative cardiology evaluation via echocardiogram for children with CP in the absence of clinical history or physical examination findings suggestive of cardiac disease is not necessary.

Major perioperative complications after spine surgery in patients with cerebral palsy: assessment of risk factors

PURPOSE

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.

METHODS

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.

RESULTS

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 < 0.05) and hospital stays (NC = 7.7 days, YC = 15.6 days, p < 0.05). Variables associated with greater risk of a complication included: increased estimated blood loss (EBL) (p < 0.001), larger preoperative kyphosis (p = 0.05), staged procedures (p < 0.05), a lack of antifibrinolytic use (p < 0.05), and a trend toward lower body mass index (BMI) (p = 0.08). Multivariate regression analysis revealed an increased EBL as independently associated with a major perioperative complication (p < 0.05).

CONCLUSIONS

In this cohort of patients with CP who underwent spinal fusion, 39.4% experienced a major perioperative complication, with pulmonary being the most common. The occurrence of a major perioperative complication lengthened both ICU and hospital stay. Risk factors for major perioperative complications included greater preoperative kyphosis, staged procedures, a lack of antifibrinolytic use, and increased EBL, with the latter being an independent predictor of a major perioperative complication.

LEVEL OF EVIDENCE

2.

Body Mass Index in Adolescent Spinal Deformity: Comparison of Scheuermann's Kyphosis, Adolescent Idiopathic Scoliosis, and Normal Controls

STUDY DESIGN

Prospective, multicenter study of Scheuermann's kyphosis (SK) and adolescent idiopathic scoliosis (AIS) compared to a control group.

OBJECTIVES

Compare body mass index (BMI) and Scoliosis Research Society Questionnaire-22 (SRS-22) scores among two diagnosis and one control group.

SUMMARY OF BACKGROUND DATA

BMI has been reported as increased in SK patients; however, there are few recent data on this subject or comparing SK to AIS.

METHODS

Ninety-two SK patients (37 female, 55 male, average age 16 years), 1,051 AIS patients (814 female, 237 male, average age 15 years), and 380 adolescents without scoliosis (controls) were compared based on age, gender, race, height (m), weight (kg), BMI, and SRS-22 scores. An analysis of variance was used to test differences in BMI and SRS-22 scores between the groups and between males and females. Pearson correlations determined the relationship between AIS T5-T12 kyphosis and BMI, SK max kyphosis and BMI, and to determine the relationship between BMI and SRS-22 scores in each group.

RESULTS

More SK patients were "obese" and "overweight" (28% and 22%) compared to the AIS (6% and 9%) and Control groups (5.8% and 17.9%) (p < .001). More AIS patients were "underweight" (27%, SK: 13%, Control: 12.1%; p < .03). T5-T12 kyphosis was weakly correlated with BMI (r = 0.17), whereas max kyphosis correlated well with BMI (r = 0.39, p < .00). The SK group had significantly lower (worse) SRS-22 scores than AIS patients in the Pain (3.97 vs. 4.10), Self-Image (2.86 vs. 3.35), Mental Health (3.72 vs. 4.02), and Total Score domains (3.62 vs. 3.92, p < .001). Increased pain scores were weakly correlated with decreasing BMI in all three groups.

CONCLUSIONS

SK patients are at increased risk for elevated BMI and worse SRS-22 scores, indicating that they may suffer from delayed diagnosis and increased surgical complications. AIS patients are at increased risk for issues related to low BMI and should also be monitored.

Prophylactic methylprednisolone to reduce inflammation and improve outcomes from one lung ventilation in children: a randomized clinical trial

BACKGROUND

One lung ventilation (OLV) results in inflammatory and mechanical injury, leading to intraoperative and postoperative complications in children. No interventions have been studied in children to minimize such injury.

OBJECTIVE

We hypothesized that a single 2-mg·kg(-1) dose of methylprednisolone given 45-60 min prior to lung collapse would minimize injury from OLV and improve physiological stability.

METHODS

Twenty-eight children scheduled to undergo OLV were randomly assigned to receive 2 mg·kg(-1) methylprednisolone (MP) or normal saline (placebo group) prior to OLV. Anesthetic management was standardized, and data were collected for physiological stability (bronchospasm, respiratory resistance, and compliance). Plasma was assayed for inflammatory markers related to lung injury at timed intervals related to administration of methylprednisolone.

