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Narendran N, Nilssen PK, Tuchman A, Skaggs DL. ALIF and LDA Likely Have Similar Reoperation Rates: A Response to "Lumbar Arthroplasty is Associated With a Lower Incidence of Adjacent Segment Disease Compared With ALIF". Spine (Phila Pa 1976) 2024; 49:E153. [PMID: 37991228 DOI: 10.1097/brs.0000000000004882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 11/14/2023] [Indexed: 11/23/2023]
Affiliation(s)
- Nakul Narendran
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Paal K Nilssen
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Alexander Tuchman
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - David L Skaggs
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
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Farivar D, Peterman NJ, Nilssen PK, Illingworth KD, Nuckols TK, Skaggs DL. Geographic Access to Pediatric Orthopedic Surgeons in the United States: An Analysis of Sociodemographic Factors. Orthopedics 2024:1-7. [PMID: 38690849 DOI: 10.3928/01477447-20240424-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
BACKGROUND It is unclear how pediatric orthopedic surgeons are geographically distributed relative to their patients. The purpose of this study was to evaluate the geographic distribution of pediatric orthopedic surgeons in the United States. MATERIALS AND METHODS County-level data of actively practicing pediatric orthopedic surgeons were identified by matching several registries and membership logs. Data were used to calculate the distance between counties and nearest surgeon. Counties were categorized as "surgeon clusters" or "surgeon deserts" if the distance to the nearest surgeon was less than or greater than the national average and the average of all neighboring counties, respectively. Cohorts were then compared for differences in population characteristics using data obtained from the 2020 American Community Survey. RESULTS A total of 1197 unique pediatric orthopedic surgeons were identified. The mean distance to the nearest pediatric orthopedic surgeon for a patient residing in a surgeon desert or a surgeon cluster was 141.9±53.8 miles and 30.9±16.0 miles, respectively. Surgeon deserts were found to have lower median household incomes (P<.001) and greater rates of children without health insurance (P<.001). Multivariate analyses showed that higher Rural-Urban Continuum codes (P<.001), Area Deprivation Index scores (P<.001), and percentage of patients without health insurance (P<.001) all independently required significantly greater travel distances to see a pediatric orthopedic surgeon. CONCLUSION Pediatric orthopedic surgeons are not equally distributed in the United States, and many counties are not optimally served. Additional studies are needed to identify the relationship between travel distances and patient outcomes and how geographic inequalities can be minimized. [Orthopedics. 202x;4x(x):xx-xx.].
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Nuckols TK, Chen PG, Shetty KD, Brara HS, Anand N, Qureshi N, Skaggs DL, Doctor JN, Pevnick JM, Mannion AF. Surgical appropriateness nudges: Developing behavioral science nudges to integrate appropriateness criteria into the decision making of spine surgeons. PLoS One 2024; 19:e0300475. [PMID: 38640131 PMCID: PMC11029649 DOI: 10.1371/journal.pone.0300475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 02/20/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Substantial variation exists in surgeon decision making. In response, multiple specialty societies have established criteria for the appropriate use of spine surgery. Yet few strategies exist to facilitate routine use of appropriateness criteria by surgeons. Behavioral science nudges are increasingly used to enhance decision making by clinicians. We sought to design "surgical appropriateness nudges" to support routine use of appropriateness criteria for degenerative lumbar scoliosis and spondylolisthesis. METHODS The work reflected Stage I of the NIH Stage Model for Behavioral Intervention Development and involved an iterative, multi-method approach, emphasizing qualitative methods. Study sites included two large referral centers for spine surgery. We recruited spine surgeons from both sites for two rounds of focus groups. To produce preliminary nudge prototypes, we examined sources of variation in surgeon decision making (Focus Group 1) and synthesized existing knowledge of appropriateness criteria, behavioral science nudge frameworks, electronic tools, and the surgical workflow. We refined nudge prototypes via feedback from content experts, site leaders, and spine surgeons (Focus Group 2). Concurrently, we collected data on surgical practices and outcomes at study sites. We pilot tested the refined nudge prototypes among spine surgeons, and surveyed them about nudge applicability, acceptability, and feasibility (scale 1-5, 5 = strongly agree). RESULTS Fifteen surgeons participated in focus groups, giving substantive input and feedback on nudge design. Refined nudge prototypes included: individualized surgeon score cards (frameworks: descriptive social norms/peer comparison/feedback), online calculators embedded in the EHR (decision aid/mapping), a multispecialty case conference (injunctive norms/social influence), and a preoperative check (reminders/ salience of information/ accountable justification). Two nudges (score cards, preop checks) incorporated data on surgeon practices and outcomes. Six surgeons pilot tested the refined nudges, and five completed the survey (83%). The overall mean score was 4.0 (standard deviation [SD] 0.5), with scores of 3.9 (SD 0.5) for applicability, 4.1 (SD 0.5) for acceptability, and 4.0 (SD 0.5), for feasibility. Conferences had the highest scores 4.3 (SD 0.6) and calculators the lowest 3.9 (SD 0.4). CONCLUSIONS Behavioral science nudges might be a promising strategy for facilitating incorporation of appropriateness criteria into the surgical workflow of spine surgeons. Future stages in intervention development will test whether these surgical appropriateness nudges can be implemented in practice and influence surgical decision making.
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Affiliation(s)
- Teryl K. Nuckols
- RAND Corporation, Santa Monica, CA, United States of America
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Peggy G. Chen
- RAND Corporation, Santa Monica, CA, United States of America
| | | | - Harsimran S. Brara
- Kaiser Permanente, Los Angeles Medical Center, Los Angeles, CA, United States of America
| | - Neel Anand
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Nabeel Qureshi
- RAND Corporation, Santa Monica, CA, United States of America
| | - David L. Skaggs
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Jason N. Doctor
- Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, Los Angeles, CA, United States of America
| | - Joshua M. Pevnick
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
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Farivar D, Vadhera AS, Illingworth KD, Skaggs DL. Evaluating Funding for Authors Achieving High Citations vs. Online Popularity. J Am Acad Orthop Surg 2024; 32:e405-e412. [PMID: 38236923 DOI: 10.5435/jaaos-d-23-00325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 11/27/2023] [Indexed: 04/06/2024] Open
Abstract
INTRODUCTION The Altmetric score is a validated tool that measures online attention of scientific studies. A relationship between government/industry funding for authors and their study's citations have been previously demonstrated. It is not known whether funding is related to greater online attention. We hypothesize authors publishing studies achieving greater online attention (higher Altmetric scores) receive greater monetary support from industry while authors publishing studies achieving critical acclaim (more citations) receive greater monetary support from the National Institute of Health (NIH). METHODS Top spine surgery studies between 2010 and 2021 were selected based on Altmetric scores and citation number. The Open Payments Database was accessed to evaluate industry financial relationships while the NIH Research Portfolio Online Reporting Tool was accessed to evaluate NIH funding. Payments were compared between groups and analyzed with the Student t-test, analysis of variance, and chi square analysis. Alpha <0.05. RESULTS There were 60 and 51 authors with payment data in the top 50 Altmetric and top 50 citation studies, respectively, with eight authors having studies in both groups. Total industry payments between groups were not markedly different. The eight authors with studies in both groups received markedly more industry payments for consulting, travel/lodging, and faculty/speaking fees. Authors with articles in both groups (50%) were significantly more likely to receive NIH support, compared with authors of the top Altmetric articles (5%; P < 0.001) and top citation articles (12%; P < 0.001). Authors receiving NIH support received significantly less industry payments compared with authors not receiving NIH support ($148,544 versus $2,159,526; P < 0.001). DISCUSSION These findings reject our hypothesis: no notable differences for industry payments and NIH funding between authors for top Altmetric and citation studies. Authors receiving funding from industry versus the NIH are generally two distinct groups, but there is a small group supported by both. These studies achieve both critical acclaim (citations) and online popularity (Altmetric scores). DATA AVAILABILITY Data can be available on reasonable request.
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Affiliation(s)
- Daniel Farivar
- From the Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, CA (Farivar, Illingworth, and Skaggs), and the Sidney Kimmel Medical College, Philadelphia, PA (Vadhera)
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CreveCoeur TS, Iyer RR, Goldstein HE, Delgardo MW, Hankinson TC, Erickson MA, Garg S, Skaggs DL, Andras L, Kennedy BC, Cahill PJ, Lenke LG, Angevine PD, Roye BD, Vitale MG, Mendiratta A, Anderson RCE. Timing of intraoperative neurophysiological monitoring (IONM) recovery and clinical recovery after termination of pediatric spinal deformity surgery due to loss of IONM signals. Spine J 2024:S1529-9430(24)00169-4. [PMID: 38614157 DOI: 10.1016/j.spinee.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/04/2024] [Accepted: 04/06/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND CONTEXT Intraoperative neurophysiological monitoring (IONM) is used to reduce the risk of spinal cord injury during pediatric spinal deformity surgery. Significant reduction and/or loss of IONM signals without immediate recovery may lead the surgeon to acutely abort the case. The timing of when monitorable signals return remains largely unknown. PURPOSE The goal of this study was to investigate the correlation between IONM signal loss, clinical examination, and subsequent normalization of IONM signals after aborted pediatric spinal deformity surgery to help determine when it is safe to return to the operating room. STUDY DESIGN/SETTING This is a multicenter, multidisciplinary, retrospective study of pediatric patients (< 18 years old) undergoing spinal deformity surgery whose surgery was aborted due to a significant reduction or loss of IONM potentials. PATIENT SAMPLE Sixty-six patients less than 18 years old who underwent spinal deformity surgery that was aborted due to IONM signal loss were enrolled into the study. OUTCOME MEASURES IONM data, operative reports, and clinical examinations were investigated to determine the relationship between IONM loss, clinical examination, recovery of IONM signals, and clinical outcome. METHODS Information regarding patient demographics, deformity type, clinical history, neurologic and ambulation status, operative details, IONM information (e.g., quality of loss [SSEPs, MEPs], laterality, any recovery of signals, etc.), intra-operative wake-up test, post-operative neurologic exam, post-operative imaging, and time to return to the operating were all collected. All factors were analyzed and compared with univariate and multivariate analysis using appropriate statistical analysis. RESULTS Sixty-six patients were enrolled with a median age of 13 years [IQR 11-14], and the most common sex was female (42/66, 63.6%). Most patients had idiopathic scoliosis (33/66, 50%). The most common causes of IONM loss were screw placement (27/66, 40.9%) followed by rod correction (19/66, 28.8%). All patients had either complete bilateral (39/66, 59.0%), partial bilateral (10/66, 15.2%) or unilateral (17/66, 25.8%) MEP loss leading to termination of the case. Overall, when patients were returned to the operating room two weeks postoperatively, nearly 75% (40/55) had monitorable IONM signals. Univariate analysis demonstrated that bilateral SSEP loss (p = 0.019), bilateral SSEP and MEP loss (p = 0.022) and delayed clinical neurologic recovery (p = 0.008) were significantly associated with having unmonitorable IONM signals at repeat surgery. Multivariate regression analysis demonstrated that delayed clinical neurologic recovery (> 72 hours) was significantly associated with unmonitorable IONM signals when returned to the operating room (p=0.006). All patients ultimately made a full neurologic recovery. CONCLUSIONS In children whose spinal deformity surgery was aborted due to intraoperative IONM loss, there was a strong correlation between combined intraoperative SSEP/MEP loss, the magnitude of IONM loss, the timing of clinical recovery, and the time of electrophysiological IONM recovery. The highest likelihood of having a prolonged postoperative neurological deficit and undetectable IONM signals upon return to the OR occurs with bilateral complete loss of SSEPs and MEPs.
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Affiliation(s)
- Travis S CreveCoeur
- Columbia University, Department of Neurological Surgery; Och Spine Hospital; New York City, NY.
| | - Rajiv R Iyer
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah/Primary Children's Hospital, Salt Lake City, UT
| | | | - Mychael W Delgardo
- Columbia University, Department of Neurological Surgery; Och Spine Hospital; New York City, NY
| | | | | | | | - David L Skaggs
- Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, Ca
| | - Lindsay Andras
- Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles; Ca
| | - Benjamin C Kennedy
- Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Patrick J Cahill
- Division of Orthopedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lawrence G Lenke
- Columbia University, Department of Orthopedic Surgery, New York, NY
| | - Peter D Angevine
- Columbia University, Department of Neurological Surgery; Och Spine Hospital; New York City, NY
| | - Benjamin D Roye
- Columbia University, Department of Orthopedic Surgery, New York, NY
| | - Michael G Vitale
- Columbia University, Department of Orthopedic Surgery, New York, NY
| | - Anil Mendiratta
- Department of Neurology, Columbia University Medical Center, New York, NY
| | - Richard C E Anderson
- Department of Neurosurgery, New York University, New York, New York; NYU Neurosurgery Network, Ridgewood, NJ
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Lin A, Skaggs DL, Andras LM, Tolo V, Tamrazi B, Illingworth KD. Increasing Cervical Kyphosis Correlates With Cervical Degenerative Disk Disease in Patients With Adolescent Idiopathic Scoliosis. Spine (Phila Pa 1976) 2024; 49:486-491. [PMID: 37694562 DOI: 10.1097/brs.0000000000004824] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/23/2023] [Indexed: 09/12/2023]
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE Our goal was to investigate the incidence of cervical degenerative disk disease (DDD) in patients with adolescent idiopathic scoliosis (AIS), before surgical intervention. SUMMARY OF BACKGROUND DATA AIS is often associated with thoracic hypokyphosis and compensatory cervical kyphosis. In adults, cervical kyphosis is associated with DDD. Although cervical kyphosis has been reported in up to 60% AIS patients, the association with cervical DDD has not been reported. MATERIALS AND METHODS A retrospective review was conducted from January 2014 to December 2019 of all consecutive AIS patients. Inclusion criteria were AIS patients over 10 years of age with cervical magnetic resonance imaging and anterior-posterior and lateral spine radiographs within 1 year of each other. Magnetic resonance imaging were reviewed for evidence of cervical DDD. Severity of cervical changes were graded using the Pfirrmann classification and by a quantitative measure of disk degeneration, the magnetic resonance signal intensity ratio. RESULTS Eighty consecutive patients were included (mean age: 14.1 years, SD=2.5 years). Increasing cervical kyphosis was significantly correlated to decreasing thoracic kyphosis ( r =0.49, P <0.01) and increasing major curve magnitude ( r =0.22, P =0.04). Forty-five patients (56%) had the presence of DDD (grades 2-4) with a mean cervical kyphosis of 11.1° (SD=9.5°, P <0.01). More cervical kyphosis was associated with more severe cervical DDD as graded by Pfirrmann classification level ( P <0.01). Increasing cervical kyphosis was also positively associated with increasing magnetic resonance signal intensity ratio ( P <0.01). Nine patients had ventral cord effacement secondary to DDD with a mean cervical kyphosis of 22.8° (SD=8.6°) compared with 2.6° (SD=11.2°) in those who did not ( P <0.01). CONCLUSIONS Cervical kyphosis was significantly associated with increasing severity of cervical DDD in patients with AIS. Patients with evidence of ventral cord effacement had the largest degree of cervical kyphosis with a mean of 22.8±8.6°. This is the first study to evaluate the association between cervical kyphosis in AIS with cervical DDD.
