The hospital at home in the USA: current status and future prospects

The annual cost of hospital care services in the US has risen to over $1 trillion despite relatively worse health outcomes compared to similar nations. These trends accentuate a growing need for innovative care delivery models that reduce costs and improve outcomes. HaH-a program that provides patients acute-level hospital care at home-has made significant progress over the past two decades. Technological advancements in remote patient monitoring, wearable sensors, health information technology infrastructure, and multimodal health data processing have contributed to its rise across hospitals. More recently, the COVID-19 pandemic brought HaH into the mainstream, especially in the US, with reimbursement waivers that made the model financially acceptable for hospitals and payors. However, HaH continues to face serious challenges to gain widespread adoption. In this review, we evaluate the peer-reviewed evidence and discuss the promises, challenges, and what it would take to tap into the future potential of HaH.

Is spinal height gain associated with rod orientation and the use of cross-links in magnetically controlled growing rods in early-onset scoliosis?

Optimal orientation for magnetically controlled growing rods (MCGRs) is unclear. The objective of this study was to investigate associations of rod orientation with implant-related complications (IRCs) and spinal height gains. Using an international early-onset scoliosis (EOS) database, we retrospectively reviewed 57 patients treated with dual MCGRs from May 2013 to July 2015 with minimum 2-year follow-up. Outcomes of interest were IRCs and left/right rod length gains and thoracic (T1-T12) and spinal (T1-S1) heights. We compared patients with two rods lengthened in the cephalad ( standard; n  = 18) versus opposite ( offset; n  = 39) directions. Groups did not differ in age, sex, BMI, duration of follow-up, EOS cause, ambulatory status, primary curve magnitude, baseline thoracic height, or number of distractions/year. We compared patients whose constructs used ≥1 cross-link (CL group; n  = 22) versus no CLs (NCL group; n  = 35), analyzing thoracic height gains per distraction ( α  = 0.05). Offset and standard groups did not differ in left or right rod length gains overall or per year or in thoracic or spinal height gain. Per distraction, the CL and NCL groups did not differ significantly in left or right rod length or thoracic or spinal height gain. Complications did not differ significantly between rod orientation groups or between CL groups. MCGR orientation and presence of cross-links were not associated with differences in rod length gain, thoracic height, spinal height, or IRCs at 2-year follow-up. Surgeons should feel comfortable using either MCGR orientation. Level of evidence: 3, retrospective.

The Coronavirus Disease 2019 Rebound Study: A Prospective Cohort Study to Evaluate Viral and Symptom Rebound Differences in Participants Treated With Nirmatrelvir Plus Ritonavir Versus Untreated Controls

BACKGROUND

The uptake of nirmatrelvir plus ritonavir (NPR) in patients with coronavirus disease 2019 (COVID-19) has been limited by concerns around the rebound phenomenon despite the scarcity of evidence around its epidemiology. The purpose of this study was to prospectively compare the epidemiology of rebound in NPR-treated and untreated participants with acute COVID-19 infection.

METHODS

We designed a prospective, observational study in which participants who tested positive for COVID-19 and were clinically eligible for NPR were recruited to be evaluated for either viral or symptom clearance and rebound. Participants were assigned to the treatment or control group based on their decision to take NPR. Following initial diagnosis, both groups were provided 12 rapid antigen tests and asked to test on a regular schedule for 16 days and answer symptom surveys. Viral rebound based on test results and COVID-19 symptom rebound based on patient-reported symptoms were evaluated.

RESULTS

Viral rebound incidence was 14.2% in the NPR treatment group (n = 127) and 9.3% in the control group (n = 43). Symptom rebound incidence was higher in the treatment group (18.9%) compared to controls (7.0%). There were no notable differences in viral rebound by age, gender, preexisting conditions, or major symptom groups during the acute phase or at the 1-month interval.

CONCLUSIONS

This preliminary report suggests that rebound after clearance of test positivity or symptom resolution is higher than previously reported. However, notably we observed a similar rate of rebound in both the NPR treatment and control groups. Large studies with diverse participants and extended follow-up are needed to better understand the rebound phenomena.

Treatment of Early-onset Scoliosis: Similar Outcomes Despite Different Etiologic Subtypes in Traditional Growing Rod Graduates

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.