RESULTS

Three children in the placebo group experienced clinically significant intraoperative and postoperative respiratory complications. Respiratory resistance was lower (P = 0.04) in the methylprednisolone group. Pro-inflammatory cytokine IL-6 was lower (P = 0.01), and anti-inflammatory cytokine IL-10 was higher (P = 0.001) in the methylprednisolone group. Tryptase, measured before and after OLV, was lower (P = 0.03) in the methylprednisolone group while increased levels of tryptase were seen in placebo group after OLV (did not achieve significance). There were no side effects observed that could be attributed to methylprednisolone in this study.

CONCLUSIONS

Methylprednisolone at 2 mg·kg(-1) given as a single dose prior to OLV provides physiological stability to children undergoing OLV. In addition, methylprednisolone results in lower pro-inflammatory markers and higher anti-inflammatory markers in the children's plasma.

Sagittal Spinopelvic Parameters in Scheuermann's Kyphosis: A Preliminary Study

STUDY DESIGN

Retrospective, controlled, clinical study.

OBJECTIVES

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Addressing morbid obesity as a barrier to renal transplantation with laparoscopic sleeve gastrectomy

Morbid obesity is a barrier to renal transplantation and is inadequately addressed by medical therapy. We present results of a prospective evaluation of laparoscopic sleeve gastrectomy (LSG) for patients failing to achieve significant weight loss with medical therapy. Over a 25-month period, 52 obese renal transplant candidates meeting NIH guidelines for metabolic surgery underwent LSG. Mean age was 50.0 ± 10.0 years with an average preoperative BMI of 43.0 ± 5.4 kg/m(2) (range 35.8-67.7 kg/m(2)). Follow-up after LSG was 220 ± 152 days (range 26-733 days) with last BMI of 36.3 ± 5.3 kg/m(2) (range 29.2-49.8 kg/m(2)) with 29 (55.8%) patients achieving goal BMI of <35 kg/m(2) at 92 ± 92 days (range 13-420 days). The mean percentage of excess weight loss (%EWL) was 32.1 ± 17.6% (range 6.7-93.8%). A segmented regression model was used to compare medical therapy versus LSG. This revealed a statistically significant increase in the BMI reduction rate (0.3 kg/m(2)/month versus 1.1 kg/m(2)/month, p < 0.0001). Patients also experienced a 40.9% decrease in anti-hypertensive medications (p < 0.001) and a 49.7% decrease in total daily insulin dose (p < 0.001). LSG is a safe and effective means for addressing obesity in kidney transplant candidates in the context of a multidisciplinary approach.

Smaller body size increases the percentage of blood volume lost during posterior spinal arthrodesis

BACKGROUND

Our goal was to analyze the relationship between patient size and the proportion of blood volume lost during spinal arthrodesis in patients with a diagnosis of adolescent idiopathic scoliosis, Scheuermann kyphosis, or cerebral palsy. We hypothesized that smaller patients (those with less blood volume) lose a greater proportion of circulating total blood volume during surgery.

METHODS

We reviewed a large, multicenter database, identifying patients with adolescent idiopathic scoliosis (1832), Scheuermann kyphosis (106), or cerebral palsy (196) who had undergone posterior spinal arthrodesis for spinal deformity. Blood volume (estimated from body weight) was used as a measure of patient size. Our primary outcome was the proportion of total circulating blood volume lost (intraoperative blood loss/blood volume, expressed as a percentage).

RESULTS

On multivariate analysis, there was a negative relationship between intraoperative blood loss/blood volume and blood volume in patients with adolescent idiopathic scoliosis (coefficient, -5.8; p < 0.001), Scheuermann kyphosis (coefficient, -2.5; p < 0.001), or cerebral palsy (coefficient, -20.3; p < 0.001), indicating that, despite adjustment for all other factors, smaller patients lost a greater proportion of their blood volume. In patients with adolescent idiopathic scoliosis or Scheuermann kyphosis, multivariate analysis showed that intraoperative blood loss/blood volume also increased significantly when the patient was male and with a greater number of levels fused.

CONCLUSIONS

There is an inverse relationship between the proportion of blood volume lost during deformity correction surgery and size in patients with adolescent idiopathic scoliosis, cerebral palsy, or Scheuermann kyphosis.