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Affiliation(s)
- Adrian Lin
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA
| | - David L Skaggs
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Lindsay M Andras
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA
| | - Vernon Tolo
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA
| | - Benita Tamrazi
- Department of Radiology, Children's Hospital Los Angeles, Los Angeles, CA
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Chan V, Skaggs DL, Cho RH, Poon SC, Shumilak G. Characterizing antibiotic prophylaxis practices in pediatric deformity spinal surgery and impact on 30-day postoperative infection: an NSQIP pediatric database study. Spine Deform 2024:10.1007/s43390-024-00844-9. [PMID: 38499968 DOI: 10.1007/s43390-024-00844-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/09/2024] [Indexed: 03/20/2024]
Abstract
PURPOSE The aim of this study was to characterize antibiotic prophylaxis practices in pediatric patients who have received posterior arthrodesis for spinal deformity and understand how these practices impact 30-day postoperative infection rates. METHODS This was a retrospective cohort study using the National Surgical Quality Improvement Program Pediatric database for year 2021. Patients 18 years of age or younger who received posterior arthrodesis for scoliosis or kyphosis correction were included. The outcome of interest was 30-day postoperative infection. Fisher's exact test and multivariable regression analysis were used to analyze the impact of intravenous antibiotic prophylaxis, intraoperative intravenous antibiotic redosing after 4 h, postoperative antibiotic prophylaxis, intraoperative topical antibiotics on 30-day postoperative infection, and various antibiotic prophylaxis regimens. RESULTS A total of 6974 patients were included in this study. The 30-day infection rate was 2.9%. Presurgical intravenous antibiotic (11.5% vs. 2.7%, p = 0.005), postoperative antibiotic (5.7% vs. 2.4%, p < 0.01), and intraoperative topical antibiotic (4.0% vs. 2.7%, p = 0.019) were associated with significantly reduced infection rates. There was no significant difference in infection rates between patients that received cefazolin versus vancomycin versus clindamycin. The addition of Gram-negative coverage did not result in significant differences in infection rates. Multivariable regression analysis found postoperative intravenous antibiotics and intraoperative topical antibiotics to reduce infection rates. CONCLUSIONS We found the use of presurgical intravenous antibiotics, postoperative intravenous antibiotics, and intraoperative topical antibiotics to significantly reduce infection rates. Results from this study can be applied to future research on implementation of standardized infection prevention protocols. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Vivien Chan
- UCLA Health, Los Angeles, 1131 Wilshire Blvd Suite 100, Santa Monica, CA, 90401, USA.
| | - David L Skaggs
- Spine Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Robert H Cho
- Shriners Children's Southern California, Pasadena, CA, USA
| | - Selina C Poon
- Shriners Children's Southern California, Pasadena, CA, USA
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Narendran N, Nilssen PK, Tuchman A, Skaggs DL. ALIF and TLIF Likely Have Similar Reoperation Rates: A Response to "TLIF is Associated With Lower Rates of Adjacent Segment Disease and Complications Compared With ALIF". Spine (Phila Pa 1976) 2024; 49:E79. [PMID: 38014761 DOI: 10.1097/brs.0000000000004883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 11/16/2023] [Indexed: 11/29/2023]
Affiliation(s)
- Nakul Narendran
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Paal K Nilssen
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Alexander Tuchman
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - David L Skaggs
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
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Regan CM, Morgan J, Hilaire TS, El-Hawary R, Pahys JM, Skaggs DL, Yaszay B, Parent S, Larson AN. Does radiographic calibration affect linear radiographic measurements in a large pediatric spine registry? Spine Deform 2024; 12:335-339. [PMID: 38147269 DOI: 10.1007/s43390-023-00793-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 11/04/2023] [Indexed: 12/27/2023]
Abstract
PURPOSE Large registries are increasingly at the forefront of modern pediatric spine research, with manual, centralized, trained radiographic measurement serving as the gold standard for spine research. However, there is limited data regarding the reliability of registry measurements which may be subject to differences in radiographic calibration. We undertook this study to evaluate reliability of T1-T12 height, L1-S1 height, and coronal balance measurements for a large registry of early onset scoliosis patients. METHODS Three trained technicians from the Pediatric Spine Study Group measured 43 radiographs for T1-T12, L1-S1, and coronal balance using 3 different calibration techniques. All radiographs were AP views of patients with magnetically controlled growing rods with known diameters. The calibration techniques used a pre-export manually drawn line, a digital automatically generated computerized marker, and the diameter of a magnetically controlled growing rod. The intraclass correlation coefficient (ICC) was calculated to determine reliability. RESULTS 1161 measurements were performed. For each of the three raters, coronal balance, T1-T12 height and L1-S1 height had excellent agreement regardless of the calibration technique (alpha 0.93-1.0). Among the parameters, coronal balance had the worst inter-rater reliability, whereas there was excellent interrater reliability regarding T1-T12 height and L1-S1 height (alpha 0.91-0.99). CONCLUSION There was excellent agreement among reviewers and between the 3 different calibration techniques. While calibration using rod diameter served as the gold standard, this data shows that other standard calibration methods were adequate and achieved excellent reliability for registry radiographs.
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Affiliation(s)
- Christina M Regan
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | | | | | | | - Joshua M Pahys
- Philadelphia Shriners Hospital for Children, Philadelphia, PA, USA
| | | | - Burt Yaszay
- Seattle Children's Hospital, Seattle, WA, USA
| | | | - A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, USA.
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Nilssen PK, Skaggs DL, Illingworth KD. Letter to the editor regarding "3D printed pedicle screw guides reduce the rate of intraoperative screw revision in adolescent idiopathic scoliosis surgery" by Jeong et al. Spine J 2024; 24:560. [PMID: 38365328 DOI: 10.1016/j.spinee.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 11/13/2023] [Indexed: 02/18/2024]
Affiliation(s)
- Paal K Nilssen
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Cedars-Sinai Medical Center 444 South San Vicente Boulevard, Los Angeles, CA 90048, USA
| | - David L Skaggs
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Cedars-Sinai Medical Center 444 South San Vicente Boulevard, Los Angeles, CA 90048, USA
| | - Kenneth D Illingworth
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Cedars-Sinai Medical Center 444 South San Vicente Boulevard, Los Angeles, CA 90048, USA.
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Tuchman A, Chen I, Walker CT, Kanim LE, Bae HW, Skaggs DL. Is single-level cervical disc arthroplasty associated with a lower reoperation rate than anterior cervical discectomy and fusion? J Neurosurg Spine 2024; 40:282-290. [PMID: 38100758 DOI: 10.3171/2023.10.spine23640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/18/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVE Long-term meta-analysis of cervical disc arthroplasty (CDA) trials report lower rates of subsequent cervical spine surgical procedures with CDA compared with anterior cervical discectomy and fusion (ACDF). The objective of this study was to compare the rate of subsequent cervical spine surgery in single-level CDA-treated patients to that of a matched cohort of single-level ACDF-treated patients by using records from 2010 to 2021 included in a large national administrative claims database (PearlDiver). METHODS This retrospective matched-cohort study used a large national insurance claims database; 525,510 patients who had undergone a single-level ACDF or CDA between 2010 and 2021 were identified. Patients with other same-day spine procedures, as well as those for trauma, infection, or tumor, were excluded, yielding 148,531 patients. ACDF patients were matched 2:1 to CDA patients on the basis of clinical and demographic characteristics. The primary outcome was the overall incidence of all-cause cervical reoperation after index surgery. Secondary outcomes included readmission, any adverse event within 90 days, and overall reintervention after index surgery. Multivariable logistic regression analyses were adjusted for covariates and were employed to estimate the effect of the index ACDF or CDA procedure on patient outcomes. Survival was assessed using Kaplan-Meier estimation, and differences between ACDF- and CDA-treated patients were compared using log-rank tests. RESULTS After the patients were matched, 28,795 ACDF patients to 14,504 CDA patients were included. ACDF patients had higher rates of 90-day adverse events (18.4% vs 14.6%, adjusted odds ratio [aOR] 0.77, 95% CI 0.73-0.82, p < 0.001) and readmission (11.5% vs 9.7%, aOR 0.87, 95% CI 0.81-0.93, p < 0.001). Over a mean 4.3 years of follow-up, 5.0% of ACDF patients and 5.4% of CDA patients underwent reoperation (aOR 1.09, 95% CI 1.00-1.19, p = 0.059). The rate of aggregate reintervention was higher in CDA patients than in ACDF patients (11.7% vs 10.7%, aOR 1.10, p = 0.002). The Kaplan-Meier 10-year reoperation-free survival rate was worse for CDA than ACDF (91.0% vs 92.0%, p = 0.05), as was the rate of reintervention-free survival (81.2% vs 82.0%, p = 0.003). CONCLUSIONS Single-level CDA was associated with a similar rate of reoperation and higher rate of subsequent injections when compared with a matched cohort that underwent single-level ACDF. CDA was associated with lower rates of 90-day adverse events and readmissions.
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Affiliation(s)
- Alexander Tuchman
- 1Departments of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ida Chen
- 2Departments of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Corey T Walker
- 1Departments of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Linda E Kanim
- 2Departments of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Hyun W Bae
- 2Departments of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - David L Skaggs
- 2Departments of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Farivar D, Peterman NJ, Narendran N, Illingworth KD, Nuckols TK, Bonda D, Skaggs DL. Geographic access to pediatric neurosurgeons in the USA: an analysis of sociodemographic factors. Childs Nerv Syst 2024; 40:905-912. [PMID: 37794171 PMCID: PMC10891277 DOI: 10.1007/s00381-023-06172-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/28/2023] [Indexed: 10/06/2023]
Abstract
PURPOSE Geographic access to physicians has been shown to be unevenly distributed in the USA, with those in closer proximity having superior outcomes. The purpose of this study was to describe how geographic access to pediatric neurosurgeons varies across socioeconomic and demographic factors. METHODS Actively practicing neurosurgeons were identified by matching several registries and membership logs. This data was used to find their primary practice locations and the distance the average person in a county must travel to visit a surgeon. Counties were categorized into "surgeon deserts" and "surgeon clusters," which were counties where providers were significantly further or closer to its residents, respectively, compared to the national average. These groups were also compared for differences in population characteristics using data obtained from the 2020 American Community Survey. RESULTS A total of 439 pediatric neurosurgeons were identified. The average person in a surgeon desert and cluster was found to be 189.2 ± 78.1 miles and 39.7 ± 19.6 miles away from the nearest pediatric neurosurgeon, respectively. Multivariate analyses showed that higher Rural-Urban Continuum (RUC) codes (p < 0.001), and higher percentages of American Indian (p < 0.001) and Hispanic (p < 0.001) residents were independently associated with counties where the average person traveled significantly further to surgeons. CONCLUSION Patients residing in counties with greater RUC codes and higher percentages of American Indian and Hispanic residents on average need to travel significantly greater distances to access pediatric neurosurgeons.
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Affiliation(s)
- Daniel Farivar
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nicholas J Peterman
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nakul Narendran
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Kenneth D Illingworth
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Teryl K Nuckols
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - David Bonda
- Department of Neurological Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - David L Skaggs
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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13
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Shetty KD, Chen PG, Brara HS, Anand N, Skaggs DL, Calsavara VF, Qureshi NS, Weir R, McKelvey K, Nuckols TK. Variations in surgical practice and short-term outcomes for degenerative lumbar scoliosis and spondylolisthesis: do surgeon training and experience matter? Int J Qual Health Care 2024; 36:mzad109. [PMID: 38156345 PMCID: PMC10849168 DOI: 10.1093/intqhc/mzad109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 11/30/2023] [Accepted: 12/28/2023] [Indexed: 12/30/2023] Open
Abstract
For diverse procedures, sizable geographic variation exists in rates and outcomes of surgery, including for degenerative lumbar spine conditions. Little is known about how surgeon training and experience are associated with surgeon-level variations in spine surgery practice and short-term outcomes. This retrospective observational analysis characterized variations in surgical operations for degenerative lumbar scoliosis or spondylolisthesis, two common age-related conditions. The study setting was two large spine surgery centers in one region during 2017-19. Using data (International Classification of Diseases-10th edition and current procedural terminology codes) extracted from electronic health record systems, we characterized surgeon-level variations in practice (use of instrumented fusion - a more extensive procedure that involves device-related risks) and short-term postoperative outcomes (major in-hospital complications and readmissions). Next, we tested for associations between surgeon training (specialty and spine fellowship) and experience (career stage and operative volume) and use of instrumented fusion as well as outcomes. Eighty-nine surgeons performed 2481 eligible operations. For the study diagnoses, spine surgeons exhibited substantial variation in operative volume, use of instrumented fusion, and postoperative outcomes. Among surgeons above the median operative volume, use of instrumented fusion ranged from 0% to >90% for scoliosis and 9% to 100% for spondylolisthesis, while rates of major in-hospital complications ranged from 0% to 25% for scoliosis and from 0% to 14% for spondylolisthesis. For scoliosis, orthopedic surgeons were more likely than neurosurgeons to perform instrumented fusion for scoliosis [49% vs. 33%, odds ratio (OR) = 2.3, 95% confidence interval (95% CI) 1.3-4.2, P-value = .006] as were fellowship-trained surgeons (49% vs. 25%, OR = 3.0, 95% CI 1.6-5.8; P = .001). Fellowship-trained surgeons had lower readmission rates. Surgeons with higher operative volumes used instrumented fusion more often (OR = 1.1, 95% CI 1.0-1.2, P < .05 for both diagnoses) and had lower rates of major in-hospital complications (OR = 0.91, 95% CI 0.85-0.97; P = .006). Surgical practice can vary greatly for degenerative spine conditions, even within the same region and among colleagues at the same institution. Surgical specialty and subspecialty, in addition to recent operative volume, can be linked to variations in spine surgeons' practice patterns and outcomes. These findings reinforce the notion that residency and fellowship training may contribute to variation and present important opportunities to optimize surgical practice over the course of surgeons' careers. Future efforts to reduce unexplained variation in surgical practice could test interventions focused on graduate medical education. Graphical Abstract.