The role of traditional growing rods in the era of magnetically controlled growing rods for the treatment of early-onset scoliosis

PURPOSE

To describe the clinical and radiographic profile of early-onset scoliosis (EOS) patients treated with traditional growing rods (TGR) during the magnetically-controlled growing rod (MCGR) era.

METHODS

A US multicenter EOS database was reviewed to identify (1) patients who underwent TGR after MCGR surgery was introduced at their institution, (2) patients who underwent MCGR during the same time period. Of 19 centers, 8 met criteria with all EOS etiologies represented. Clinical notes were reviewed to determine the indication for TGR. Patient demographics and pre-operative radiographs were compared between groups.

RESULTS

A total of 25 TGR and 127 MCGR patients were identified. The TGR patients were grouped by indication into the sagittal plane profile (n = 11), trunk height (n = 6), co-morbidities/need for MRI (n = 4), and other (ex: behavioral issues, remaining growth). Four patients had a combination of sagittal profile and short stature with sagittal profile listed as primary factor. The TGR short trunk group had a mean T1-S1 length of 192 mm vs 273 mm for the MCGR group (p = 0.0002). The TGR sagittal profile group, had a mean maximal kyphosis of 61° vs 55° for the MCGR group (p = 0.09).

CONCLUSION

TGR continues to have a role in the MCGR era. In this study, the most commonly reported indications for TGR were sagittal plane profile and trunk height. These results suggest that TGR is indicated in patients of short stature with stiff hyperkyphotic curves. As further experience is gained with MCGR, the indications for TGR will likely be refined.

An initial effort to define an early onset scoliosis "graduate"-The Pediatric Spine Study Group experience

PURPOSE

Increasingly, patients with early onset scoliosis (EOS) are completing a growth friendly surgical program followed by observation, removal of implants or a definitive spinal fusion. These patients are colloquially referred to as "graduates". A standardized definition of a graduate is needed for research and comparing the outcomes, family counseling, and a better understanding of the population.

METHODS

A 15-question electronic survey was completed by 39 experienced pediatric spine surgeons to identify factors salient to the definition of a graduate of EOS surgical programs. A Delphi/Nominal group technique session with nine questions was then performed face-to-face with 21 members of the Pediatric Spine Study Group to discuss and refine the definition. A follow-up electronic survey was then distributed to these same 21 members to gain consensus on the final definition.

RESULTS

From the initial survey, it was identified that a graduate did not require definitive spinal fusion after a growing program. From the Delphi session, it was determined that skeletal maturity was the most important factor in defining a graduate. A strictly defined minimum length of follow-up was not felt to be a prerequisite for qualification of graduation. After the final electronic version was distributed, > 80% of respondents agreed upon the final definition, thereby achieving consensus.

CONCLUSION

The Pediatric Spine Study Group recommends adoption of the following definition: a "graduate" is a patient who has undergone any surgical program to treat early onset scoliosis, and has reached skeletal maturity and does not have a planned surgical intervention for EOS in the future.

LEVEL OF EVIDENCE

V.

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

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.

Risk Factors for Reoperation Following Final Fusion After the Treatment of Early-Onset Scoliosis with Traditional Growing Rods

BACKGROUND

Although there is a high rate of reoperation after final fusion following the treatment of early-onset scoliosis with use of traditional growing rods, the risk factors for reoperation are unknown. The purpose of the present study was to identify risk factors associated with the need for reoperation after final fusion for the treatment of early-onset scoliosis.

METHODS

A multicenter database for patients with early-onset scoliosis was retrospectively analyzed. Patients managed with traditional growing rods and final fusion were identified (n = 248). The inclusion criteria were ≥1 lengthening procedure with traditional growing rods and ≥2 years of follow-up after final fusion or revision surgery within 2 years after final fusion (167 patients; 67%). Patients requiring reoperation following final fusion were compared with patients who did not require reoperation. The data that were analyzed included demographic characteristics, comorbidities, spinal deformity characteristics, radiographic measurements, perioperative details, and complications during all stages of treatment. A multivariate regression model was used to identify independent risk factors.

RESULTS

The mean duration of follow-up from the initial visit to the latest visit was 10.7 ± 4.1 years, and the mean duration of follow-up after final fusion was 4.9 ± 3.1 years. Thirty-two (19%) of the 167 patients required reoperation following final fusion. Curve progression requiring revision surgery during lengthening with traditional growing rods (adjusted odds ratio [aOR], 21.137 per event; p = 0.028), the number of levels spanned with traditional growing rods (aOR, 1.378 per level; p = 0.007), and the duration of treatment with traditional growing rods (aOR, 1.220 per year; p = 0.035) were independently associated with revision surgery after final fusion.