Regional deposition of mometasone furoate nasal spray suspension in humans

Nasal deposition studies can demonstrate whether nasal sprays treating allergic rhinitis and polyposis reach the ciliated posterior nasal cavity, where turbinate inflammation and other pathology occurs. However, quantifying nasal deposition is challenging, because in vitro tests do not correlate to human nasal deposition; gamma scintigraphy studies are thus used. For valid data, the radiolabel must distribute, as the drug, into different-sized droplets, remain associated with the drug in the formulation after administration, and not alter its deposition. Some nasal deposition studies have demonstrated this using homogenous solutions. However, most commercial nasal sprays are heterogeneous suspensions. Using mometasone furoate nasal suspension (MFS), we developed a technique to validate radiolabel deposition as a surrogate for nasal cavity drug deposition and characterized regional deposition and nasal clearance in humans. Mometasone furoate (MF) formulation was spiked with diethylene triamine pentacaetic acid. Both unlabeled and radiolabeled formulations (n = 3) were sprayed into a regionally divided nasal cast. Drug deposition was quantified by high pressure liquid chromatography within each region; radiolabel deposition was determined by gamma camera. Healthy subjects (n = 12) were dosed and imaged for six hours. Scintigraphic images were coregistered with magnetic resonance imaging scans to quantify anterior and posterior nasal cavity deposition and mucociliary clearance. The ratio of radiolabel to unlabeled drug was 1.05 in the nasal cast and regionally appeared to match, indicating that in vivo radiolabel deposition could represent drug deposition. In humans, MFS delivered 86% (9.2) of metered dose to the nasal cavity, approximately 60% (9.1) of metered dose to the posterior nasal cavity. After 15 minutes, mucociliary clearance removed 59% of the initial radiolabel in the nasal cavity, consistent with clearance rates from the ciliated posterior surface. MFS deposited significant drug into the posterior nasal cavity. Both nasal cast validation and mucociliary clearance confirm the radiolabel deposition distribution method accurately represented corticosteroid nasal deposition.

The effect of surgeon experience on outcomes of surgery for adolescent idiopathic scoliosis

BACKGROUND

Single-surgeon series investigating the learning curve involved in surgery for spinal deformity may be confounded by changes in technology and techniques. Our objective with this multicenter, prospective study was to present a cross-sectional analysis of the impact of surgeon experience on surgery for adolescent idiopathic scoliosis.

METHODS

All posterior-only surgical procedures for adolescent idiopathic scoliosis performed in the 2007 to 2008 academic year, with a minimum of two years of patient follow-up, were included. Two groups were created on the basis of surgeon experience: a young surgeons' group, which included patients of surgeons with less than five years of experience, and an experienced surgeons' group, which included patients of surgeons with five or more years of experience.

RESULTS

Nine surgeons (four young and five experienced) operated on a total of one hundred and sixty-five patients with adolescent idiopathic scoliosis. The surgeons' experience ranged from less than one year to thirty-six years in practice. The two groups had similar preoperative curve-magnitude measurements, SRS-22 (Scoliosis Research Society-22) scores, and distribution by Lenke curve type. There were significant operative and postoperative differences. The young surgeons fused an average of 1.2 levels more than the experienced surgeons (p = 0.045). The mean intraoperative estimated blood loss (EBL) of the young surgeons' group was more than twice that of the experienced surgeons' group (2042 mL compared with 1013 mL; p < 0.001). The duration of surgery was 458 minutes for the young surgeons compared with 265 minutes for the experienced surgeons (p < 0.001). The overall SRS-22 scores were significantly worse in the young surgeons' group (a mean of 4.1 compared with 4.5; p = 0.001). The difference between groups was also significant for the domains of pain (p = 0.016), self-image (p = 0.008), and function (p < 0.001). Complication rates did not differ significantly between the groups.

CONCLUSIONS

Operative results and health-related quality of life following surgery for adolescent idiopathic scoliosis were significantly and positively correlated with surgeon experience.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Active contact investigation and treatment support: an integrated approach in rural and urban Sindh, Pakistan

BACKGROUND

Although household contacts of persons with tuberculosis (TB) have high rates of active TB, contact investigations are often not conducted. We present the results from a large-scale active contact investigation combined with treatment support in Sindh, Pakistan.