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Affiliation(s)
- Kanaka D Shetty
- RAND Health Care, RAND Corporation, 1776 Main Street, Santa Monica, CA 90401, USA
| | - Peggy G Chen
- RAND Health Care, RAND Corporation, 1776 Main Street, Santa Monica, CA 90401, USA
| | - Harsimran S Brara
- Kaiser Permanente, Los Angeles Medical Center, 4867 W Sunset Blvd, Los Angeles, CA 90027, USA
| | - Neel Anand
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA
| | - David L Skaggs
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA
| | | | - Nabeel S Qureshi
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA
| | - Rebecca Weir
- RAND Health Care, RAND Corporation, 1776 Main Street, Santa Monica, CA 90401, USA
| | - Karma McKelvey
- Rocky Vista University, Montana College of Osteopathic Medicine, 4130 Rocky Vista Way, Billings, Montana 59106, USA
| | - Teryl K Nuckols
- RAND Health Care, RAND Corporation, 1776 Main Street, Santa Monica, CA 90401, USA
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA
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Nilssen PK, Narendran N, Chen I, Kanim LE, Walker CT, Bae HW, Skaggs DL, Tuchman A. Risk Factors for Reoperation Following Single-Level Cervical Disc Arthroplasty as Utilized in a Representative Sample of United States Clinical Practice: A Retrospective PearlDiver Study. Global Spine J 2024:21925682241230965. [PMID: 38279691 DOI: 10.1177/21925682241230965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2024] Open
Abstract
STUDY DESIGN Retrospective Cohort. OBJECTIVES Most data regarding cervical disc arthroplasty (CDA) outcomes are from highly controlled clinical trials with strict inclusion/exclusion criteria. This study aimed to identify risk factors for CDA reoperation, in "real world" clinical practice using a national insurance claims database. METHODS The PearlDiver database was queried for patients (2010-2020) who underwent a subsequent cervical procedure following a single-level CDA. Patients with less than 2 years follow-up were excluded. Primary outcome was to evaluate risk factors for reoperation. Secondary outcome was to evaluate the types of reoperations. Risk factors were compared using descriptive statistics. Multivariate regression analyses were used to ascertain the association among risk factors and reoperation. RESULTS Of 14,202 patients who met inclusion criteria, 916 (6.5%) underwent reoperation. Patients undergoing reoperation were slightly older with higher Elixhauser Comorbidity Index (ECI) scores, however both were not risk factors for reoperation. Patients with diagnoses such as smoking, myelopathy, inflammatory disorders, spinal deformity, trauma, or a history of prior cervical surgery were at greater risk for reoperation. No association was found between the year of index surgery and reoperation risk. The most common reoperation procedure was cervical fusion. CONCLUSIONS As billed for in the United States since 2010, CDA was associated with a 6.5% reoperation rate over a mean follow-up time of 5.3 years. Smoking, myelopathy, inflammatory disorders, spinal deformity, and a history of prior cervical surgery or trauma are risk factors for reoperation following CDA. Though patients who underwent a reoperation were older, age was not found to be an independent risk factor for a subsequent procedure.
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Affiliation(s)
- Paal K Nilssen
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nakul Narendran
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ida Chen
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Linda E Kanim
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Corey T Walker
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Hyun W Bae
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - David L Skaggs
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alexander Tuchman
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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15
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Narendran N, Nilssen PK, Walker CT, Skaggs DL. New technique and case report: Robot-assisted intralaminar screw fixation of spondylolysis in an adolescent. N Am Spine Soc J 2023; 16:100284. [PMID: 38025938 PMCID: PMC10654584 DOI: 10.1016/j.xnsj.2023.100284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 12/01/2023]
Abstract
Introduction Management of spondylolysis in adolescents is generally successful with conservative management. Uncommonly, surgical fixation is necessary for refractory cases. Direct repair with intralaminar screws is one commonly utilized technique. Recently, less invasive spinal procedures are becoming viable with the enabling of technologies, including robotics. Case description A 14-year-old baseball player and surfer presented with low back pain, diagnosed by MRI as bony edema and stress fractures of the posterior spinal elements. After 18 months, the pain was unresponsive to rest, physical therapy, and bracing. There was no radicular pain or neurologic symptoms. Computed tomography (CT) revealed bilateral, chronic nonhealing pars defects at L5. He underwent outpatient, robot-assisted percutaneous intralaminar fixation with hydroxyapatite-coated screws through a 2 cm skin incision. Outcome On postoperative day 1, the patient reported relief of his preoperative pain and he was ambulating without difficulty. At 2 weeks follow-up, the patient was completely pain free and surfing. At 2 months follow-up, low-dose CT demonstrated partial incorporation of the hydroxyapatite-coated screws, and the patient returned to sports. At 6 months follow-up, the patient had no pain and was swinging his baseball bat with full force. Low-dose CT revealed complete healing of the defects with full incorporation of the hydroxyapatite-coated screws. Conclusions A novel minimally invasive robotic percutaneous approach for direct spondylolysis repair using hydroxyapatite-coated screws is a potential surgical treatment option for non-healing pars defects in adolescent patients.
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Affiliation(s)
- Nakul Narendran
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 South San Vicente Blvd, Los Angeles, CA, United States
| | - Paal K. Nilssen
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 South San Vicente Blvd, Los Angeles, CA, United States
| | - Corey T. Walker
- Department of Neurosurgery, Cedars-Sinai Medical Center, 444 South San Vicente Blvd, Los Angeles, CA, United States
| | - David L. Skaggs
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 South San Vicente Blvd, Los Angeles, CA, United States
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Farivar D, Kim TT, Sy CA, Baron EM, Nomoto EK, Walker CT, Skaggs DL. Complications Have Not Improved With Newer Generation Robots. Global Spine J 2023:21925682231216081. [PMID: 37965963 DOI: 10.1177/21925682231216081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The purpose of this study was to see whether upgrades in newer generation robots improve safety and clinical outcomes following spine surgery. METHODS All patients undergoing robotic-assisted spine surgery with the Mazor X Stealth EditionTM (Medtronic, Minneapolis, MN) from 2019 to 2022 at a combined orthopedic and neurosurgical spine service were retrospectively reviewed. Robot related complications were recorded. RESULTS 264 consecutive patients (54.1% female; age at time of surgery 63.5 ± 15.3 years) operated on by 14 surgeons were analyzed. The average number of instrumented levels with robotics was 4.2 ± 2.7, while the average number of instrumented screws with robotics was 8.3 ± 5.3. There was a nearly 50/50 split between an open and minimally invasive approach. Six patients (2.2%) had robot related complications. Three patients had temporary nerve root injuries from misplaced screws that required reoperation, one patient had a permanent motor deficit from the tap damaging the L1 and L2 nerve roots, one patient had a durotomy from a misplaced screw that required laminectomy and intra-operative repair, and one patient had a temporary sensory L5 nerve root injury from a drill. Half of these complications (3/6) were due to a reference frame error. In total, four patients (1.5%) required reoperation to fix 10 misplaced screws. CONCLUSION Despite newer generation robots, robot related complications are not decreasing. As half the robot related complications result from reference frame errors, this is an opportunity for improvement.
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Affiliation(s)
- Daniel Farivar
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Terrence T Kim
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Christopher A Sy
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eli M Baron
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Edward K Nomoto
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Corey T Walker
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - David L Skaggs
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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17
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Heyer JH, Anari JB, Baldwin KD, Mitchell SL, Flynn JM, Sankar WN, Andras LM, Skaggs DL, Smith JT, Luhmann SJ, Swarup I, Truong WH, Brooks JT, Fitzgerald R, Li Y, Cahill PJ. Rib-to-spine and rib-to-pelvis magnetically controlled growing rods: does the law of diminishing returns still apply? Spine Deform 2023; 11:1517-1527. [PMID: 37450222 DOI: 10.1007/s43390-023-00718-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 06/03/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE The Law Of Diminishing Returns (LODR) has been demonstrated for traditional growing rods, but there is conflicting data regarding the lengthening behavior of Magnetically Controlled Growing Rods (MCGR). This study examines a cohort of patients with early-onset scoliosis (EOS) with rib-to-spine or rib-to-pelvis-based MCGR implants to determine if they demonstrate the LODR, and if there are differences in lengthening behaviors between the groups. METHODS A prospectively collected multicenter EOS registry was queried for patients with MCGR with a minimum 2-year follow-up. Patients with rib-based proximal anchors and either spine- or pelvis-based distal anchors were included. Patients with non-MCGR, unilateral constructs, < 3 lengthenings, or missing > 25% datapoints were excluded. Patients were further divided into Primary-MCGR (pMCGR) and Secondary-MCGR (sMCGR). RESULTS 43 rib-to-spine and 31 rib-to-pelvis MCGR patients were included. There was no difference in pre-implantation, post-implantation and pre-definitive procedure T1-T12 height, T1-S1 height, and major Cobb angles between the groups (p > 0.05). Sub-analysis was performed on 41 pMCGR and 19 sMCGR rib-to-spine patients, and 31 pMCGR and 17 sMCGR rib-to-pelvis patients. There is a decrease in rod lengthenings achieved at subsequent lengthenings for each group: rib-to-spine pMCGR (rho = 0.979, p < 0.001), rib-to-spine sMCGR (rho = 0.855, p = 0.002), rib-to-pelvis pMCGR (rho = 0.568, p = 0.027), and rib-to-pelvis sMCGR (rho = 0.817, p = 0.007). Rib-to-spine pMCGR had diminished lengthening over time for idiopathic, neuromuscular, and syndromic patients (p < 0.05), with no differences between the groups (p > 0.05). Rib-to-pelvis pMCGR neuromuscular patients had decreased lengthening over time (p = 0.01), but syndromic patients had preserved lengthening over time (p = 0.65). CONCLUSION Rib-to-spine and rib-to-pelvis pMCGR and sMCGR demonstrate diminished ability to lengthen over subsequent lengthenings.
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Affiliation(s)
- Jessica H Heyer
- Department of Pediatric Orthopaedics, Hospital for Special Surgery, New York, NY, USA
| | - Jason B Anari
- Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Keith D Baldwin
- Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Stuart L Mitchell
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC, USA
| | - John M Flynn
- Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Wudbhav N Sankar
- Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Lindsay M Andras
- Department of Orthopaedics, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - David L Skaggs
- Department of Orthopaedics, Cedars Sinai, Los Angeles, CA, USA
| | - John T Smith
- Department of Orthopaedics, University of Utah Health, Salt Lake City, UT, USA
| | - Scott J Luhmann
- Department of Orthopaedic Surgery, Shriners Children's Pediatric Specialty Care, St. Louis, MO, USA
| | - Ishaan Swarup
- Department of Orthopaedics, UCSF Benioff Children's Hospitals, San Francisco, CA, USA
| | - Walter H Truong
- Department of Orthopaedics, Gilette Children's, St. Paul, MN, USA
| | - Jaysson T Brooks
- Department of Orthopaedics, Scottish Rite for Children, Dallas, TX, USA
| | - Ryan Fitzgerald
- Children's Orthopaedic and Scoliosis Surgery Associates, St. Petersburg, FL, USA
| | - Ying Li
- Department of Orthopaedics, Univeristy of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - Patrick J Cahill
- Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA.
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18
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Blakemore L, Garg S, Goodwin R, Gordon JE, Hahn G, Mehlman CT, Mencio G, Rathjen K, Sabatini C, Schmale G, Skaggs DL. Letter to the Editor: Grauberger et al, J Pediatr Orthop , 2020 and Sullivan et al, J Pediatr Orthop , 2020. J Pediatr Orthop 2023; 43:e828. [PMID: 37599613 DOI: 10.1097/bpo.0000000000002501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Affiliation(s)
| | | | | | | | - Gregory Hahn
- Johns Hopkins All Children's Hospital St. Petersburg, FL
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Farivar D, Illingworth KD, Lin AJ, Nigh ED, Finkel R, Skaggs DL. Subject matter predicts where top pediatric spine articles are shared: citations vs. social media. J Pediatr Orthop B 2023:01202412-990000000-00157. [PMID: 37811586 DOI: 10.1097/bpb.0000000000001132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
STUDY DESIGN Systematic review. The purpose of this study was to compare the top 25 articles on pediatric spine surgery by number of citations and Altmetric score. All published articles pertaining to pediatric spine surgery from 2010 to 2021 were assessed for: Altmetric scores, Altmetric score breakdown (e.g. Twitter, News), citation counts, and article topics. The top 25 Altmetric articles and top 25 cited articles were identified. Out of the 50 total articles, only 3 (6.0%) overlapped between the two groups. The top Altmetric articles had averages (mean ± SD) of 167 ± 130 Altmetric score and 66 ± 135 citations, while the top citation articles had averages of 22 ± 45 Altmetric score and 196 ± 114 citations. When evaluating article topics, articles on 'back pain' (36% vs. 4%; P = 0.003) and 'backpacks' (16% vs. 0%; P = 0.030) were published significantly more in the top Altmetric group, while articles on 'scoliosis' (93% vs. 36%; P < 0.001) and 'growth friendly surgery' (24% vs. 4%; P = 0.041) were published significantly more in the top citation group. The total number of citations and online mentions for both groups are presented in Table 2. The biggest differences were the top Altmetric score articles receiving greater percentages of Twitter mentions relative to overall mentions (87% vs. 57%). The most socially popular articles focused on back pain and backpacks, and the most cited articles focused on scoliosis and growth-friendly surgery. Twitter had the most mentions of all social media for both the top cited articles and the top Altmetric articles.
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Affiliation(s)
- Daniel Farivar
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California, USA
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20
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Finkel RA, Narendran N, Nilssen PK, Skaggs DL, Illingworth KD. Vertebral Artery Dissection in the Setting of Unstable Os Odontoideum: A Case Report. JBJS Case Connect 2023; 13:01709767-202312000-00054. [PMID: 38134303 DOI: 10.2106/jbjs.cc.23.00466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
CASE A healthy 5-year-old boy presented with a gradual onset of headaches and acute global right-sided weakness over 10 days. The work-up revealed unstable os odontoideum leading to multiple posterior circulation infarcts with vertebral artery dissection. He underwent antiplatelet therapy, cervical collar immobilization, and delayed occiput to C2 posterior spinal fusion and instrumentation with iliac crest autograft. At 2-year follow-up, the patient had a solid fusion mass, appropriate cervical alignment, and was without neurologic sequelae. CONCLUSION This case adds to a sparse body of literature in the management of vertebral artery dissection with vertebrobasilar insufficiency secondary to unstable os odontoideum.
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Affiliation(s)
- Ryan A Finkel
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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21
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Farivar D, Skaggs DL, Gabriel K, Illingworth KD. Breast Cancer Incidence, Mortality, and Cost in Adolescent Idiopathic Scoliosis Patients and the Role of Low Dose Biplanar Radiography. J Am Acad Orthop Surg 2023; 31:e633-e637. [PMID: 37432975 DOI: 10.5435/jaaos-d-23-00062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 05/23/2023] [Indexed: 07/13/2023] Open
Abstract
INTRODUCTION Patients with adolescent idiopathic scoliosis (AIS) are susceptible to high doses of radiation from radiographs. The purpose of this study was to examine the future cost of radiation-induced breast cancer in patients with AIS and its potential financial and mortality impact. METHODS A literature review identified articles relating radiation exposure in patients with AIS to increased risk for cancer. Based on population statistics and breast cancer treatment costs in the year 2020, the financial impact of radiation-induced breast cancer and the estimated number of additional deaths per year due to breast cancer for patients with AIS were calculated. RESULTS The US female population in 1970 was 205.1 million. Based on a prevalence of 3.0%, an estimated 3.1 million patients had AIS in 1970. With an incidence of breast cancer in the general population of 128.3/100,000 and a standardized incidence ratio of 1.82-2.4 for breast cancer in patients with scoliosis, there will be a 3,282 to 5,603 patient increase in radiation-induced breast cancer in patients with scoliosis over the general population. With a projected base cost of $34,979 per patient for the first year of breast cancer diagnosis in 2020, the cost of radiation-induced breast cancer will be 114.8 to 196.0 million dollars per year. Using a standardized mortality ratio of 1.68 for scoliosis radiation-induced breast cancer, there will be an expected increase in deaths of 420 patients due to breast cancer presumably secondary to radiation exposure in the evaluation and treatment of AIS. CONCLUSION The estimated radiation-induced breast cancer financial impact in 2020 will be between 114.8 and 196.0 million dollars per year, with an increase in deaths of 420 patients per year. Low-dose imaging systems reduce radiation exposure by up to 45 times while maintaining sufficient image quality. New low-dose radiography should be used whenever possible with patients with AIS. LEVEL OF EVIDENCE Level 5.