CONCLUSIONS

Independent risk factors for curve progression requiring reoperation during lengthening with traditional growing rods that require operative intervention include increasing number of levels spanned with traditional growing rods and longer duration of treatment with traditional growing rods. These findings may help with patient counseling and potentially guide surgeon decision-making.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

MRI utilization and rates of abnormal pretreatment MRI findings in early-onset scoliosis: review of a global cohort

STUDY DESIGN

Retrospective review OBJECTIVES: To report the frequency of pretreatment magnetic resonance imaging (MRI) utilization and rates and types of intra-spinal abnormalities identified on MRI in patients with early-onset scoliosis (EOS). MRI can help identify spinal cord abnormalities in patients with EOS.

METHODS

We reviewed data from patients enrolled from 1993-2018 in an international EOS registry. Patients with incomplete/unverifiable data and those with spinal deformities secondary to infection or tumor were excluded, leaving 1343 patients for analysis. Demographic characteristics, pretreatment major curve magnitude, treatment type, and MRI findings were analyzed. Patients were categorized by EOS type (congenital, idiopathic, neuromuscular, syndromic), pretreatment MRI utilization, and presence of intra-spinal abnormality on MRI. Univariate testing and multivariate logistic regression were performed to identify demographic, radiographic, and clinical predictors of MRI utilization and abnormal MRI findings.

RESULTS

MRI was used in 836 patients (62%). Pretreatment MRI utilization rates ranged from 42% in neuromuscular EOS to 74% in congenital EOS. Prevalence of abnormal MRI findings was 24% overall, ranging from 13% in patients with idiopathic EOS to 39% in neuromuscular EOS. Compared with white/Caucasian patients, Asian/Asian-American patients had higher odds of MRI utilization and abnormal MRI findings. Treatment type, pretreatment major curve magnitude, age at MRI, and age at treatment were not associated with abnormal MRI findings. Overall, 249 abnormalities were identified in 197 patients. The most common findings were syrinx and tethered cord. Syrinx with Chiari malformation was the most frequent combination of abnormal findings.

CONCLUSION

In the two-thirds of patients who underwent MRI before EOS treatment, findings were abnormal in 24%. EOS type and race/ethnicity were associated with both MRI utilization and abnormal findings. The most frequent abnormalities were syrinx and tethered cord, and the type of abnormalities appeared to differ by EOS type.

LEVEL OF EVIDENCE

Prognostic, Level III.

Outcomes of growing rod surgery for severe compared with moderate early-onset scoliosis: a matched comparative study

Aims

The aim of this study was to compare the outcomes of surgery using growing rods in patients with severe versus moderate early-onset scoliosis (EOS).

Patients and Methods

A review of a multicentre EOS database identified 107 children with severe EOS (major curve ≥ 90°) treated with growing rods before the age of ten years with a minimum follow-up of two years and three or more lengthening procedures. From the same database, 107 matched controls with moderate EOS were identified.

Results

The mean preoperative major curve was 101° (90 to 139) in the severe group and 67° (33° to 88°) in the moderate group (p < 0.001), which was corrected at final follow-up to 57° (10° to 96°) in the severe group and 40° (3° to 85°) in the moderate group (p < 0.001). T1-S1 height increased by a mean of 54 mm (-8 to 131) in the severe group and 27 mm (-4 to 131) in the moderate group at the initial surgery (p < 0.001), and by 50 mm (-17 to 200) and 54 mm (-11 to 212), respectively, during distraction (p = 0.84). The mean number of complications per patient was 2.6 (0 to 14) in the severe group and 1.9 (0 to 10) in the moderate group (p = 0.040). Five patients (4.7%) in the severe group and three (2.8%) in the moderate group developed a neurological deficit postoperatively (p = 0.47).

Conclusion

Severe EOS can be treated effectively using growing rods, but the risk of complications is high. Cite this article: Bone Joint J 2018;100-B:772-9.

Final Fusion After Growing-Rod Treatment for Early Onset Scoliosis: Is It Really Final?

BACKGROUND

Final fusion is thought to be the end point for patients with early onset scoliosis following treatment with the use of growing rods. But is it? The purpose of this study was to determine the incidence and cause of any reoperation after final fusion.