METHODS

Trained lay workers visited consenting smear-positive index patient homes in seven urban and 15 rural facilities. People with suspected TB were provided free transport to diagnostic centres, and sputum samples were collected for microscopy. Those diagnosed with smear-positive TB were given food baskets and sent text reminders to promote adherence.

RESULTS

From 3037 index cases, 19,191 household contacts were screened for TB symptoms and 3478 (18.1%) symptomatic persons were identified. Of these, 2160 (62.1%) produced sputum samples on the spot for testing and 490 (22.7%) had smear-positive results. TB prevalence in urban households was 1504 per 100,000 population compared to 4044/100,000 in rural households (P < 0.001) and 2553/100,000 overall. Treatment success was high, with 80.4% cured and 17.6% completing treatment.

DISCUSSION

Lay workers given basic training can conduct active contact investigations and provide treatment support to improve case detection and treatment outcomes in urban and rural areas of Pakistan. In areas with high levels of undiagnosed TB, particularly in rural areas, contact investigation should be prioritised as a means of improving case detection and early diagnosis.

Identification of a novel mutation (p.Ile198Thr) in gene TYR in a Pakistani family with nonsyndromic oculocutaneous albinism

The TYR gene (MIM #6069333) is located at position 11q14.3 on the human chromosome, and encodes tyrosinase, which is expressed in melanocytes and controls the biosynthesis of melanin. Most TYR mutations eliminate the activity of tyrosinase, preventing melanocytes from producing any melanin throughout life. People with this form of albinism have white hair, light-coloured eyes and very pale skin. Some mutations in TYR reduce but do not completely eliminate tyrosinase activity, and allow some melanin to be produced. We report a Pakistani family with four members affected by oculocutaneous albinism (OCA). Blood samples were collected from all affected individuals, normal siblings and their parents. Genomic DNA was extracted, and sequence analysis of all the coding exons and adjacent intronic sequences of TYR was performed, which identified a novel missense substitution (p.Ile198Thr). Sequencing of TYR in 90 unrelated healthy individuals showed no sequence variant at this location. Our study expands the mutational spectrum of OCA1.

Distraction-Based Treatment Maintains Predicted Thoracic Dimensions in Early-Onset Scoliosis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Examination of distraction-based treatment effect on thoracic dimensions in patients compared to predicted individual normal values, at initial treatment and subsequent follow-up after lengthenings.

SUMMARY OF BACKGROUND DATA

Change in thoracic dimensions and spine length is an important outcome measure in treatment of children with early-onset scoliosis; however, it is difficult to use to make comparisons between patients and the normal population because of the heterogeneous nature of early-onset scoliosis.

METHODS

Early-onset scoliosis patients treated with distraction-based therapy who had radiographic parameters (pelvic inlet width, chest width, and thoracic height) preoperatively, immediately postoperatively, and at a minimum 5-year follow-up were included. Individual thoracic measurements were compared with predicted normal measures based on pelvic inlet width, and expressed as a percentile of predicted measure.

RESULTS

Comparisons were made in 41 patients; mean age at time of primary surgery was 4.5 years, and median follow-up was 6.5 years. Thoracic height percentile increased from a mean preoperative value of .78 to a postoperative percentile of .88 (p < .001); at long-term follow-up, it was .85. Absolute thoracic height increased at all 3 time points: 141.6, 159.79, and 203.45 mm, respectively Mean chest width was similar preoperatively (170 mm) and immediately postoperatively (166.5 mm) but increased at latest follow-up (206.9 mm). Chest width percentile was similar at all 3 times (.93, .90, and .91).

CONCLUSIONS

Distraction-based treatment increases absolute thoracic height over time. There is significant improvement in the thoracic height percentile normalized after initial surgery, which was maintained over time. Measuring expected gains as a percentile normalized for pelvic width may be a more relevant outcome measure compared with measuring only absolute values.

Body image in patients with adolescent idiopathic scoliosis: validation of the Body Image Disturbance Questionnaire--Scoliosis Version

BACKGROUND

Appearance concerns in individuals with adolescent idiopathic scoliosis can result in impairment in daily functioning, or body image disturbance. The Body Image Disturbance Questionnaire (BIDQ) is a self-reported, seven-question instrument that measures body image disturbance in general populations; no studies have specifically examined body image disturbance in those with adolescent idiopathic scoliosis. This study aimed to validate a modified version of the BIDQ in a population with adolescent idiopathic scoliosis and to establish discriminant validity by comparing responses of operatively and nonoperatively treated patients with those of normal controls.