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Affiliation(s)
- Daniel Farivar
- From the Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, CA (Farivar, Skaggs, and Illingworth), and the Division of Orthopaedic Surgery, Southern Illinois University School of Medicine, Springfield, IL (Gabriel)
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22
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Prior A, Hardesty CK, Emans JB, Thompson GH, Sponseller PD, Smith JT, Skaggs DL, Vaughan M, Barfield WR, Murphy RF. A Comparative Analysis of Revision Surgery Before or After 2 Years After Graduation From Growth-friendly Surgery for Early Onset Scoliosis. J Pediatr Orthop 2023:01241398-990000000-00320. [PMID: 37400093 DOI: 10.1097/bpo.0000000000002467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
INTRODUCTION After discontinuation of growth-friendly (GF) surgery for early onset scoliosis, patients are termed graduates: they undergo a spinal fusion, are observed after final lengthening with GF implant maintenance, or are observed after GF implant removal. The purpose of this study was to compare the rates of and reasons for revision surgery in two cohorts of GF graduates: before or after 2 years of follow-up from graduation. METHODS A pediatric spine registry was queried for patients who underwent GF spine surgery with a minimum of 2 years of follow-ups after graduation by clinical and/or radiographic evidence. Scoliosis etiology, graduation strategy, number of, and reasons for revision surgery were queried. RESULTS There were 834 patients with a minimum of 2-year follow-up after graduation who were analyzed. There were 241 (29%) congenital, 271 (33%) neuromuscular, 168 (20%) syndromic, and 154 (18%) idiopathic. 803 (96%) had traditional growing rod/vertical expandable titanium rib as their GF construct and 31 (4%) had magnetically controlled growing rod. Five hundred ninety-six patients (71%) underwent spinal fusion at graduation, 208 (25%) had GF implants retained, and 30 (4%) had GF implants removed.In the entire cohort, there were 108/834 (13%) patients who underwent revision surgery. Of the revisions, 71/108 (66%) occurred as acute revisions (ARs) between 0 and 2 years from graduation (mean 0.6 y), and the most common AR indication was infection (26/71, 37%). The remaining 37/108 (34%) patients underwent delayed revision (DR) surgery >2 years (mean 3.8 y) from graduation, and the most common DR indication was implant issues (17/37, 46%).Graduation strategy affected revision rates. Of the 596 patients with spinal fusion as a graduation strategy, 98/596 (16%) underwent revision, compared with only 8/208 (4%) patients who had their GF implants retained, and 2/30 (7%) that had their GF implants removed (P ≤ 0.001).A significantly higher percentage of the ARs had a spinal fusion as the graduation strategy (68/71, 96%) compared with 30/37 DRs, (81%, P = 0.015). In addition, the 71 patients who underwent AR undergo more revision surgeries (mean: 2, range: 1 to 7) than 37 patients who underwent DR (mean: 1, range: 1 to 2) (P = 0.001). CONCLUSION In this largest reported series of GF graduates to date, the overall risk of revision was 13%. Patients who undergo a revision at any time, as well as ARs in particular, are more likely to have a spinal fusion as their graduation strategy. Patients who underwent AR, on average, undergo more revision surgeries than patients who underwent DR. LEVEL OF EVIDENCE Level III, comparative.
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Affiliation(s)
- Anjali Prior
- Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston SC
| | | | | | | | | | | | | | | | - William R Barfield
- Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston SC
| | - Robert F Murphy
- Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston SC
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Farivar D, Parent S, Miyanji F, Heffernan MJ, El-Hawary R, Larson AN, Andras LM, Skaggs DL. Concave and convex growth do not differ over tethered vertebral segments, even with open tri-radiate cartilage. Spine Deform 2023; 11:881-886. [PMID: 37004694 PMCID: PMC10261211 DOI: 10.1007/s43390-023-00683-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/18/2023] [Indexed: 04/04/2023]
Abstract
PURPOSE To assess the following hypotheses related to vertebral body tethering (VBT): 1. VBT is associated with asymmetric (concave > convex) increases in height over the instrumented vertebra. 2. The instrumented Cobb angle improves following VBT surgery with growth. METHODS This is a retrospective case series of pediatric patients from a multicenter scoliosis registry treated with VBT between 2013 to 2021. INCLUSION CRITERIA patients with standing radiographs at < 4 months and ≥ 2 years after surgery. Distances between the superior endplate of the UIV and the inferior endplate of the LIV were measured at the concave corner, mid-point, and convex corner of the endplates. The UIV-LIV angle was recorded. Subgroup analyses included comparing different Risser scores and tri-radiate cartilage (TRC) closed versus open using student t-tests. RESULTS 83 patients met inclusion criteria (92% female; age at time of surgery 12.5 ± 1.4 years) with mean follow-up time of 3.8 ± 1.4 years. Risser scores at surgery were: 0 (n = 33), 1 (n = 12), 2 (n = 10), 3 (n = 11), 4 (n = 12), and 5 (n = 5). Of the 33 Risser 0 patients, 17 had an open TRC, 16 had a closed TRC. The UIV-LIV distance at concave, middle, and convex points significantly increased from immediate post-op to final-follow-up for Risser 0 patients, but not for Risser 1-5 patients. Increases in UIV-LIV distance were not significantly different between concave, middle, and convex points for all groups. There was no significant improvement or worsening in UIV-LIV angle for any group. CONCLUSION At a mean of 3.8 years following VBT, 33 Risser 0 patients demonstrated significant growth in the instrumented segment, though there was no difference between concave or convex growth, even for patients with open TRC.
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Affiliation(s)
- Daniel Farivar
- Cedars-Sinai Spine, 444 S San Vicente Blvd, Ste 901, Los Angeles, CA, 90048, USA
| | - Stefan Parent
- Department of Surgery, Université de Montréal, Montreal, QC, Canada
| | - Firoz Miyanji
- Department of Orthopedics, BC Children's Hospital, Vancouver, BC, Canada
| | - Michael J Heffernan
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Ron El-Hawary
- Orthopedics, Izaak Walton Killam (IWK) Health Centre, Halifax, Canada
| | - A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Lindsay M Andras
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - David L Skaggs
- Cedars-Sinai Spine, 444 S San Vicente Blvd, Ste 901, Los Angeles, CA, 90048, USA.
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Illingworth KD, Siddiqui AA, Skaggs DL, Andras LM. Deformity angular ratio is associated with neuromonitoring changes without a vertebral column resection: spinal deformity is more influential than type of surgery. Spine Deform 2023; 11:951-956. [PMID: 36930440 PMCID: PMC10261247 DOI: 10.1007/s43390-023-00669-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 02/18/2023] [Indexed: 03/18/2023]
Abstract
PURPOSE The purpose of this study is to investigate the effect of the deformity angular ratio (DAR) on intra-operative neuromonitoring (IONM) signal changes during posterior spinal fusion (PSF) without vertebral column resection (VCR). METHODS Retrospective review of severe pediatric spinal deformity patients treated with PSF without VCR or three-column osteotomy from 2008 to 2018. Exclusion criteria were prior instrumentation, lack of IONM, and incomplete radiographic data. Coronal DAR (C-DAR), sagittal DAR (S-DAR), and total DAR (T-DAR) were calculated and compared between patients with IONM signal loss and those without. RESULTS Two hundred and fifty-three patients met inclusion criteria. Forty-seven of two hundred and fifty-three (19%) patients had IONM signal loss. Intra-operative wake-up test was performed in seven cases; three of seven (43%) had a neurological deficit on wake-up test. All neurological deficits resolved at a mean of 41 days postop. IONM loss was associated with increased kyphosis (p = 0.003) and was not associated with Cobb angle (p = 0.16). S-DAR (p = 0.03) and T-DAR (p = 0.005) were associated with IONM signal loss but C-DAR was not (p = 0.06). Increased incidence of IONM signal loss was seen with S-DAR > 7 (p = 0.02) or T-DAR > 27 (p = 0.02). Twenty-four of ninety-two (26%) patients with S-DAR > 7 had IONM signal loss compared to twenty-three of one hundred and sixty-one (14%) with S-DAR ≤ 7 (OR, 2.1; 95% CI, 1.1-4.0). Seven of sixteen (44%) patients with T-DAR > 27 had signal loss compared to forty of two hundred and thirty-seven (17%) patients with T-DAR ≤ 27 (OR, 3.8; 95% CI, 1.3-10.9). CONCLUSION Patients with S-DAR > 7 or T-DAR > 27 have a higher risk of IONM loss during pediatric PSF even in the absence of a VCR or three-column osteotomies. LEVEL OF EVIDENCE II
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Affiliation(s)
| | - Ali A Siddiqui
- Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA, 90027, USA
- Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
- University of FL College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - David L Skaggs
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Lindsay M Andras
- Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA, 90027, USA.
- Keck School of Medicine of University of Southern California, Los Angeles, CA, USA.
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25
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Nielsen E, Andras LM, Sanders JO, Brown M, Noble K, Skaggs DL. Physician collections are 71% less for early onset scoliosis casting than for growing rod instrumentation: A retrospective cohort study. Medicine (Baltimore) 2023; 102:e33312. [PMID: 37000094 PMCID: PMC10063290 DOI: 10.1097/md.0000000000033312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 04/01/2023] Open
Abstract
Growing rod (GR) instrumentation and the elongation, derotation, and flexion (EDF) casting technique are 2 alternatives for the treatment of early-onset scoliosis. Our purpose was to investigate the cost of these treatment options. This was a retrospective cohort study of patients with early-onset scoliosis treated at 2 institutions from 2007 to 2014 with either GR instrumentation or EDF casting. Patients with <2 years of follow-up were excluded. Physician and hospital charges and collections, total procedures, and procedure times until final follow-up or time of fusion were compared. Nineteen patients met the inclusion criteria; 8 in the GR group and 11 in the EDF casting group. There were no significant differences between the groups in age (P = .23), public versus private insurance (P = 1.0), or major curve (P = .21) at the initiation of treatment. Excluding final fusion, the EDF casting patients had an average of 2.1 (range: 0.7-6.6) procedures/year while the GR patients had an average of 1.5 (range: 0.8-2.7) procedures/year. The average procedure time for the EDF group was 104.2 minutes; the average procedure time for the GR group, excluding the index procedure, was 62.40 minutes (P = .001). Physician charges were 85% less for the EDF group (EDF= $1892.75, GR= $12,354.53, P < .001). Physician collections were 71% less for the EDF group (EDF= $731.10, GR= $2554.88, P = .001). Hospital charges and collections were similar between the groups (P = .82, P = .42). Physician charges for casting were approximately 18% of that of GRs. Compared to GRs, physician collections were 71% less for EDF casting patients per year.
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Affiliation(s)
- Ena Nielsen
- Children’s Orthopedic Center, Children’s Hospital Los Angeles, CA
| | | | | | | | - Krista Noble
- University of Rochester Medical Center, Rochester, NY
| | - David L. Skaggs
- Children’s Orthopedic Center, Children’s Hospital Los Angeles, CA
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26
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CreveCoeur TS, Alexiades NG, Bonfield CM, Brockmeyer DL, Browd SR, Chu J, Figaji AA, Groves ML, Hankinson TC, Harter DH, Hwang SW, Jea A, Kernie SG, Leonard JR, Martin JE, Oetgen ME, Powers AK, Rozzelle CJ, Skaggs DL, Strahle JM, Wellons JC, Vitale MG, Anderson RCE. Building consensus for the medical management of children with moderate and severe acute spinal cord injury: a modified Delphi study. J Neurosurg Spine 2023:1-14. [PMID: 36933257 DOI: 10.3171/2023.1.spine221188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/31/2023] [Indexed: 03/19/2023]
Abstract
OBJECTIVE The focus of this modified Delphi study was to investigate and build consensus regarding the medical management of children with moderate and severe acute spinal cord injury (SCI) during their initial inpatient hospitalization. This impetus for the study was based on the AANS/CNS guidelines for pediatric SCI published in 2013, which indicated that there was no consensus provided in the literature describing the medical management of pediatric patients with SCIs. METHODS An international, multidisciplinary group of 19 physicians, including pediatric neurosurgeons, orthopedic surgeons, and intensivists, were asked to participate. The authors chose to include both complete and incomplete injuries with traumatic as well as iatrogenic etiologies (e.g., spinal deformity surgery, spinal traction, intradural spinal surgery, etc.) due to the overall low incidence of pediatric SCI, potentially similar pathophysiology, and scarce literature exploring whether different etiologies of SCI should be managed differently. An initial survey of current practices was administered, and based on the responses, a follow-up survey of potential consensus statements was distributed. Consensus was defined as ≥ 80% of participants reaching agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). A final meeting was held virtually to generate final consensus statements. RESULTS Following the final Delphi round, 35 statements reached consensus after modification and consolidation of previous statements. Statements were categorized into the following eight sections: inpatient care unit, spinal immobilization, pharmacological management, cardiopulmonary management, venous thromboembolism prophylaxis, genitourinary management, gastrointestinal/nutritional management, and pressure ulcer prophylaxis. All participants stated that they would be willing or somewhat willing to change their practices based on consensus guidelines. CONCLUSIONS General management strategies were similar for both iatrogenic (e.g., spinal deformity, traction, etc.) and traumatic SCIs. Steroids were recommended only for injury after intradural surgery, not after acute traumatic or iatrogenic extradural surgery. Consensus was reached that mean arterial pressure ranges are preferred for blood pressure targets following SCI, with goals between 80 and 90 mm Hg for children at least 6 years of age. Further multicenter study of steroid use following acute neuromonitoring changes was recommended.
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Affiliation(s)
| | - Nikita G Alexiades
- 2Department of Neurological Surgery, University of Arizona-Phoenix, Arizona
| | | | - Douglas L Brockmeyer
- 4Department of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Samuel R Browd
- 5Department of Neurosurgery, University of Washington/Seattle Children's Hospital, Seattle, Washington
| | - Jason Chu
- 6Department of Neurosurgery, Children's Hospital of Los Angeles, California
| | - Anthony A Figaji
- 7Department of Neurosurgery, University of Cape Town, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Mari L Groves
- 8Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Todd C Hankinson
- 9Department of Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - David H Harter
- 10Department of Neurosurgery, New York University, New York, New York
| | - Steven W Hwang
- 11Shriners Hospital for Children, Philadelphia, Pennsylvania
| | - Andrew Jea
- 12Department of Neurological Surgery, University of Oklahoma, Oklahoma City, Oklahoma
| | - Steven G Kernie
- 13Department of Pediatrics, Columbia University, New York, New York
| | - Jeffrey R Leonard
- 14Department of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Jonathan E Martin
- 15Department of Pediatric Neurosurgery, Connecticut Children's Hospital, Hartford, Connecticut
| | - Matthew E Oetgen
- 16Department of Orthopedic Surgery, Children's National Hospital, Washington, DC
| | - Alexander K Powers
- 17Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina
| | - Curtis J Rozzelle
- 18Department of Pediatric Neurosurgery, University of Alabama, Birmingham, Alabama
| | - David L Skaggs
- 19Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Jennifer M Strahle
- 20Department of Neurosurgery, Washington University in St. Louis, Missouri
| | - John C Wellons
- 3Department of Neurological Surgery, Vanderbilt University, Nashville, Tennessee
| | - Michael G Vitale
- 21Orthopedic Surgery, Columbia University Medical Center, New York, New York
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27
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Badin D, Gupta A, Skaggs DL, Sponseller PD. Temporary internal distraction for severe scoliosis: two-year minimum follow-up. Spine Deform 2023; 11:341-350. [PMID: 36264539 DOI: 10.1007/s43390-022-00602-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 10/08/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Temporary internal distraction (TID) is a surgical technique used to correct severe scoliosis. We sought to evaluate the long-term outcomes associated with temporary internal distraction (TID) for severe scoliosis. METHODS Scoliosis patients who underwent TID from 2006 to 2019 at a single institution were identified. Patients with coronal Cobb angles ≥ 90° or congenital scoliosis, and ≥ 2-year follow-up were included. Clinical and imaging data were reviewed for patient and operative characteristics and complications. Patient-reported outcomes were also analyzed. RESULTS 51 patients (37 female) were included. Mean age at surgery was 14.3 ± 3.5 years. Mean follow-up was 5.8 ± 3.0 years. Eighteen (35%) curves were idiopathic, 24 (47%) were cerebral palsy (CP) related, and 9 (18%) were congenital. Mean Cobb angle was 103° preoperatively and 20° at final follow-up, with an intermediate angle of 55º in staged procedures. Intraoperative neuromonitoring changes occurred in 13 (25.4%) cases, but all returned to baseline with immediate lessening of distraction. Overall, three (5.8%) cases of wound dehiscence, five (9.7%) cases of deep infections, one (2%) case of screw protrusion, and one (2%) case of delayed extremity weakness occurred. Patient-reported outcomes significantly improved at final follow-up. CONCLUSION Our findings suggest that TID is a valuable adjunct for correcting severe scoliosis. The mean Cobb reduction achieved (81%) was higher than that reported for halo-traction and was sustained over long-term follow-up. TID also allowed a shorter a hospital stay. While intraoperative neuromonitoring changes were not uncommon, they were reversible. However, care must always be exercised as major corrections may rarely result in delayed neurologic deficits despite intact neuromonitoring. LEVEL OF EVIDENCE Therapeutic-Level III.