METHODS

A multicenter database of patients with early onset scoliosis was retrospectively analyzed to identify patients treated with growing rods with a minimum of 2 years of follow-up after final fusion. All reoperations were recorded. Reoperation was defined as a return to the operating room for any complication related to the final fusion surgery or etiology of the spinal deformity.

RESULTS

One hundred (84%) of 119 patients met the inclusion criteria: for 38 of the patients, the etiology of scoliosis was neuromuscular; for 31, syndromic; for 22, idiopathic; and for 9, congenital. The mean age at final fusion was 12.2 years (range, 8.5 to 18.7 years). The mean follow-up after final fusion was 4.3 years (range, 2 to 11.2 years). Twenty (20%) of the patients had 30 complications requiring reoperation (57 procedures). There was a mean of 1.5 complications per patient after final fusion. Eight patients with neuromuscular scoliosis, 8 with syndromic, 4 with idiopathic, and no patient with congenital scoliosis required reoperation. Nine (9%) of the patients experienced infection (33 reoperation procedures); 6 (6%) had instrumentation failure (8 procedures); 5 (5%) had painful or prominent instrumentation (6 procedures); 3 (3%) each had coronal deformity (3 procedures), pseudarthrosis (3 procedures), or sagittal deformity (3 procedures); and 1 (1%) had progressive crankshaft chest wall deformity requiring a thoracoplasty (1 procedure).

CONCLUSIONS

A higher-than-anticipated percentage of patients treated with growing rods required unplanned reoperation following final fusion. Long-term follow-up after final fusion is necessary to determine true final results. Patients and parents need to be counseled regarding the possibility of further surgery after final fusion.

LEVEL OF EVIDENCE

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

Cost analysis of magnetically controlled growing rods compared with traditional growing rods for early-onset scoliosis in the US: an integrated health care delivery system perspective

Purpose

Traditional growing rod (TGR) for early-onset scoliosis (EOS) is effective but requires repeated invasive surgical lengthenings under general anesthesia. Magnetically controlled growing rod (MCGR) is lengthened noninvasively using a hand-held magnetic external remote controller in a physician office; however, the MCGR implant is expensive, and the cumulative cost savings have not been well studied. We compared direct medical costs of MCGR and TGR for EOS from the US integrated health care delivery system perspective. We hypothesized that over time, the MCGR implant cost will be offset by eliminating repeated TGR surgical lengthenings.

Methods

For both TGR and MCGR, the economic model estimated the cumulative costs for initial implantation, lengthenings, revisions due to device failure, surgical-site infections, device exchanges (at 3.8 years), and final fusion, over a 6-year episode of care. Model parameters were estimated from published literature, a multicenter EOS database of US institutions, and interviews. Costs were discounted at 3.0% annually and represent 2015 US dollars.

Results

Of 1,000 simulated patients over 6 years, MCGR was associated with an estimated 270 fewer deep surgical-site infections and 197 fewer revisions due to device failure compared with TGR. MCGR was projected to cost an additional $61 per patient over the 6-year episode of care compared with TGR. Sensitivity analyses indicated that the results were sensitive to changes in the percentage of MCGR dual rod use, months between TGR lengthenings, percentage of hospital inpatient (vs outpatient) TGR lengthenings, and MCGR implant cost.

Conclusion

Cost neutrality of MCGR to TGR was achieved over the 6-year episode of care by eliminating repeated TGR surgical lengthenings. To our knowledge, this is the first cost analysis comparing MCGR to TGR – from the US provider perspective – which demonstrates the efficient provision of care with MCGR.

Age at Initiation and Deformity Magnitude Influence Complication Rates of Surgical Treatment With Traditional Growing Rods in Early-Onset Scoliosis

STUDY DESIGN

Multi-center retrospective review.

OBJECTIVE

The purpose of this study was to identify preoperative variables associated with postoperative complications in early-onset scoliosis (EOS) patients treated with traditional growing rods (TGR); and to develop a model to predict the incidence of postoperative complications based on preoperative variables.

SUMMARY OF BACKGROUND DATA

TGRs are commonly used to treat progressive EOS. Prior research has demonstrated a high rate of postoperative complications using this technique; however, few studies have identified preoperative factors that contribute to such complications.