METHODS

In the first phase, a multicenter study of forty-nine patients (mean age, fourteen years; thirty-seven female) with adolescent idiopathic scoliosis was performed to validate the BIDQ-Scoliosis version (BIDQ-S). Participants completed the BIDQ-S, Scoliosis Research Society (SRS)-22, Children's Depression Index (CDI), and Body Esteem Scale for Adolescents and Adults (BESAA) questionnaires. Descriptive statistics and Pearson correlation coefficients were calculated. In the second phase, ninety-eight patients with adolescent idiopathic scoliosis (mean age, 15.7 years; seventy-five female) matched by age and sex with ninety-eight healthy adolescents were enrolled into a single-center study to evaluate the discriminant validity of the BIDQ-S. Subjects completed the BIDQ-S and a demographic form before treatment. Independent-sample t tests and Pearson correlation coefficients were calculated.

RESULTS

The BIDQ-S was internally consistent (Cronbach alpha = 0.82), and corrected item total correlations ranged from 0.47 to 0.67. The BIDQ-S was significantly correlated with each domain of the SRS-22 and the total score (r = -0.50 to -0.72, p ≤ 0.001), with the CDI (r = 0.31, p = 0.03), and with the BESAA (r = 0.60, p < 0.001). BIDQ-S scores differed significantly between patients (1.50) and controls (1.06, p < 0.005), establishing discriminant validity.

CONCLUSIONS

The BIDQ-S is an internally consistent outcomes instrument that correlated with the SRS-22, CDI, and BESAA outcomes instruments in a scoliosis population. The scores of the patients with scoliosis indicated greater back-related body image disturbance compared with healthy controls. To our knowledge, this user-friendly instrument is the first to examine body image disturbance in adolescent idiopathic scoliosis, and it provides a comprehensive evaluation of how scoliosis-related appearance concerns impact psychosocial and daily functioning.

Fatigue is highly associated with poor health-related quality of life, disability and depression in newly-diagnosed patients with inflammatory bowel disease, independent of disease activity

BACKGROUND

Fatigue is common in Crohn's disease (CD) and ulcerative colitis (UC). Data on fatigue in newly diagnosed patients are unavailable.

AIM

To report prevalence of fatigue in newly diagnosed CD and UC patients and examine its association with health-related quality of life (HRQOL), depression and disability.

METHODS

The Ocean State Crohn's and Colitis Area Registry (OSCCAR) is a statewide cohort of newly diagnosed inflammatory bowel disease patients in Rhode Island. Fatigue was assessed using the Functional Assessment of Chronic Illness Therapy-Fatigue Scale. Patients were administered instruments measuring HRQOL, overall disability and work impairment, and depression.

RESULTS

Fatigue was prevalent in 26.4% of 220 subjects. Cohen's d effect sizes for fatigue were large: Short-Form 36 Health Survey mental health component (CD 1.5, UC 1.4) and physical health component (CD 1.4, UC 1.4), EuroQol-5D valuation of current health state (CD 1.2, UC 1.0), Inflammatory Bowel Disease Questionnaire (CD 1.9, UC 1.6) and Patient Health Questionnaire depression scale (CD 1.8, UC 1.7). Fatigued patients reported more work impairment (Score difference: CD 29.5%, UC 23.8%) and activity impairment (score difference: CD 32.3%, UC 25.7%) on the Work Productivity and Activity Impairment Questionnaire. Fatigue's association with all scores remained highly significant despite controlling for disease activity.

CONCLUSIONS

Fatigue is strongly associated with poor HRQOL, disability and depression similarly in CD and UC even when controlling for disease activity. Fatigue's association with a wide range of patient-reported outcome measures suggests that monitoring fatigue is a simple way to screen for overall disruption in patient life.

Differences in early sagittal plane alignment between thoracic and lumbar adolescent idiopathic scoliosis

BACKGROUND CONTEXT

It has previously been shown that rotational stability of spinal segments is reduced by posteriorly directed shear loads that are the result of gravity and muscle tone. Posterior shear loads act on those segments of the spine that are posteriorly inclined, as determined by each individual's inherited sagittal spinal profile. Accordingly, it can be inferred that certain sagittal spinal profiles are more prone to develop a rotational deformity that may lead to idiopathic scoliosis; and lumbar scoliosis, on one end of the spectrum, develops from a different sagittal spinal profile than thoracic scoliosis on the other end.