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Affiliation(s)
- Daniel Badin
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, 1800 Orleans St., Baltimore, MD, 21287, USA.
| | - Arjun Gupta
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, 1800 Orleans St., Baltimore, MD, 21287, USA
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - David L Skaggs
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, 1800 Orleans St., Baltimore, MD, 21287, USA
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28
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Compton E, Illingworth KD, Stephan S, Skaggs DL, Andras LM. Rate and risk factors for pediatric cervical spine fusion pseudarthrosis: opportunity for improvement. Spine Deform 2023; 11:627-633. [PMID: 36745301 PMCID: PMC10147783 DOI: 10.1007/s43390-023-00641-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 12/31/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE Although the pediatric population typically has a high union rate, the cervical spine has a reputation for frequent pseduarthrosis, as high as 38% in some prior series. Our purpose was to examine the rate and risk factors for pseudarthrosis in pediatric cervical spine fusions. METHODS Retrospective review of all patients with ≥ 2 years follow-up undergoing cervical spinal fusion between January 2004 and December 2019 at a tertiary pediatric hospital. Pseudarthrosis was defined as an absence of radiographic union as assessed by the attending surgeon for which revision surgery was performed. RESULTS 64 patients (mean age: 8.4 ± 4.7 years) met inclusion criteria. Mean follow-up was 63.3 ± 41.4 months (range: 24-187 months). 28 fusions (44%) included the occiput. 41 patients (64%) had instrumentation, while 23 patients (36%) had uninstrumented fusions. 48 (75%) patients had a halo for a mean of 97.6 ± 49.5 days. The incidence of pseudarthrosis was as follows: overall = 8/64 (12.5%); posterior fusion = 14.8% (8/54); anterior fusions = 0% (0/4); and anteroposterior fusions = 0% (0/6). The rate of pseudarthrosis was over 8 times higher in fusions involving the occiput (occipitocervical fusion: 25.0%; 7/28 vs. cervical alone: 2.8%; 1/36; p = 0.02). Although not statistically significant, the rate of pseudarthrosis was 3 times higher in uninstrumented fusions (21.7%; 5/23) than instrumented fusions (7.3%; 3/41) (p = 0.12). In patients with uninstrumented fusion to the occiput, pseudarthrosis rate was 35.7% (5/14), which was higher compared to those who did not (6.0%; 3/50) (p = 0.01). Incidence of pseudarthrosis was similar in patients who received autograft (13.0%; 7/54) compared to allograft alone (10.0%; 1/10) (p > 0.999). CONCLUSIONS The pseudarthrosis rate in pediatric cervical spine fusions remained high despite frequent use of halo immobilization and autograft. Patients with uninstrumented occipitocervical fusions are at particularly high risk with more than 1 in 3 developing a pseudarthrosis. STUDY DESIGN Retrospective, Comparative. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Edward Compton
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS #69, Los Angeles, CA, 90027, USA
| | - Kenneth D Illingworth
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS #69, Los Angeles, CA, 90027, USA
| | | | | | - Lindsay M Andras
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS #69, Los Angeles, CA, 90027, USA.
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Jalloh H, Andras LM, Sanders A, Iantorno S, Hamilton A, Choi PD, Skaggs DL. Adolescent idiopathic scoliosis patients treated with bracing, surgery, or observation showed no difference in behavioral and emotional function over a 2-year period. Medicine (Baltimore) 2023; 102:e32610. [PMID: 36701729 PMCID: PMC9857555 DOI: 10.1097/md.0000000000032610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
The purpose of this study was to assess if behavior and emotional function, as measured by the Pearson Behavioral Assessment Survey for Children, Second Edition (BASC-2) in patients and parents, changes with differing treatment protocols in patients with adolescent idiopathic scoliosis (AIS). One previous study showed abnormal BASC-2 scores in a substantial number of patients diagnosed with AIS; however, no study has assessed how these scores change over the course of treatment. AIS patients aged 12 to 21 years completed the BASC-2. The 176-item questionnaire was administered to subjects at enrollment, assessing behavioral and emotional problems across 16 subscales of 5 domains: school problems, internalizing problems, inattention/hyperactivity, emotional symptoms index, and personal adjustment. Parents were given an equivalent assessment survey. Surveys were administered again after 2 years. Subject treatment groups (bracing, surgery, and observation) were established at enrollment. Patients were excluded if they did not complete the BASC-2 at both time points. Forty-six patients met the inclusion criteria, with 13 patients in the surgical, 20 in the bracing, and 13 in the observation treatment groups. At enrollment, 26% (12/46) of subjects with AIS had a clinically significant score in 1 or more subscales, and after 2 years 24% (11/46) of subjects reported a clinically significant score in at least 1 subscale (P = .8). There were no significant differences in scores between enrollment and follow-up in any treatment group. Similar to what was reported in a previous study, only 36% (4/11) of patients had clinically significant scores reported by both patient and parent, conversely 64% (7/11) of parents were unaware of their child's clinically significant behavioral and emotional problems. Common patient-reported subscales for clinically significant and at-risk scores at enrollment included anxiety (24%; 11/46), hyperactivity (24%; 11/46), attention problems (17%; 8/46), and self-esteem (17%; 8/46). At 2-year follow-up, the most commonly reported subscales were anxiety (28%; 13/46), somatization (20%; 9/46), and self-esteem (30%; 14/46). Patients with AIS, whether observed, braced or treated surgically, showed no significant change in behavior and emotional distress over the course of their treatment, or compared with each other at 2-year follow-up.
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Affiliation(s)
- Hulaimatu Jalloh
- Jackie and Gene Autry Orthopedic Center, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Lindsay M. Andras
- Jackie and Gene Autry Orthopedic Center, Children’s Hospital Los Angeles, Los Angeles, CA
- * Correspondence: Lindsay M. Andras, Jackie and Gene Autry Orthopedic Center, Children’s Hospital Los Angeles, 4650 Sunset Blvd, MS #69, Los Angeles, CA 90027 (e-mail: )
| | - Austin Sanders
- Jackie and Gene Autry Orthopedic Center, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Stephanie Iantorno
- Jackie and Gene Autry Orthopedic Center, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Anita Hamilton
- Jackie and Gene Autry Orthopedic Center, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Paul D. Choi
- Jackie and Gene Autry Orthopedic Center, Children’s Hospital Los Angeles, Los Angeles, CA
| | - David L. Skaggs
- Jackie and Gene Autry Orthopedic Center, Children’s Hospital Los Angeles, Los Angeles, CA
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30
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Matsumoto H, Fano AN, Quan T, Akbarnia BA, Blakemore LC, Flynn JM, Skaggs DL, Smith JT, Snyder BD, Sponseller PD, McCarthy RE, Sturm PF, Roye DP, Emans JB, Vitale MG. Correction: Re-evaluating consensus and uncertainty among treatment options for early onset scoliosis: a 10-year update. Spine Deform 2023; 11:263. [PMID: 36171501 DOI: 10.1007/s43390-022-00596-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Hiroko Matsumoto
- Department of Orthopedics and Sports Medicine, Boston Children's Hospital, Boston, MA, 02115, USA. .,Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, 02115, USA.
| | - Adam N Fano
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, NY, 10032, New York, USA
| | - Theodore Quan
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, NY, 10032, New York, USA
| | - Behrooz A Akbarnia
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, 92037, USA
| | | | - John M Flynn
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - David L Skaggs
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - John T Smith
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, 84113, USA
| | - Brian D Snyder
- Department of Orthopedics and Sports Medicine, Boston Children's Hospital, Boston, MA, 02115, USA.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, 02115, USA
| | - Paul D Sponseller
- Division of Pediatric Orthopaedics, Johns Hopkins University, Baltimore, MD, 21287, USA
| | - Richard E McCarthy
- Department of Orthopaedics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, 72205, USA
| | - Peter F Sturm
- Department of Orthopedic Surgery, Cincinnati Children's Hospital, Cincinnati, OH, 45229, USA
| | - David P Roye
- Department of Orthopedics and Sports Medicine, Boston Children's Hospital, Boston, MA, 02115, USA.,Division of Pediatric Orthopaedic Surgery, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - John B Emans
- Department of Orthopedics and Sports Medicine, Boston Children's Hospital, Boston, MA, 02115, USA.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, 02115, USA
| | - Michael G Vitale
- Department of Orthopedics and Sports Medicine, Boston Children's Hospital, Boston, MA, 02115, USA.,Division of Pediatric Orthopaedic Surgery, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY, 10032, USA
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Matsumoto H, Fano AN, Quan T, Akbarnia BA, Blakemore LC, Flynn JM, Skaggs DL, Smith JT, Snyder BD, Sponseller PD, McCarthy RE, Sturm PF, Roye DP, Emans JB, Vitale MG. Re-evaluating consensus and uncertainty among treatment options for early onset scoliosis: a 10-year update. Spine Deform 2023; 11:11-25. [PMID: 35947359 DOI: 10.1007/s43390-022-00561-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/23/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Consensus and uncertainty in early onset scoliosis (EOS) treatment were evaluated in 2010. It is currently unknown how treatment preferences have evolved over the past decade. The purpose of this study was to re-evaluate consensus and uncertainty among treatment options for EOS patients to understand how they compare to 10 years ago. METHODS 11 pediatric spinal surgeons (similar participants as in 2010) were invited to complete a survey of 315 idiopathic and neuromuscular EOS cases (same cases as in 2010). Treatment options included the following: conservative management, distraction-based methods, growth guidance/modulation, and arthrodesis. Consensus was defined as ≥ 70% agreement, and uncertainty was < 70%. Associations between case characteristics and consensus for treatments were assessed via chi-squared and multiple regression analyses. Case characteristics associated with uncertainty were described. RESULTS Eleven surgeons [31.7 ± 7.8 years of experience] in the original 2010 cohort completed the survey. Consensus for conservative management was found in idiopathic patients aged ≤ 3, whereas in 2010, some of these cases were selected for surgery. There is currently consensus for casting idiopathic patients aged 1 or 2 with moderate curves, whereas in 2010, there was uncertainty between casting and bracing. Among neuromuscular cases with consensus for surgery, arthrodesis was chosen for patients aged 9 with larger curves. CONCLUSION Presently, preferences for conservative management have increased in comparison to 2010, and casting appears to be preferred over bracing in select infantile cases. Future research efforts with higher levels-of-evidence should be devoted to elucidate the areas of uncertainty to improve care in the EOS population. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Hiroko Matsumoto
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA, 02115, USA.
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, 02115, USA.
| | - Adam N Fano
- Department of Orthopedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Irving Medical Center, 3959 Broadway, CHONY 8-N, New York, NY, 10032, USA
| | - Theodore Quan
- Department of Orthopedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Irving Medical Center, 3959 Broadway, CHONY 8-N, New York, NY, 10032, USA
| | - Behrooz A Akbarnia
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, 92037, USA
| | | | - John M Flynn
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - David L Skaggs
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - John T Smith
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, 84113, USA
| | - Brian D Snyder
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA, 02115, USA
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, 02115, USA
| | - Paul D Sponseller
- Division of Pediatric Orthopaedics, Johns Hopkins University, Baltimore, MD, 21287, USA
| | - Richard E McCarthy
- Department of Orthopaedics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, 72205, USA
| | - Peter F Sturm
- Department of Orthopedic Surgery, Cincinnati Children's Hospital, Cincinnati, OH, 45229, USA
| | - David P Roye
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA, 02115, USA
- Division of Pediatric Orthopaedic Surgery, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - John B Emans
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA, 02115, USA
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, 02115, USA
| | - Michael G Vitale
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA, 02115, USA
- Division of Pediatric Orthopaedic Surgery, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY, 10032, USA
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32
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Fraser HG, Krakow A, Lin A, Harris H, Andras LA, Skaggs DL, Flynn JM, Fletcher ND. Outcomes of Posterior Spinal Fusion in Pediatric Patients with Down Syndrome. J Bone Joint Surg Am 2022; 104:2068-2073. [PMID: 36166508 DOI: 10.2106/jbjs.22.00588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Trisomy 21 or Down syndrome is associated with multiple orthopaedic manifestations. Although cervical instability is the most common spinal condition associated with Down syndrome, the prevalence of scoliosis has been estimated at 4.8% to 8.7%. Very few prior studies have documented the role of spinal fusion in this population, and all have included ≤10 patients. METHODS An institutional review board-approved multicenter retrospective analysis of patients with Down syndrome treated with spinal fusion between January 2009 and December 2019 was performed by cross-referencing Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth and Tenth Revisions (ICD-9 and ICD-10) codes. Patients were followed for ≥2 years, with a mean follow-up of 3.77 years. Clinical and radiographic outcomes were collected, and complications were documented using the Clavien-Dindo-Sink (CDS) classification. RESULTS A total of 23 patients were included: 96% had ≥1 medical comorbidities, including 16 (70%) with congenital heart disease, of whom 88% had previous cardiac surgery, and 10 (44%) with thyroid disorders. All 23 patients underwent posterior spinal fusion. The mean estimated blood loss was 617 ± 459 mL, the mean length of the surgical procedure was 290 ± 92.7 minutes, and the mean length of hospital stay was 6.03 ± 2.91 days. The major Cobb angle measured 61.7° ± 17.6°, which corrected to 19.4° ± 14.8° (68.6% correction; p < 0.001), with well-maintained correction at 2 years of 22.0° ± 10.3° (64.3% correction; p = 0.158). Thirteen (57%) of 23 patients had a change in curve of >5°. There were no intraoperative complications; however, 12 patients (52%) sustained postoperative complications (e.g., need for reoperation, implant failure, and pulmonary complications), including 6 patients with CDS type 3 or 4 (e.g., wound dehiscence, late superficial abscess, pleural effusion, pseudarthrosis, and readmission for hypoxia). Four patients (17%) required a revision surgical procedure. One patient (4%) required an unplanned intensive care unit admission. CONCLUSIONS Although instrumented spinal fusion can effectively correct spinal deformity in these patients, complications are more frequent than in children with adolescent idiopathic scoliosis, with over half of patients sustaining a complication. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Helyn G Fraser
- Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - Arielle Krakow
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Adrian Lin
- Children's Hospital of Los Angeles, Los Angeles, California
| | - Hilary Harris
- Department of Orthopaedics, Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - David L Skaggs
- Children's Hospital of Los Angeles, Los Angeles, California
| | - John M Flynn
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nicholas D Fletcher
- Department of Orthopaedics, Children's Healthcare of Atlanta, Atlanta, Georgia
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Skaggs KF, Stephan S, Perry TG, Skaggs DL. Adjacent Segment Impingement: A New Type of Adjacent Segment Disease?: A Report of 3 Cases. JBJS Case Connect 2022; 12:01709767-202212000-00037. [PMID: 36862103 DOI: 10.2106/jbjs.cc.22.00364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
CASE We present 3 cases in which spinal rods extending beyond the intended level of fusion caused injury to adjacent structures, which we term "adjacent segment impingement." All cases presented as back pain with no neurological symptoms, with a minimum 6 years of follow-up from the initial procedure. Treatment consisted of extending the fusion to include the affected adjacent segment. CONCLUSION We recommend surgeons check to ensure spinal rods are not abutting adjacent level structures at the time of the initial implant while considering that adjacent levels may move closer to the rod during spine extension or twisting.