METHODS

A total of 110 patients who initiated TGR treatment before 10 years of age and completed final treatment were identified from a multi-center database. Overall treatment effect was calculated for major curve size, thoracic kyphosis, thoracic height, and total spine height. Univariable and multivariable logistic regression identified preoperative predictors of complications. An algorithm was developed and validated to calculate the probability of complications based on preoperative data.

RESULTS

All patients completed TGR treatment (average follow-up 8.1 years). The overall treatment effect was a significant decrease in major curve magnitude, increase in thoracic height, increase in spine height, and no significant change in thoracic kyphosis. There were 263 total complications in 87 patients (79%) resulting in 84 unplanned surgeries. The most common complications were implant-related (49%), surgical site infection (23%), medical (19%), alignment (6%), and neurologic (3%). The significant independent preoperative predictors of complications were age at implantation and preoperative thoracic kyphosis. Multivariable regression showed that age less than 7.6 years, thoracic kyphosis greater than 38 degrees, or major curve magnitude greater than 84 degrees significantly increased the probability of complications.

CONCLUSIONS

Earlier age at implantation, greater thoracic kyphosis, and larger major curves increased the probability of complications following TGR instrumentation. These findings provide a valuable tool for predicting complications that may aid in surgical planning and shared decision making with patients and their families.

LEVEL OF EVIDENCE

IV.

Avoidance of "Final" Surgical Fusion After Growing-Rod Treatment for Early-Onset Scoliosis

BACKGROUND

Definitive "final" surgical fusion is the common end point for growing-rod treatment of early-onset scoliosis. However, final surgical fusion may be unnecessary for patients who have reached skeletal maturity with good alignment. This study characterizes patients who completed growing-rod treatment but did not undergo final surgical fusion.

METHODS

Using a multicenter early-onset-scoliosis database, we identified 167 patients who received growing-rod treatment from 1995 through 2010, reached skeletal maturity, and had a minimum 2-year follow-up after their last surgery. Thirty patients did not undergo final surgical fusion (observation group) and were compared clinically and radiographically with 137 patients who did undergo final fusion (final surgical fusion group).

RESULTS

No significant differences were found between the groups with regard to the age at which treatment was initiated (p = 0.127), distribution of diagnoses (p = 0.84), or number of lengthening procedures (p = 0.692). In the observation group, 26 patients retained the growing rods and 4 patients had them removed at the last surgery because of infection. The mean primary curve correction at the end of treatment was 48% (from an initial mean magnitude of 79° to a mean final curve of 41°) in the observation group compared with 38% (from 74° to 46°) in the final surgical fusion group. There was no significant difference in final curve magnitude (41° in the observation group and 46° in the final surgical fusion group; p = 0.182). The mean increase in trunk height was 30.5% in the observation group and 35% in the final surgical fusion group. The final trunk height in the observation group was not significantly less than that in the final surgical fusion group (p = 0.142).

CONCLUSIONS

Because of progressive ankylosis, avoiding final surgical fusion at skeletal maturity is a viable option for patients treated with growing rods for all diagnostic subgroups of early-onset scoliosis who have satisfactory final alignment and trunk height, a minimal gain in length at the last distraction, and no clinical or radiographic evidence of implant-related problems.

LEVEL OF EVIDENCE

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

Longitudinal Pilot Analysis of Radiation Exposure During the Course of Growing Rod Treatment for Early-Onset Scoliosis

STUDY DESIGN

Retrospective consecutive case series.

OBJECTIVES

To estimate the amount of ionizing radiation (IR) exposure in growing rod (GR) surgery for early-onset scoliosis.

SUMMARY OF BACKGROUND DATA

There is substantial evidence of the health hazards attributed to IR exposure. However, no studies have estimated the amount of IR exposure in GR surgery.

MATERIALS AND METHODS

A consecutive single-center series of GR patients were retrospectively reviewed. Of 28 total patients, 24 had a minimum 2-year follow-up and complete records available for analysis. All spine-related IR imaging studies excluding intraoperative fluoroscopy were tabulated and IR estimated based on historical controls in millisieverts (mSv).

RESULTS

Initial x-ray evaluation for scoliosis was performed at a mean age of 4.0 years (range = birth to 9.7). Mean radiographic period was 8.5 years (range = 2.2 to 19.4). There was a statistically significant inverse correlation between patient age at time of initial IR and total mean IR (p < .05). Total IR was 3.4 times greater than that of estimated background radiation (2.4 mSv per year). Mean IR before index surgery and during the first postoperative year were 22.41 mSv and 10.78 mSv, respectively. Annual IR after the first postoperative year averaged 7.02 mSv (range = 2.25 to 13.45). Patients who underwent at least one revision surgery experienced significantly higher IR than nonrevision patients (79.95 vs. 46.58 mSv; p < .05). Overall, 89% of total IR was attributed to x-rays and 11% from computed tomography.