PURPOSE

To examine the role of sagittal spinopelvic alignment in the etiopathogenesis of different types of idiopathic scoliosis.

STUDY DESIGN/SETTING

Multicenter retrospective analysis of lateral radiographs of patients with small thoracic and lumbar adolescent idiopathic scoliotic curves.

PATIENTS SAMPLE

We included 192 adolescent idiopathic scoliosis patients with either a thoracic (n=128) or lumbar (n=64) structural curve with a Cobb angle of less than 20° were studied. Children with other spinal pathology or with more severe idiopathic scoliosis were excluded, because this disturbs their original sagittal profile. Subjects who underwent scoliosis screening and had a normal spine were included in the control cohort (n=95).

OUTCOME MEASURES

Thoracic kyphosis, lumbar lordosis, T9 sagittal offset, C7 and T4 sagittal plumb lines, pelvic incidence, pelvic tilt, and sacral slope, as well as parameters describing orientation in space of each individual vertebra between C7 and L5 and length of the posteriorly inclined segment.

METHODS

On standardized lateral radiographs of the spine, a systematic, semi-automatic measurement of the different sagittal spinopelvic parameters was performed for each subject using in-house developed computer software.

RESULTS

Early thoracic scoliosis showed a significantly different sagittal plane from lumbar scoliosis. Furthermore, both scoliotic curve patterns were different from controls, but in a different sense. Thoracic kyphosis was significantly decreased in thoracic scoliosis compared with both lumbar scoliosis patients and controls. For thoracic scoliosis, a significantly longer posteriorly inclined segment, and steeper posterior inclination of C7-T8 was observed compared with both lumbar scoliosis and controls. In lumbar scoliosis, the posteriorly inclined segment was shorter and located lower in the spine, and T12-L4 was more posteriorly inclined than in the thoracic group. The lumbar scoliosis cohort had a posteriorly inclined segment of the same length as controls, but T12-L2 showed steeper posterior inclination. Lumbar lordosis, pelvic incidence, pelvic tilt, and sacral slope, however, were similar for the two scoliotic subgroups as well as the controls.

CONCLUSIONS

This study demonstrates that even at an early stage in the condition, the sagittal profile of thoracic adolescent idiopathic scoliosis differs significantly from lumbar scoliosis, and both types of scoliosis differ from controls, but in different aspects. This supports the theory that differences in underlying sagittal profile play a role in the development of different types of idiopathic scoliosis.

Preoperative Pulmonary Function in Patients With Operative Scheuermann Kyphosis

STUDY DESIGN

A multicenter, prospective study of consecutively enrolled surgical patients with Scheuermann kyphosis (SK).

OBJECTIVES

To evaluate the impact of SK on preoperative pulmonary function and to determine which radiographic criteria may help predict pulmonary impairment.

SUMMARY OF BACKGROUND DATA

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.

METHODS

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.

RESULTS

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%).

Surgical Site Infection in Adolescent Idiopathic Scoliosis Surgery

OBJECTIVE

To define the current rate of postoperative surgical site infections (SSIs) in a large prospective series of surgical adolescent idiopathic scoliosis (AIS) cases.

METHODS

A multicenter, prospective database of patients who underwent surgical correction of AIS was reviewed. Early SSIs were defined as occurring within 90 days after the index operation, as per the Center for Disease Control's definitions. Treatment and outcome information on all confirmed SSIs was compiled. Variables associated with the occurrence of an SSI were evaluated.

RESULTS

Of the 1,757 patients analyzed, 28 developed an SSI within the first 90 days postoperatively (1.6%). Patient weight was associated with SSI (p < .001). There was a trend in correlation with the number of levels fused (p = .07) and blood loss as a percentage of blood volume (p = .07) and the incidence of SSI. There was no correlation with any other variables. There was variation in the rate of SSI among the 9 centers, ranging from 0.6% to 4.4% (p = .27). Of the 28 infections, 26 resolved with surgery and/or antibiotics and did not need implant removal. Only 2 patients had late pain. In addition to the 28 confirmed SSIs, there were an additional 68 other wound issues (4.2%) that did not meet the Center for Disease Control criteria for an SSI.