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Affiliation(s)
- Kira F Skaggs
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Stephen Stephan
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Tiffany G Perry
- Department of Neurosurgery Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - David L Skaggs
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
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Badin D, Skaggs DL, Sponseller PD. Temporary Internal Distraction for Severe Scoliosis. JBJS Essent Surg Tech 2022; 12:e22.00006. [PMID: 36816523 PMCID: PMC9931036 DOI: 10.2106/jbjs.st.22.00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Temporary internal distraction (TID) is a surgical technique that can be utilized to correct severe scoliotic deformities. It allows the correction of severe curves (i.e., exceeding 90° to 100°) while minimizing the risk of neurologic injury associated with large corrections1,2. Description TID can be performed as a single or staged procedure. During the first part, cephalad anchors are placed on the spine or ribs, and caudad anchors are placed on the spine or pelvis. Temporary distraction rods are inserted, osteotomies and/or releases are performed, and iterative distractions are utilized for the duration of the procedure. If adequate correction is achieved, the final fusion may be completed at this time. If not, a staged approach may be performed: the wound is closed and the patient is returned to the operating room 1 to 3 weeks later, at which time the temporary rods are removed, further distraction is performed, and the final fusion instrumentation is placed. Around 80% to 90% cumulative correction of the major coronal angle should be achievable. Alternatives The mainstay of treatment for large scoliotic curves is typically surgical correction and fusion. The main alternative to TID is traditional halo-gravity traction followed by fusion3-5. In rare cases, nonoperative treatment may be appropriate if comorbidities and/or prognoses that preclude surgery exist. Rationale Halo traction is an effective adjunct for the treatment of large scoliotic curves; nonetheless, it has several disadvantages. First, halo traction requires a prolonged hospital stay with restriction of mobility and interference with daily activities. Second, this procedure may be less effective in cases of lumbar deformity, in which halo traction achieves limited tensile forces. Third, this procedure is associated with several risks, such as cranial nerve injuries and pin track complications3-6. Finally, halo traction is contraindicated for certain conditions, such as cervical instability.TID, on the other hand, involves the application of iterative corrective forces directly to the area of deformity, allowing a stronger correction1. TID takes advantage of the viscoelastic nature of the spine to achieve a higher percent correction compared with halo traction, with a low risk of neurologic injury1,2. TID also avoids the prolonged hospital stay, mobility restriction, and complications associated with halo traction. When performed as a staged procedure, TID allows accurate assessment of neurologic function with the patient awake and moving.TID is most effective for severe scoliotic multisegment deformities rather than short rigid curves, which are better treated by osteotomies. Expected Outcomes This procedure provides satisfactory outcomes and a low risk of complications. In our retrospective case series, TID resulted in a mean major coronal angle correction of 53% after the first distraction and 80% to 90% after definitive fusion1. The overall percent correction was higher than that reported for halo traction1.The major risks of TID include infection and spinal injury. The risk of infection is decreased by antibiotic prophylaxis, perioperative nutritional optimization, and careful soft-tissue handling and wound closure. The risk of spinal cord injury is decreased by intraoperative neuromonitoring. Neuromonitoring changes occur in around 40% of cases, but these are almost always reversible and seldom lead to neurologic deficits if detected and appropriately treated, as described below2.Although risks exist, no complications have occurred among the 32 cases we presented in our series1,2. Important Tips Temporary anchors should be expected to loosen during distraction. Therefore, temporary anchors must be placed strategically so as to not jeopardize the purchase of the final implants.Gradual corrections must be performed over time, utilizing the viscoelastic nature of the spine to minimize risk of neurologic injury.Accurate neuromonitoring is essential for this procedure.If neuromonitoring changes occur, distraction must be stopped and the correction attained must be decreased. Acronyms and Abbreviations TID = temporary internal distractionLIV = lowest instrumented vertebraAP = anteroposteriorTP = transverse processSAI = sacral-alar-iliacMAP = mean arterial pressureTPN = total parenteral nutritionVCR = vertebral column resectionJIS = juvenile idiopathic scoliosisAIS = adolescent idiopathic scoliosis.
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Affiliation(s)
- Daniel Badin
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland
| | - David L. Skaggs
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Paul D. Sponseller
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland,Email for corresponding author:
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35
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Matsumoto H, Franzone JM, Sinha R, Roye BD, Glotzbeker MP, Skaggs DL, Flynn JM, Lenke LG, Sponseller PD, Vitale MG. A novel risk calculator predicting surgical site infection after spinal surgery in patients with cerebral palsy. Dev Med Child Neurol 2022; 64:1034-1043. [PMID: 35229288 DOI: 10.1111/dmcn.15193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 01/28/2022] [Accepted: 02/08/2022] [Indexed: 11/30/2022]
Abstract
AIM To develop and validate a risk calculator based on preoperative factors to predict the probability of surgical site infection (SSI) in patients with cerebral palsy (CP) undergoing spinal surgery. METHOD This was a multicenter retrospective cohort study of pediatric patients with CP who underwent spinal fusion. In the development stage, preoperative known factors were collected, and a risk calculator was developed by comparing multiple models and choosing the model with the highest discrimination and calibration abilities. This model was then tested with a separate population in the validation stage. RESULTS Among the 255 patients in the development stage, risk of SSI was 11%. A final prediction model included non-ambulatory status (odds ratio [OR] 4.0), diaper dependence (OR 2.5), age younger than 12 years (OR 2.5), major coronal curve magnitude greater than 90° (OR 1.3), behavioral disorder/delay (OR 1.3), and revision surgery (OR 1.3) as risk factors. This model had a predictive ability of 73.4% for SSI, along with excellent calibration ability (p = 0.878). Among the 390 patients in the validation stage, risk of SSI was 8.2%. The discrimination of the model in the validation phase was 0.743 and calibration was p = 0.435, indicating 74.3% predictive ability and no difference between predicted and observed values. INTERPRETATION This study provides a risk calculator to identify the risk of SSI after spine surgery for patients with CP. This will allow us to enhance decision-making and patient care while providing valid hospital comparisons, public reporting mechanisms, and reimbursement determinations.
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Affiliation(s)
- Hiroko Matsumoto
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, New York, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Jeanne M Franzone
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Rishi Sinha
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Benjamin D Roye
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Michael P Glotzbeker
- Department of Orthopaedic Surgery, University Hospital Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - David L Skaggs
- Spine Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - John M Flynn
- Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Philadelphia, USA
| | - Lawrence G Lenke
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA.,Bloomberg Children's Center, Baltimore, Maryland, USA
| | - Michael G Vitale
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, New York, USA
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Gomez JA, Ge DH, Boden E, Hanstein R, Alvandi LM, Lo Y, Hwang S, Samdani AF, Sponseller PD, Garg S, Skaggs DL, Vitale MG, Emans J. Posterior-only Resection of Single Hemivertebrae With 2-Level Versus >2-Level Fusion: Can We Improve Outcomes? J Pediatr Orthop 2022; 42:354-360. [PMID: 35499167 DOI: 10.1097/bpo.0000000000002165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The outcomes of congenital scoliosis (CS) patients undergoing hemivertebra (HV) resection surgery with a 2-level fusion versus a >2-level fusion are unclear. We hypothesized that CS patients undergoing HV resection and a >2-level fusion have decreased curve progression and reoperation rates compared with 2-level fusions. METHODS Retrospective review of prospectively collected data from a multicenter scoliosis database. Fifty-three CS patients (average age 4.5, range 1.2 to 10.9 y) at index surgery were included. Radiographic and surgical parameters, complications, as well as revision surgery rates were tracked at a minimum of 2-year follow-up. RESULTS Twenty-six patients had a 2-level fusion while 27 patients had a >2-level fusion with similar age and body mass index between groups. The HV was located in the lumbar spine for 69% (18/26) 2-level fusions and 30% (8/27) >2-level fusions ( P =0.006). Segmental HV scoliosis curve was smaller in 2-level fusions compared to >2-level fusions preoperatively (38 vs. 50 degrees, P =0.016) and at follow-up (25 vs. 34 degrees, P =0.038). Preoperative T2-T12 (28 vs. 41 degrees, P =0.013) and segmental kyphosis (11 vs. 23 degrees, P =0.046) were smaller in 2-level fusions, but did not differ significantly at postoperative follow-up (32 vs. 39 degrees, P =0.22; 13 vs. 11 degrees, P =0.64, respectively). Furthermore, the 2 groups did not significantly differ in terms of surgical complications (27% vs. 22%, P =0.69; 2-level fusion vs. >2-level fusion, respectively), unplanned revision surgery rate (23% vs. 22%, 0.94), growing rod placement or extension of spinal fusion (15% vs. 15%, P =0.95), or health-related quality of life per the EOS-Questionnaire 24 (EOSQ-24). Comparison of patients with or without the need for growing rod placement or posterior spinal fusion revealed no significant differences in all parameters analyzed. CONCLUSIONS Two-level and >2-level fusions can control congenital curves successfully. No differences existed in curve correction, proximal junctional kyphosis or complications between short and long-level fusion after HV resection. Both short and long level fusions are viable options and generate similar risk of revision. The decision should be individualized by patient and surgeon.
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Affiliation(s)
- Jaime A Gomez
- Department of Orthopaedic Surgery, Montefiore Medical Center
| | - David H Ge
- Department of Orthopaedic Surgery, Montefiore Medical Center
| | - Emma Boden
- Department of Orthopaedic Surgery, Montefiore Medical Center
| | - Regina Hanstein
- Department of Orthopaedic Surgery, Montefiore Medical Center
| | - Leila Mehraban Alvandi
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx
| | - Yungtai Lo
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx
| | | | | | - Paul D Sponseller
- Departments of Orthopaedic Surgery and Anesthesiology, The Johns Hopkins University, Baltimore, MD
| | | | - David L Skaggs
- Department of Orthopaedics, Cedars-Sinai, Los Angeles, CA
| | - Michael G Vitale
- Columbia University Medical Center/Morgan Stanley Children's Hospital, New York, NY
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Stephan SR, Skaggs DL. Think and Talk Like You Went to Business School. J Pediatr Orthop 2022; 42:S53-S55. [PMID: 35405705 DOI: 10.1097/bpo.0000000000002122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Most orthopaedic surgeons do not have formal training in business education. We have learned that success comes to those who study hard, choose the correct answer on multiple-choice tests, and focus on patient care and operating. In contrast, business school graduates learned that success comes to those who apply interpersonal skills to build relationships and trust, in addition to taking risks. Medical school and business school teach one to confront the "real world" with quite a different perspective. In this manuscript, we will touch on a few things that we can learn from business school graduates.
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Affiliation(s)
- Stephen R Stephan
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
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38
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Matsumoto H, Larson EL, Warren SI, Hammoor BT, Bonsignore-Opp L, Troy MJ, Barrett KK, Striano BM, Li G, Terry MB, Roye BD, Lenke LG, Skaggs DL, Glotzbecker MP, Flynn JM, Roye DP, Vitale MG. A Clinical Risk Model for Surgical Site Infection Following Pediatric Spine Deformity Surgery. J Bone Joint Surg Am 2022; 104:364-375. [PMID: 34851324 DOI: 10.2106/jbjs.21.00751] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite tremendous efforts, the incidence of surgical site infection (SSI) following the surgical treatment of pediatric spinal deformity remains a concern. Although previous studies have reported some risk factors for SSI, these studies have been limited by not being able to investigate multiple risk factors at the same time. The aim of the present study was to evaluate a wide range of preoperative and intraoperative factors in predicting SSI and to develop and validate a prediction model that quantifies the risk of SSI for individual pediatric spinal deformity patients. METHODS Pediatric patients with spinal deformity who underwent primary, revision, or definitive spinal fusion at 1 of 7 institutions were included. Candidate predictors were known preoperatively and were not modifiable in most cases; these included 31 patient, 12 surgical, and 4 hospital factors. The Centers for Disease Control and Prevention definition of SSI within 90 days of surgery was utilized. Following multiple imputation and multicollinearity testing, predictor selection was conducted with use of logistic regression to develop multiple models. The data set was randomly split into training and testing sets, and fivefold cross-validation was performed to compare discrimination, calibration, and overfitting of each model and to determine the final model. A risk probability calculator and a mobile device application were developed from the model in order to calculate the probability of SSI in individual patients. RESULTS A total of 3,092 spinal deformity surgeries were included, in which there were 132 cases of SSI (4.3%). The final model achieved adequate discrimination (area under the receiver operating characteristic curve: 0.76), as well as calibration and no overfitting. Predictors included in the model were nonambulatory status, neuromuscular etiology, pelvic instrumentation, procedure time ≥7 hours, American Society of Anesthesiologists grade >2, revision procedure, hospital spine surgical cases <100/year, abnormal hemoglobin level, and overweight or obese body mass index. CONCLUSIONS The risk probability calculator encompassing patient, surgical, and hospital factors developed in the present study predicts the probability of 90-day SSI in pediatric spinal deformity surgery. This validated calculator can be utilized to improve informed consent and shared decision-making and may allow the deployment of additional resources and strategies selectively in high-risk patients. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Hiroko Matsumoto
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Elaine L Larson
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY.,School of Nursing, Columbia University Irving Medical Center, New York, NY
| | - Shay I Warren
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Bradley T Hammoor
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Lisa Bonsignore-Opp
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Michael J Troy
- Department of Orthopedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Kody K Barrett
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, California
| | - Brendan M Striano
- Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Gen Li
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Mary Beth Terry
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Benjamin D Roye
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Lawrence G Lenke
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY
| | - David L Skaggs
- Spine Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael P Glotzbecker
- Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospital Cleveland Medical Center, Cleveland, Ohio
| | - John M Flynn
- Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David P Roye
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Michael G Vitale
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY
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Luhmann SJ, Skaggs DL, Pahys J, Samdani A, El-Hawary R. Single distraction-rod constructs in severe early-onset scoliosis: Indications and outcomes. Spine J 2022; 22:305-312. [PMID: 34547389 DOI: 10.1016/j.spinee.2021.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 09/02/2021] [Accepted: 09/09/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Since the study of Thompson, et al in 2005, use of dual-growing rod constructs have become the gold standard for operative treatment in early-onset scoliosis. However, use of dual-growing rod constructs may not be possible, due to patient size and the type, location and severity of the spinal deformity. PURPOSE The purpose of this study is to: (1) describe the deformities treated with single-growing rod constructs, and (2) report the outcomes of single-growing rods since 2005. STUDY DESIGN Observational, descriptive case series METHODS: A prospective, multi-center, international database of early-onset scoliosis patients were queried to identify all patients with single traditional growing rods (sTGR) or magnetically-controlled growing rods (sMCGR) since the 2005. Patients were excluded if there were greater than 1 rod or if there was less than 2 years of follow-up postoperatively. Twenty-five patients (13 female, 12 male) were identified from the database query, which satisfied the inclusion and exclusion criteria. RESULTS Mean age at index surgery was 4.7 years (1.3 to 9.3 years) and mean follow-up was 4.3 years (2.0 to 10.6 years). Eleven patients were classified as congenital (all mixed-type), six neuromuscular, five idiopathic and three syndromic. Proximal foundations were ribs in 23 patients and pedicle screws in two patients. The distal foundations were the spine in 25 patients and three pelvic S-hooks. All single rods were on the concave side of the deformity. Interpretation of preoperative radiographs determined in 72% (18/25) of cases dual growing rods would be difficult and/or suboptimal due to patient size (longitudinal a/o weight) and/or kyphosis/kyphoscoliosis with severe rotation. Maximal coronal deformity improved 30% (83.9 degrees to 58.6 degrees) at latest follow-up. Maximal kyphosis increased 17% (45.6 degrees to 57.4 degrees). Postoperative length increase: T1-T12, 17.0 mm (4.6 mm/year); T1-S1, 34 mm (9.4 mm/year). Total secondary surgeries for TGRs were 100: 66 lengthenings, 32 revisions, two unknown. 10 MCGRs secondary surgeries occurred in nine patients (seven for maximized actuators and three for foundation migration). At latest follow-up 20 continued with lengthenings (five TGR & 15 MCGR), four underwent definitive fusions, and one completed lengthening (implants retained). CONCLUSIONS Treatment of severe EOS with single rods demonstrated a 30% coronal correction. T1-S1 length increased at 9.4 mm/year and T1-T12 length at 4.6 mm/year, which are comparable to published reports on dual MCGRs. Single TGRs and MCGRs in EOS can provide acceptable short-term outcomes when dual rods are not deemed appropriate. CLINICAL SIGNIFICANCE The use of single growing rod constructs, in the 4-8 years old patient with EOS, can achieve reasonable short-term radiographic outcomes.