CONCLUSIONS

Compared to the general public, GR patients had 3.4 times more IR than the estimated background radiation for the same duration of time. Younger patients and those requiring revision surgery had significantly higher IR doses. This study underscores the importance of recognizing the amount of IR used in the management of GR patients and its potential long-term risks.

LEVEL OF EVIDENCE

III.

Is There an Optimal Time to Distract Dual Growing Rods?

STUDY DESIGN

Retrospective multicenter observational cohort study.

OBJECTIVES

To determine whether there is a significant difference in final spinal height achieved, instrumented height, or Cobb angle related to the mean time interval between distractions of dual growing rods.

SUMMARY OF BACKGROUND DATA

Patients were prospectively enrolled in "The Treatment of Progressive Early Onset Spinal Deformities: A Multi-Center Study." Additional data were collected via a retrospective review of medical records.

METHODS

Using data from a multicenter database, the authors identified 46 patients (23 boys and 23 girls) with early-onset scoliosis who were treated with dual growing rods and who had surgical treatment spanning more than 4 years. The patients were divided into 2 groups: those who had less than 9 months (16 patients) and those who had 9 months or more (30 patients) between distractions. Standard univariate statistics were calculated. The researchers performed 2-tailed t tests. Significance was set at p = .05.

RESULTS

The differences in primary Cobb angle, T1-S1 height, and instrumented segment length at the last distraction or final arthrodesis, compared with the post-index procedure values, were not significantly different (p = .52, .58, and .60, respectively) between groups with the available data. The normalized instrumented height gains, in millimeters per year, were not significantly different (p = .22).

CONCLUSIONS

Patients with longer times between growing-rod distractions (9 or more months) had no significant differences in primary Cobb angle, T1-S1 length, or instrumented length gain compared with patients with shorter times (less than 9 months) between distractions.

Traditional Growing Rods Versus Magnetically Controlled Growing Rods for the Surgical Treatment of Early-Onset Scoliosis: A Case-Matched 2-Year Study

INTRODUCTION

Traditional growing rod (TGR) surgery is a treatment technique commonly used for progressive early-onset scoliosis. Studies have shown that repeated TGR lengthenings can significantly increase the risk of complications. Magnetically controlled growing rods (MCGR) are currently available outside of the United States and early results have been promising. The purpose of this study was to compare the effectiveness of MCGR versus TGR for the treatment of early-onset scoliosis.

METHODS

Magnetically controlled growing rod patients were selected based on the following criteria: aged less than 10 years, major curve greater than 30°, thoracic height less than 22 cm, no previous spine surgery, and minimum 2-year follow-up. A total of 17 MCGR patients met the inclusion criteria, 12 of whom had complete data available for analysis. Each MCGR patient was matched with a TGR patient by etiology, gender, single versus dual rods, preoperative age, and preoperative major curve.

RESULTS

Magnetically controlled growing rod patients had a mean age of 6.8 years and mean follow-up of 2.5 years. Mean follow-up was greater for TGR patients by 1.6 years. Major curve correction was similar between MCGR and TGR patients throughout treatment. The MCGR patients experienced an average of 8.1 mm/year increase in T1-S1 during the lengthening period, compared with 9.7 mm/year for TGR patients (p = .73). There was a mean increase in T1-T12 of 1.5 mm/year for MCGR patients and 2.3 mm/year for TGR patients (p = .83). The TGR patients had 73 open surgeries, 56 of which were lengthenings. The MCGR patients had 16 open surgeries and 137 noninvasive lengthenings. Three TGR patients underwent 5 unplanned revision surgeries whereas 3 MCGR patients underwent 4 unplanned revisions.

CONCLUSIONS

Major curve correction was similar between MCGR and TGR patients throughout treatment. Annual T1-S1 and T1-12 growth was also similar between groups. The MCGR patients had 57 fewer surgical procedures than TGR patients. Incidence of unplanned surgical revisions as a result of complications was similar between groups.

Do Thoracolumbar/lumbar Curves Respond Differently to Growing Rod Surgery Compared With Thoracic Curves?