CONCLUSIONS

Early SSIs after AIS surgery occurred at a rate of 1.6%. The federal mandate to eliminate SSI and the proposed lack of reimbursement for its treatment may change clinical practice, and these data provide average SSI rates across multiple centers for future comparison. Investigations into variations in practice between centers might yield areas for potential improvement in SSI for AIS patients. Fortunately, 92% of patients were able to retain their implants and were free of pain at final follow-up.

Disruption of basal lamina components in neuromotor synapses of children with spastic quadriplegic cerebral palsy

Cerebral palsy (CP) is a static encephalopathy occurring when a lesion to the developing brain results in disordered movement and posture. Patients present with sometimes overlapping spastic, athetoid/dyskinetic, and ataxic symptoms. Spastic CP, which is characterized by stiff muscles, weakness, and poor motor control, accounts for ∼80% of cases. The detailed mechanisms leading to disordered movement in spastic CP are not completely understood, but clinical experience and recent studies suggest involvement of peripheral motor synapses. For example, it is recognized that CP patients have altered sensitivities to drugs that target neuromuscular junctions (NMJs), and protein localization studies suggest that NMJ microanatomy is disrupted in CP. Since CP originates during maturation, we hypothesized that NMJ disruption in spastic CP is associated with retention of an immature neuromotor phenotype later in life. Scoliosis patients with spastic CP or idiopathic disease were enrolled in a prospective, partially-blinded study to evaluate NMJ organization and neuromotor maturation. The localization of synaptic acetylcholine esterase (AChE) relative to postsynaptic acetylcholine receptor (AChR), synaptic laminin β2, and presynaptic vesicle protein 2 (SV2) appeared mismatched in the CP samples; whereas, no significant disruption was found between AChR and SV2. These data suggest that pre- and postsynaptic NMJ components in CP children were appropriately distributed even though AChE and laminin β2 within the synaptic basal lamina appeared disrupted. Follow up electron microscopy indicated that NMJs from CP patients appeared generally mature and similar to controls with some differences present, including deeper postsynaptic folds and reduced presynaptic mitochondria. Analysis of maturational markers, including myosin, syntrophin, myogenin, and AChR subunit expression, and telomere lengths, all indicated similar levels of motor maturation in the two groups. Thus, NMJ disruption in CP was found to principally involve components of the synaptic basal lamina and subtle ultra-structural modifications but appeared unrelated to neuromotor maturational status.

Risk factors associated with Clostridium difficile infection after kidney and pancreas transplantation

BACKGROUND

Clostridium difficile infection (CDI) is a common cause of nosocomial antibiotic-associated diarrhea with an increased incidence reported in solid organ transplant recipients. We sought to determine if kidney and/or pancreas transplant recipients possess unique risk factors for CDI.

METHODS

Between January 2009 and February 2011, 942 kidney and 56 pancreas transplants were performed at the 2 centers. Of these, 28 recipients (kidney, n = 24; pancreas, n = 4) developed CDI. Cases were matched to controls (n = 56) in a 1:2 ratio.

RESULTS

Those with CDI were mostly male patients (82% vs. 48%, P = 0.003), deceased-donor organ recipients (86% vs. 64%, P = 0.045), more likely to have leukopenia (18% vs. 4%, P = 0.038), and had undergone a gastrointestinal procedure within 3 months preceding CDI diagnosis (18% vs. 4%, P = 0.038). Cases had higher cumulative and restricted antimicrobial exposure in days (37 ± 79 vs. 8 ± 12, P = 0.009 and 27 ± 69 vs. 7 ± 10, P = 0.032). Cephalosporin use was more common among cases (43% vs. 16%, P = 0.008).

CONCLUSION

Careful antimicrobial selection and assurance of optimal treatment duration in the kidney and pancreas transplant population is prudent. Clinicians should have a heightened awareness of CDI risk particularly during periods of leukopenia and in the setting of gastrointestinal procedures.

Are More Screws Better? A Systematic Review of Anchor Density and Curve Correction in Adolescent Idiopathic Scoliosis

STUDY DESIGN

Systematic review of clinical studies.

OBJECTIVES

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.

SUMMARY OF BACKGROUND DATA

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.