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Affiliation(s)
| | | | - Joshua Pahys
- Shriners Hospitals for Children - Philadelphia, Philadelphia, PA
| | - Amer Samdani
- Shriners Hospitals for Children - Philadelphia, Philadelphia, PA
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Claeson AA, Schwab FJ, Gandhi AA, Skaggs DL. Power-assisted Pedicle Screw Technique Protects Against Risk of Surgeon Overuse Injury: A Comparative Electromyography Study of the Neck and Upper Extremity Muscle Groups in a Simulated Surgical Environment. Spine (Phila Pa 1976) 2022; 47:E86-E93. [PMID: 33973563 DOI: 10.1097/brs.0000000000004097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cadaveric. OBJECTIVE The aim of this study was to quantify the amplitude and duration of surgeons' muscle exertion from pedicle cannulation to screw placement using both manual and power-assisted tools in a simulated surgical environment using surface electromyography (EMG). SUMMARY OF BACKGROUND DATA A survey of Scoliosis Research Society members reported rates of neck pain, rotator cuff disease, lateral epicondylitis, and cervical radiculopathy at 3 ×, 5 ×, 10 ×, and 100 × greater than the general population. The use of power-assisted tools in spine surgery to facilitate pedicle cannulation through screw placement during open posterior fixation surgery may reduce torque on the upper limb and risk of overuse injury. METHODS Pedicle preparation and screw placement was performed from T4-L5 in four cadavers by two board-certified spine surgeons using both manual and power-assisted techniques. EMG recorded muscle activity from the flexor carpi radialis, extensor carpi radialis, biceps, triceps, deltoid, upper trapezius, and neck extensors. Muscle activity was reported as a percentage of the maximum voluntary exertion of each muscle group (%MVE) and muscle exertion was linked to low- (0-20% MVE), moderate- (20%-45% MVE), high- (45%-70% MVE) and highest- (70%-100% MVE) risk of overuse injury based on literature. RESULTS Use of power-assisted tools for pedicle cannulation through screw placement maintains average muscle exertion at low risk for overuse injury for every muscle group. Conversely with manual technique, the extensor carpi radialis, biceps, upper trapezius and neck extensors operate at levels of exertion that risk overuse injury for 50% to 92% of procedure time. Powerassisted tools reduce average muscle exertion of the biceps, triceps, and deltoid by upwards of 80%. CONCLUSION Power-assisted technique protects against risk of overuse injury. Elevated muscle exertion of the extensor carpi radialis, biceps, upper trapezius, and neck extensors during manual technique directly correlate with surgeons' self-reported diagnoses of lateral epicondylitis, rotator cuff disease, and cervical myelopathy.Level of Evidence: N/A.
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Saarinen AJ, Sponseller PD, Andras LM, Skaggs DL, Emans JB, Thompson GH, Helenius IJ. Matched Comparison of Magnetically Controlled Growing Rods with Traditional Growing Rods in Severe Early-Onset Scoliosis of ≥90°: An Interim Report on Outcomes 2 Years After Treatment. J Bone Joint Surg Am 2022; 104:41-48. [PMID: 34644282 DOI: 10.2106/jbjs.20.02108] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Severe early-onset scoliosis (EOS) is managed surgically but represents a challenge due to limited implant fixation points, large curve size, and fragile patients with comorbidities. Magnetically controlled growing rods (MCGRs) have the advantage of avoiding surgical intervention for routine lengthening, but their ability to address severe EOS has not been studied, to our knowledge. METHODS A retrospective review of a prospectively collected international database identified 44 children with severe (≥90°) EOS treated with MCGRs who met our study criteria. Etiology, age, and sex-matched patients treated with traditional growing rods (TGRs) were identified from the same database. Patients were evaluated at a 2-year follow-up. No patients with vertically expandable prosthetic titanium ribs (VEPTRs) were included. The health-related quality of life was evaluated with the 24-Item Early Onset Scoliosis Questionnaire (EOSQ-24). RESULTS The mean preoperative major coronal curve was 104° in the MCGR group and 104° in the TGR group. At the 2-year follow-up, the mean major coronal curves were 52° and 66° (p = 0.001), respectively. The mean T1-T12 heights were 155 mm and 152 mm preoperatively and 202 mm and 192 mm at the 2-year follow-up (p = 0.088). According to Kaplan-Meier analysis, the 2-year unplanned-revision-free survival was 91% in the MCGR group and 71% in the TGR group (p < 0.005). The 2-year score in the EOSQ-24 pulmonary function domain was better in the MCGR group. There were no other significant differences in the EOSQ-24 scores between the groups. CONCLUSIONS MCGRs for severe EOS provided significantly better major curve correction with significantly fewer unplanned revisions than TGRs at a 2-year follow-up. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Antti J Saarinen
- Department of Paediatric Orthopaedic Surgery, University of Turku and Turku University Hospital, Turku, Finland.,Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Lindsay M Andras
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, California
| | - David L Skaggs
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, California
| | - John B Emans
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - George H Thompson
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Ilkka J Helenius
- Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Akbarnia BA, Pawelek JB, Hosseini P, Salari P, Kabirian N, Marks D, Shah SA, Skaggs DL, Emans JB, Elsebaie H, Thompson GH, Sponseller PD. Treatment of Early-onset Scoliosis: Similar Outcomes Despite Different Etiologic Subtypes in Traditional Growing Rod Graduates. J Pediatr Orthop 2022; 42:10-16. [PMID: 34739435 DOI: 10.1097/bpo.0000000000001985] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND It is unclear whether traditional growing rod (TGR) treatment outcomes vary by early-onset scoliosis (EOS) subtype. The goal of this study was to compare radiographic outcomes and complications of TGR treatment by EOS subtype. METHODS We queried an international database of EOS patients from 20 centers to identify "graduates" who had (1) undergone primary TGR treatment from 1993 to 2014; (2) completed TGR treatment; and (3) had an uneventful clinical examination within 6 months after completion of TGR treatment with no anticipated further intervention. We included 202 patients in 4 etiologic subgroups: neuromuscular (n=65), syndromic (n=57), idiopathic (n=52), and congenital (n=28). Mean age at surgery was 7.1 years (range, 1.6 to 14.9 y); mean duration of follow-up was 8 years (range, 2 to 18.6 y). The groups did not differ by mean age, body mass index, sex, number of lengthenings, or duration of follow-up. The following preoperative differences were significant: (1) greater mean major curve in the neuromuscular versus idiopathic subgroup; (2) shorter spinal height (T1-S1) in the congenital versus idiopathic subgroup; and (3) smaller proportion of ambulatory patients in the neuromuscular subgroup versus all other subgroups. RESULTS We found no significant differences among subgroups in mean major curve correction or changes in thoracic height (T1-T12), spinal height, or global kyphosis at any point. Rates of deep surgical site infection, implant-related complications, and neurological complications were not different among subgroups. The medical complication rate was significantly lower in the idiopathic group compared with the other groups. CONCLUSIONS Major curve correction and spinal and thoracic height increases did not differ significantly at any point by EOS subtype. Rates of deep surgical site infection, implant-related complications, and neurological complications did not differ by subtype. Except for the lower rate of medical complications in the idiopathic group, our findings suggest that, after TGR treatment, patients can expect similar outcomes regardless of their EOS subtype. LEVEL OF EVIDENCE Level III, therapeutic.
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Affiliation(s)
- Behrooz A Akbarnia
- San Diego Spine Foundation, San Diego
- Department of Orthopaedic Surgery, University of California San Diego School of Medicine, La Jolla
| | | | | | | | | | - David Marks
- Birmingham Children's Hospital, Birmingham, UK
| | - Suken A Shah
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - David L Skaggs
- Children's Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, CA
| | - John B Emans
- Division of Spine Surgery, Department of Orthopedic Surgery, Harvard Medical School, Boston, MA
| | | | - George H Thompson
- Department of Orthopaedic Surgery, Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
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Nazareth A, Andras LM, Illingworth KD, Miller DJ, Cahill PJ, Skaggs DL. Outcomes of Operatively Managed Lumbar and Sacral Facet Fractures in Pediatric Athletes: A Case Series. J Pediatr Orthop 2022; 42:e45-e49. [PMID: 34608037 DOI: 10.1097/bpo.0000000000001971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Facet fractures have been reported in a total of 6 young athletes in 4 previous publications. These injuries were not diagnosed on magnetic resonance imaging (MRI) or radiographs, and were identified on computed tomography (CT). Our purpose was to report a series of athletes with operatively managed facet fractures. This may be an under-recognized diagnosis. METHODS Retrospective review of pediatric patients with operatively managed isolated lumbar or sacral facet fractures from 3 tertiary pediatric hospitals from 2014 to 2019. Clinical records and imaging studies were reviewed. RESULTS Ten patients with symptomatic lumbar or sacral facet fractures met inclusion criteria (mean age at presentation; 13.3±2.1 years, 70% Female). All patients reported competitive participation in sports. On physical examination, 10/10 (100%) of patients had lower back pain that was exacerbated with lumbar spine extension. Limited CT scans demonstrated facet fractures in 10/10 (100%) patients not detected on plain film or MRI. All patients experienced significant relief of pain following excision of the facet fracture fragment. At time of first postoperative visit, 9/10 (90%) patients were pain free while one had generalized back pain thought to be related to fibromyalgia and not facet pathology. At time of last follow-up, 2/10 (20%) of patients reported nonspecific back pain that was not localized in the area of the facet fracture, while 80% (8/10) remained pain free. All patients 100% (10/10) returned to full participation to sports. There were no complications noted in this series. Average follow-up was 27 months (range: 1 to 68 mo). CONCLUSIONS Athletes with localized back pain exacerbated by spine extension may have a facet fracture. As facet fractures are usually not identified with radiographs or MRI, a limited CT scan should be considered in the evaluation of pediatric athletes with localized back pain exacerbated by extension. In this series, surgical excision of facet fracture fragments was safe and provided predictable pain relief.
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Affiliation(s)
- Alexander Nazareth
- Children's Orthopaedic Center, Children's Hospital Los Angeles
- Harbor-UCLA Medical Center, Torrance, CA
| | - Lindsay M Andras
- Children's Orthopaedic Center, Children's Hospital Los Angeles
- Keck School of Medicine, University of Southern California
| | - Kenneth D Illingworth
- Children's Orthopaedic Center, Children's Hospital Los Angeles
- Keck School of Medicine, University of Southern California
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Nazareth A, Schur M, Schroeder AJ, Whitlock PW, Skaggs DL, Goldstein RY. Obesity as a Predictor of Outcomes in Type III and Type IV Supracondylar Humerus Fractures. J Orthop Trauma 2021; 35:e418-e422. [PMID: 33591065 DOI: 10.1097/bot.0000000000002081] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/04/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To investigate the association of obesity with fracture characteristics and outcomes of operatively treated pediatric supracondylar humerus fractures. DESIGN Retrospective multicenter. SETTING Two Level I pediatric hospitals. PATIENTS Patients (age <18 years) with operatively treated Gartland type III and type IV fractures 2010-2014. INTERVENTION Closed or open reduction and percutaneous pinning of supracondylar humerus fractures. MAIN OUTCOME MEASURE Incidence of Gartland IV fracture, preoperative nerve palsy, open reduction and complication rates. RESULTS Patients in the obese group had a significantly higher likelihood of having a Gartland IV fracture (not obese: 17%; obese: 35%; P = 0.007). There was a significantly higher incidence of nerve palsy on presentation in the obese group (not obese: 20%; obese: 33%; P = 0.03). No significant differences were found between groups regarding incidence of open reduction, compartment syndrome, and rates of reoperation. CONCLUSIONS The present study demonstrates that obese children with a completely displaced supracondylar humerus fractures have an increased risk of Gartland type IV and preoperative nerve palsy compared with normal weight children. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander Nazareth
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA; and
| | - Mathew Schur
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Amanda J Schroeder
- Division of Pediatric Orthopaedics, Cincinnati Children's Hospital, Cincinnati, OH
| | - Patrick W Whitlock
- Division of Pediatric Orthopaedics, Cincinnati Children's Hospital, Cincinnati, OH
| | - David L Skaggs
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA; and
| | - Rachel Y Goldstein
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA; and
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Mitchell BC, Skaggs DL, Lenke LG, Bastrom TP, Bartley CE, Newton PO. Defining risk factors for adding-on in Lenke 1 and 2 AR curves. Spine Deform 2021; 9:1569-1579. [PMID: 34216354 DOI: 10.1007/s43390-021-00382-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 06/22/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To identify curve/correction characteristics associated with adding-on at 2 years after posterior spinal fusion (PSF) in Lenke 1/2 AR curves. METHODS A prospective multicenter registry was queried to identify patients with adolescent idiopathic scoliosis (AIS), Lenke 1/2 AR curves, who underwent PSF with a minimum of 2-year follow-up. Patient characteristics as well as pre- and post- operative radiographic variables were evaluated using Classification and Regression Tree (CART) analysis to determine which factors contribute to adding-on. RESULTS 253 patients treated with PSF were assessed for adding-on, of which 50 met our adding-on criteria. Univariate analysis revealed adding-on was associated several factors including: post-operative thoracic and lumbar curve magnitude (p > 0.001), first erect (FE) end instrumented vertebra (EIV) angulation (p = 0.009) and EIV translation (p = 0.001), younger age (p = 0.027), Risser stage (p = 0.024), and a more proximal lowest instrumented vertebra (LIV) (p < 0.001). Multivariate CART analysis showed the chance of adding-on was more than 2 times greater (42 vs 16%) when the chosen LIV was translated more than 2.7 cm from the CSVL. When the LIV was within 2.7 cm, the post-op risk of adding-on was increased when the LIV was not perfectly leveled (> 0.5°). CONCLUSION In Lenke 1 and 2 AR curves, pre-operative LIV translation appears to be an independent risk factor for adding-on; and in those with < 2.7 cm of LIV translation, FE LIV angulation also seems to increase the risk of adding-on. These factors are relevant in determining appropriate LIV selection and aid in identifying patients at risk for developing adding-on.