STUDY DESIGN

Retrospective study.

OBJECTIVES

To compare radiographic outcomes between primary thoracic and primary thoracolumbar/lumbar curves in patients with early-onset scoliosis (EOS) after growing rod (GR) surgery.

SUMMARY OF BACKGROUND DATA

Previous studies have shown the efficacy of GR surgery for progressive EOS. However, there is no information on the behavior of different curve patterns in EOS after GR surgery.

METHODS

A multicenter international EOS database query identified 175 patients who met the following inclusion criteria: non-congenital etiology, GR surgery, ≤ 10 years of age at index surgery, minimum 2-year follow-up, and at least 3 lengthenings. Patients were categorized into 2 groups based on the Scoliosis Research Society definition of the anatomical location of primary curves: group 1 included thoracic apices (T2 to T11/12 disc) and group 2 included thoracolumbar (T12 to L1) and lumbar (L1/2 disc to L4) apices. Radiographic measurements were performed before and after index surgery and at latest follow-up.

RESULTS

A total of 139 patients (79%) had primary thoracic (group 1) and 36 (21%) had primary thoracolumbar or lumbar curves (group 2). Mean number of levels instrumented was statistically greater in group 2 (15.0) versus group 1 (13.6) (p < .05). Group 2 had statistically better mean curve correction than group 1 after the index GR surgery (51% and 44%, respectively; p < .05). However, there was no significant difference in mean percent curve correction at latest follow-up (46% and 39%, respectively; p > .05). Implant complication rate was 45% and 47% for groups 1 and 2, respectively. Preoperative curve flexibility was greater in group 2 (45%) compared with group 1 (40%) (p > .05).

CONCLUSIONS

Overall, thoracolumbar/lumbar and thoracic curves achieve similar major curve correction and have a similar complication profile.

Deep Surgical Site Infection Following 2344 Growing-Rod Procedures for Early-Onset Scoliosis: Risk Factors and Clinical Consequences

BACKGROUND

Deep surgical site infection may change the course of growing-rod treatment of early-onset scoliosis. Our goal was to assess the effect of this complication on subsequent treatment.

METHODS

A multicenter international database was retrospectively reviewed; 379 patients treated with growing-rod surgery and followed for a minimum of two years were identified. Deep surgical site infection was defined as any infection requiring surgical intervention.

RESULTS

Forty-two patients (11.1%; twenty-five males and seventeen females) developed at least one deep surgical site infection. The mean age at the initial growing-rod surgery was 6.3 years (range, 0.6 to 13.2 years) and the mean duration of follow-up was 5.3 years (range, 2.2 to 14.3 years). The mean interval between the initial surgery and the first deep surgical site infection was 2.8 years (range, 0.02 to 7.9 years). Ten (2.6%) of the 379 patients developed deep surgical site infection before the first lengthening. Twenty-nine patients (7.7%) developed the infection during the course of the lengthening procedures, and three patients (0.8%) developed it after final fusion surgery. Thirty (13.6%) of 221 patients with stainless-steel implants had at least one deep surgical site infection compared with twelve (8%) of 150 patients with titanium implants (p < 0.05). (The remaining patients were treated with chromium-cobalt implants.) Twenty-two (52.4%) of the forty-two patients with deep surgical site infection underwent implant removal, which was complete in thirteen and partial in nine. Growing-rod treatment was terminated in two patients with partial removal and six patients with complete removal. An increased risk of deep surgical site infection was associated with stainless-steel implants (odds ratio [OR] = 5.7), non-ambulatory status (OR = 2.9), and the number of revisions before the development of deep surgical site infection (OR = 3.3). Neuromuscular etiology and non-ambulatory status increased the possibility of implant removal to treat infection (p < 0.05).

CONCLUSIONS

The prevalence of deep surgical site infection associated with growing-rod surgery is higher than that associated with standard pediatric spinal fusion (historical data). Non-ambulatory status, more revisions, and stainless-steel implants increased the risk of deep surgical site infection. After eight surgical procedures, the risk of deep surgical site infection increased to approximately 50%. When patients have implant removal, efforts should be made to retain one longitudinal implant to continue treatment.

LEVEL OF EVIDENCE

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

Surgical treatment of main thoracic scoliosis with thoracoscopic anterior instrumentation. Surgical technique

BACKGROUND

The surgical outcomes in patients with scoliosis at two years following anterior thoracoscopic spinal instrumentation and fusion have been reported. The purpose of this study was to evaluate the results at five years.