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Affiliation(s)
- Brendon C Mitchell
- Department of Orthopaedic Surgery, University of California - San Diego, San Diego, CA, USA
| | - David L Skaggs
- Department of Orthopedics, Cedars Sinai Hospital, Los Angeles, CA, USA
| | - Lawrence G Lenke
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Tracey P Bastrom
- Division of Orthopedics & Scoliosis, Rady Children's Hospital, San Diego, CA, USA
| | - Carrie E Bartley
- Division of Orthopedics & Scoliosis, Rady Children's Hospital, San Diego, CA, USA
| | - Peter O Newton
- Department of Orthopaedic Surgery, University of California - San Diego, San Diego, CA, USA. .,Division of Orthopedics & Scoliosis, Rady Children's Hospital, San Diego, CA, USA. .,, 3020 Children's Way, MC 5062, San Diego, CA 92123, USA.
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Skaggs DL, Compton E, Vitale MG, Garg S, Stone J, Fletcher ND, Illingworth KD, Kim HJ, Ball J, Kim EB, Keil L, Harris H, Shah SP, Andras LM. Power versus manual pedicle tract preparation: a multi-center study of early adopters. Spine Deform 2021; 9:1395-1402. [PMID: 33891296 DOI: 10.1007/s43390-021-00347-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 04/07/2021] [Indexed: 10/21/2022]
Abstract
STUDY DESIGN Retrospective cohort, multicenter. A single surgeon study demonstrated that pedicle tract preparation with power tools was associated with lower fluoroscopy times and revision rates compared to manual tools, while maintaining patient safety. OBJECTIVE Our purpose was to determine the safety of power-assisted pedicle tract preparation by early adopters of this technology. METHODS Retrospective review comparing patients that underwent posterior spinal fusion by seven pediatric spine surgeons at six institutions between January 1, 2008 and August 31, 2019. The manual pedicle tract preparation used a pedicle awl. Power tract preparation used a flexible 2.0-2.4 mm drill bit, followed by a larger drill bit or a reamer. All screws were inserted with power technique. RESULTS In the manual tract preparation group, 9424 screws were placed in 585 cases. In the power tract preparation group, 22,209 screws were placed in 1367 cases. Seven patients (7/1952; 0.36%; 95% CI: 0.14-0.74%) had 11 mal-positioned screws (11/31,633; 0.03%; 95% CI: 0.017-0.062%). Seven screws (7/9424; 0.07%; 95% CI: 0.030-0.15%) were in the manual cohort and four (4/22,209; 0.02%; 95% CI: 0.0049-0.046%) were in the power cohort. There were significantly more revisions per screw in the manual cohort (p = 0.02). However, there were not significantly more revisions per patient in the manual cohort (manual: 0.5%, 3/585 vs. power: 0.3%, 4/1,367; p = 0.43). Of these seven, three patients (3/585; 0.5%; 95% CI: 0.1-1.5%) experienced neurologic injury or neuro-monitoring changes requiring screw removal in the manual cohort, and 1 patient (1/1,367, 0.07%; 95% CI: 0.002-0.4%) in the power cohort (p = 0.08). Three additional patients underwent revision in the power cohort: 1 for an asymptomatic lateral breech, 1 for a spinal headache/medial breech that developed after an MVA, and 1 for an iliac vein injury during pedicle tract preparation. CONCLUSION This is the first multi-center study examining power pedicle preparation. Overall, 99.9% of pedicle screws placed with power pedicle preparation did not have complications or revision. Equivalent patient safety was demonstrated compared to manual technique. LEVEL OF EVIDENCE III.
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Affiliation(s)
- David L Skaggs
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA. .,Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA.
| | - Edward Compton
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | | | - Sumeet Garg
- Children's Hospital Colorado, Aurora, CO, USA
| | - Joseph Stone
- Department of Orthopaedics, University of North Carolina, Chapel Hill, Chapel Hill, NC, USA
| | | | - Kenneth D Illingworth
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Jacob Ball
- Columbia University Medical Center, New York, NY, USA
| | - Eun Bi Kim
- Children's Hospital Colorado, Aurora, CO, USA
| | - Lukas Keil
- Department of Orthopaedics, University of North Carolina, Chapel Hill, Chapel Hill, NC, USA
| | - Hilary Harris
- Emory Orthopedics and Spine Center, Atlanta, GA, USA
| | - Sachin P Shah
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Lindsay M Andras
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA
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Clement RC, Yaszay B, McClung A, Bartley CE, Nabizadeh N, Skaggs DL, Thompson GH, Boachie-Adjei O, Sponseller PD, Shah SA, Sanders JO, Pawelek J, Mundis GM, Akbarnia BA. Growth-preserving instrumentation in early-onset scoliosis patients with multi-level congenital anomalies. Spine Deform 2021; 9:1491. [PMID: 34152580 DOI: 10.1007/s43390-021-00370-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/31/2021] [Indexed: 12/01/2022]
Affiliation(s)
- R Carter Clement
- Department of Orthopaedics, Children's Hospital of New Orleans, New Orleans, LA, USA
| | - Burt Yaszay
- Department of Orthopedics, Rady Children's Hospital, San Diego, CA, USA.
| | | | - Carrie E Bartley
- Department of Orthopedics, Rady Children's Hospital, San Diego, CA, USA
| | - Naveed Nabizadeh
- Department of Orthopedics, Rady Children's Hospital, San Diego, CA, USA
| | - David L Skaggs
- Children's Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - George H Thompson
- Rainbow Babies and Childrens Hospital, Case Western Reserve University, Cleveland, OH, USA
| | | | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Suken A Shah
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - James O Sanders
- Department of Orthopedics, University of North Carolina, Chapel Hill, NC, USA
| | | | - Gregory M Mundis
- Department of Orthopaedics, Children's Hospital of New Orleans, New Orleans, LA, USA
| | - Behrooz A Akbarnia
- Department of Orthopeadics, University of California, San Diego, San Diego, CA, USA
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Compton E, Gupta P, Gomez JA, Illingworth KD, Skaggs DL, Sponseller PD, Samdani AF, Hwang SW, Oetgen ME, Schottler J, Thompson GH, Vitale MG, Smith JT, Andras LM. How low can you go? Implant density in posterior spinal fusion converted from growing constructs for early onset scoliosis. Spine Deform 2021; 9:1479-1488. [PMID: 34228310 DOI: 10.1007/s43390-021-00321-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 02/22/2021] [Indexed: 10/20/2022]
Abstract
STUDY DESIGN Retrospective, multicenter comparative. OBJECTIVES Our purpose was to compare early onset scoliosis (EOS) patients treated with ultra-low, low, and high implant density constructs when undergoing conversion to definitive fusion. Larson et al. demonstrated that implant density (ID) at fusion does not correlate with outcomes in the treatment of adolescent idiopathic scoliosis, but did not address growth-friendly graduates. METHODS EOS patients treated with growth-friendly constructs converted to fusion between 2000 and 2017 were reviewed from a multicenter database. ID was defined as number of pedicle screws, hooks, and sublaminar/bands per level fused. Patients were divided into ultra-low ID (< 1.3), low (≥ 1.3 and < 1.6), and high ID (≥ 1.6). EXCLUSION CRITERIA < 2 years follow-up from fusion or inadequate radiographs. RESULTS A total of 152 patients met inclusion criteria with 39 (26%) patients in the high ID group, 33 (22%) patients in the low ID group, and 80 (52%) in the ultra-low ID group. Groups were similar in operative time (p = 0.61), pre-fusion major curve (p = 0.71), mean number of levels fused (p = 0.58), clinical follow-up (p = 0.30), and radiographic follow-up (p = 0.90). Patients in the low ID group (11.6 ± 1.5 years) were slightly younger at the time of definitive fusion than patients in the ultra-low ID group (12.9 ± 2.2 years) and high ID group (12.5 ± 1.7 years) (p = 0.009). There was significantly more blood loss in the high ID group than the other two groups (high ID: 946.8 ± 606.0 mL vs. low ID: 733.9 ± 434.5 mL and ultra-low ID: 617.4 ± 517.2 mL; p = 0.01), but there was no significant difference with regard to percent of total blood volume lost (high ID: 59.3 ± 48.7% vs. low ID: 54.5 ± 37.5% vs. ultra-low ID: 51.7 ± 54.9%; p = 0.78). There was a difference in initial improvement in major curve between the groups (high ID: 21.6° vs. low ID: 18.0° vs. ultra-low ID: 12.6°; p = 0.01). However, during post-fusion follow-up, correction decreased 7.1° in the high ID group, 2.6 in the low ID group, and 2.8 in the ultra-low ID group (p = 0.19). At final follow-up, major curve correction from pre-fusion was similar between groups (high ID: 14.5° vs. low ID: 15.5° vs. ultra-low ID: 9.7°, p = 0.14). At final follow-up, there was no difference in T1-T12 length gain (p = 0.85), T1-S1 length gain (p = 0.68), coronal balance (p = 0.56), or sagittal balance (p = 0.71). The revision rate was significantly higher in the ultra-low ID group (13.8%; 11/80) versus the high ID group (2/39; 5.1%) and low ID group (0/33; 0%) (p = 0.04). CONCLUSIONS Although an ID < 1.3 in growth-friendly graduates produces similar outcomes with regard to curve correction and spinal length gain as low and high ID, this study suggests that an ID < 1.3 is associated with an increased revision rate. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Edward Compton
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA, 90027, USA
| | | | - Jaime A Gomez
- Division of Pediatric Orthopaedics, Children's Hospital At Montefiore Medical Center, Bronx, NY, USA
| | - Kenneth D Illingworth
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA, 90027, USA
| | - David L Skaggs
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA, 90027, USA
| | | | - Amer F Samdani
- Shriners Hospitals for Children-Philadelphia, Philadelphia, PA, USA
| | - Steven W Hwang
- Shriners Hospitals for Children-Philadelphia, Philadelphia, PA, USA
| | | | | | - George H Thompson
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Michael G Vitale
- Division of Pediatric Orthopedics, Columbia University Medical Center, New York, NY, USA
| | - John T Smith
- Department of Orthopedic Surgery, University of Utah, Salt Lake City, UT, USA
| | | | - Lindsay M Andras
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA, 90027, USA.
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Stephan SR, Andras LM, Skaggs DL, Illingworth KD. C1-C2 Distraction Ligamentous Injury Treated with Halo-Vest Application: A Case Report. JBJS Case Connect 2021; 11:01709767-202103000-00052. [PMID: 33729184 DOI: 10.2106/jbjs.cc.20.00456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE There is a paucity of literature regarding pediatric upper cervical spine traumatic instability, atlanto-occipital dislocations, and fractures, with no clear treatment algorithm. We present a 12-year-old girl with significant posterior C1-C2 distraction and resultant ligamentous injury after a motor vehicle collision who was treated with a halo vest for 3 months. At 8-month follow-up, follow-up magnetic resonance imaging demonstrated complete ligamentous healing without instability on dynamic radiographs, and at 18-month follow-up, the patient made a full recovery. CONCLUSION In some pediatric patients with isolated posterior ligamentous injury, as long as anatomic alignment can be achieved with halo-vest application, a fusion may be avoided.
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Affiliation(s)
- Stephen R Stephan
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Lindsay M Andras
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, California
| | - David L Skaggs
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, California
| | - Kenneth D Illingworth
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, California
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50
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Matsumoto H, Skaggs DL, Akbarnia BA, Pawelek JB, Hilaire TS, Levine S, Sturm P, Perez-Grueso FJS, Luhmann SJ, Sponseller PD, Smith JT, White KK, Vitale MG. Comparing health-related quality of life and burden of care between early-onset scoliosis patients treated with magnetically controlled growing rods and traditional growing rods: a multicenter study. Spine Deform 2021; 9:239-245. [PMID: 32851598 DOI: 10.1007/s43390-020-00173-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/20/2020] [Indexed: 11/30/2022]
Abstract
STUDY DESIGN Multicenter retrospective cohort study. OBJECTIVES To compare pre-operative and post-operative EOSQ-24 scores in magnetically controlled growing rods (MCGR) and traditional growing rod (TGR) patients. Since the introduction of MCGR, early-onset scoliosis patients have been afforded a reduction in the number of surgeries compared to the TGR technique. However, little is known about (health-related quality of life) and burden of care outcomes between these surgical techniques. METHODS This is a retrospective cohort study using a multicenter registry on patients with EOS undergoing MCGR or TGR between 2008 and 2017. The EOSQ-24 was administered at preoperative and postoperative 2-year assessments. The EOSQ-24 scores were compared between MCGR and TGR as well as preoperatively and postoperatively within each procedure. RESULTS 110 patients were analyzed in this study (TGR, N = 32; MCGR, N = 78). There were no significant differences in preoperative age, gender, etiology, main coronal curve or maximum kyphosis between TGR and MCGR groups. Patients with TGR had averaged 3.9 surgical lengthenings and MCGR had averaged 7.7 non-invasive lengthenings by the 2-year follow-up. When changes in preoperative to postoperative scores were compared, MCGR had more improvements in pain, emotion, child satisfaction and parent satisfaction than TGR although there were no statistical significance. When analyzed separately, MCGR cohort had improvement in scores for all four domains and four sub-domains; while, TGR cohort only had improvement in financial burden domain and pulmonary function sub-domain. CONCLUSION Although there was no statistical significance, the improvement in pain, emotion and satisfaction scores was larger in MCGR than TGR. Since these areas can be influenced more by mental well-being than other sub-domains, the results may prove our hypothesis that compared to TGR, MCGR with reduced number of surgeries have better psychosocial effects. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | - David L Skaggs
- Children's Orthopedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd., MS #69, Los Angeles, CA, 90027, USA.
| | | | | | | | - Sonya Levine
- Columbia University Medical Center, New York, NY, USA
| | - Peter Sturm
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | | | - John T Smith
- Primary Children's Hospital, Salt Lake City, UT, USA
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