METHODS

A consecutive series of forty-one patients with major thoracic scoliosis treated with anterior thoracoscopic spinal instrumentation was evaluated at regular intervals. Prospectively collected data included patient demographics, radiographic measurements, clinical deformity measures, pulmonary function, an assessment of intervertebral fusion, and the scores on the Scoliosis Research Society (SRS-24) outcomes instrument. Perioperative and postoperative complications were recorded. Patient data for the preoperative, two-year, and five-year postoperative time points were compared. In addition, a univariate analysis compared selected two-year radiographic, pulmonary function, and SRS-24 data of the study cohort and those of the patients lost to follow-up.

RESULTS

Twenty-five (61%) of the original forty-one patients had five-year follow-up data and were included in the analysis. Between the two-year and five-year follow-up visits, no significant changes were observed with regard to the average percent correction of the major Cobb angle (56% +/- 11% and 52% +/- 14%, respectively), average total lung capacity as a percent of the predicted value (95% +/- 14% and 91% +/- 10%), and the average total SRS-24 score (4.2 +/- 0.4 and 4.1 +/- 0.7). Radio-graphic evaluation of intervertebral fusion at five years revealed convincing evidence of a fusion with remodeling and trabeculae present at 151 (97%) of the 155 instrumented motion segments. No postoperative infections or clinically relevant neurovascular complications were observed. Rod failure occurred in three patients, and three patients required a surgical revision with posterior spinal instrumentation and fusion.

CONCLUSIONS

Thoracoscopic anterior instrumentation for main thoracic idiopathic scoliosis results in five-year outcomes comparable with those reported previously for open anterior and posterior techniques. The radiographic findings, pulmonary function, and clinical measures remain stable between the two and five-year follow-up time points. Thoracoscopic instrumentation provides a viable alternative to treat spinal deformity; however, the risks of pseudarthrosis, hardware failure, and surgical revision should be considered along with the advantages of limited muscular dissection and improved scar appearance.

Surgical treatment of main thoracic scoliosis with thoracoscopic anterior instrumentation. a five-year follow-up study

BACKGROUND

The surgical outcomes in patients with scoliosis at two years following anterior thoracoscopic spinal instrumentation and fusion have been reported. The purpose of this study was to evaluate the results at five years.

METHODS

A consecutive series of forty-one patients with major thoracic scoliosis treated with anterior thoracoscopic spinal instrumentation was evaluated at regular intervals. Prospectively collected data included patient demographics, radiographic measurements, clinical deformity measures, pulmonary function, an assessment of intervertebral fusion, and the scores on the Scoliosis Research Society (SRS-24) outcomes instrument. Perioperative and postoperative complications were recorded. Patient data for the preoperative, two-year, and five-year postoperative time points were compared. In addition, a univariate analysis compared selected two-year radiographic, pulmonary function, and SRS-24 data of the study cohort and those of the patients lost to follow-up.

RESULTS

Twenty-five (61%) of the original forty-one patients had five-year follow-up data and were included in the analysis. Between the two-year and five-year follow-up visits, no significant changes were observed with regard to the average percent correction of the major Cobb angle (56% +/- 11% and 52% +/- 14%, respectively), average total lung capacity as a percent of the predicted value (95% +/- 14% and 91% +/- 10%), and the average total SRS-24 score (4.2 +/- 0.4 and 4.1 +/- 0.7). Radiographic evaluation of intervertebral fusion at five years revealed convincing evidence of a fusion with remodeling and trabeculae present at 151 (97%) of the 155 instrumented motion segments. No postoperative infections or clinically relevant neurovascular complications were observed. Rod failure occurred in three patients, and three patients required a surgical revision with posterior spinal instrumentation and fusion.

CONCLUSIONS

Thoracoscopic anterior instrumentation for main thoracic idiopathic scoliosis results in five-year outcomes comparable with those reported previously for open anterior and posterior techniques. The radiographic findings, pulmonary function, and clinical measures remain stable between the two and five-year follow-up time points. Thoracoscopic instrumentation provides a viable alternative to treat spinal deformity; however, the risks of pseudarthrosis, hardware failure, and surgical revision should be considered along with the advantages of limited muscular dissection and improved scar appearance.

LEVEL OF EVIDENCE

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