Amy L. McIntosh

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Purpose: This case series aims to highlight Horner’s syndrome, a clinical diagnosis of unilateral ptosis, miosis, and anhidrosis, as a rare complication of posterior spinal surgery in pediatric patients. Methods: In this series, we present three pediatric patients who developed Horner’s syndrome after surgical correction of scoliosis involving the cervicothoracic region. Results: Case 1 is a 12-year-old female with DiGeorge syndrome who underwent revision surgery with extension into the cervical spine after developing proximal junctional kyphosis 2 years after her index spinal fusion procedure. Case 2 is a 9-year-old girl who had posterior spinal fusion for progressive thoracic congenital scoliosis. Case 3 is a 4-year-old female with Klippel–Feil syndrome who underwent correction of a cervicothoracic curve and hemivertebrae excision. Postoperatively, all three patients were noted to have either unilateral miosis or ptosis, with an eventual diagnosis of acquired Horner’s syndrome. Conclusions: This case series demonstrates that Horner’s syndrome is a rare complication after a posterior spinal fusion in the pediatric population. Each case highlights that the oculosympathetic pathway can be susceptible to injury during deformity correction, specifically near the cervicothoracic region, whether from traction injury or overt nerve root transection.

Schwartz–Jampel syndrome (SJS) is associated with neuromuscular and structural abnormalities that can complicate perioperative and anesthetic management. The syndrome has been noted to create increased difficulty in anesthetic airway management with age. We report the perioperative course of a 13‐year‐old female with presumed SJS undergoing combined anterior and posterior spinal fusion for severe progressive congenital scoliosis. Preoperative evaluation revealed features predictive of a difficult airway, including limited mouth opening and restricted neck mobility, requiring video laryngoscopy for successful intubation. During the anterior thoracoscopic phase, dense pleural adhesions were encountered, requiring extensive pleural dissection and adhesiolysis to allow completion of the release of the anterior spinal column. After repositioning prone for the posterior procedure, the patient developed acute ventilation difficulty with markedly elevated airway pressures and severe hypercarbia. Flexible bronchoscopy revealed a nearly occlusive sanguineous mucus plug within the endotracheal tube, prompting abortion of the procedure. The patient returned 1 week later for completion of surgery, and difficulty with endotracheal tube depth was encountered due to a foreshortened trachea. She otherwise recovered without major complications. This case highlights the perioperative management of a complex pediatric neuromuscular scoliosis patient undergoing combined anterior and posterior spinal procedures. It underscores the importance of anticipating unexpected pulmonary complications in patients with difficult airway anatomy and severe restrictive lung disease. Heightened awareness of endotracheal tube obstruction and malposition is imperative.

Background Literature is scarce regarding health-related quality of life priorities between caregivers and children with scoliosis with an underlying neuromuscular, syndromic, or skeletal dysplasia diagnosis (NSSD). Section 7 of the CPCHILD offers a tool for assessing unique QoL concerns in this population with a 36-item assessment. Our objective was to identify areas of agreement/disagreement between caregivers and children regarding QoL priorities. Methods A retrospective review of prospectively, consecutively enrolled NSSD patients who underwent scoliosis surgery from 2016 to 2022. Descriptive statistics were performed to rank the responses in order of priority. Based on rankings, the 36 QoL items were grouped into concordant agreement (high/low priority) and discordant agreement (high priority to caregiver or children). The cohort was further analyzed by diagnosis and ambulatory status. Results 195 CPCHILD questionnaires were analyzed. “Overall health”, “Happiness”, and “Comfort while sitting” were items both caregivers and children agreed were high priorities. Conversely, items such as “Putting on/taking off upper clothes”, “Putting on/wearing footwear”, “Hair care/grooming”, “Transferring into/out of a wheelchair/chair”, “Standing for exercise/transfers”, and “Able to play alone” were low priorities. Conclusion NSSD families share global QoL priorities, however, distinct priorities can be identified between diagnostic and functional groups. Understanding these areas of concordance and discordance may help providers address and assess the outcomes of scoliosis surgery. Our findings recognize that the impact of scoliosis surgery extends beyond improving spinal alignment and function. Factors such as emotional well-being, social engagement, and functional independence clearly influence perceptions of QoL in anticipation of scoliosis surgery.

Purpose: To examine if coronal deformity angular ratio (C-DAR) serves as a predictor for progression to surgical magnitude in patients with Adolescent Idiopathic Scoliosis (AIS) treated with thoracolumbar sacral orthosis (TLSO). Methods: Patients with AIS, prescribed a full-time TLSO, Cobb angle 20–40°, Risser 0–2, who wore the brace ≥ 12.9 h and reached skeletal maturity/surgery were included retrospectively. C-DAR was defined as the Cobb angle divided by the number of vertebrae in the curve, yielding a larger value in short curves. The association between C-DAR and the risk of progression to surgical magnitude (> 45°) was assessed. Secondly, we evaluated the association between pre-treatment Cobb angle and in-brace correction on the risk of progression to > 45°. Results: We included 165 patients with a mean Cobb angle of 30 ± 6°. Of these, 46/165 (28%) progressed ≥ 6° and 26/165 (16%) reached surgical magnitude at the end of treatment. C-DAR was a significant predictor for risk of progression to surgical magnitude with an OR of 1.9 (CI 1.2–2.9) per unit increase in C-DAR. A threshold value of 5.15 was established and demonstrated an OR 5.9 (CI 2.1–17.9) for curve progression to a surgical magnitude. Likewise, pre-treatment Cobb angle showed a significant OR 1.3(CI 1.2–1.4) per degree increase in Cobb, whereas in-brace % correction showed OR 0.96 (CI 0.93–0.98). Conclusion: C-DAR is an independent predictor for progression to a surgical magnitude in AIS patients treated with bracing. Patients with a higher C-DAR should be counseled to help set realistic expectations regarding the likelihood of curve progression despite compliance with brace wear.

Purpose This study calculated the rates of Unplanned Return to the Operating Room (UPROR) in early-onset scoliosis patients who had no previous spine surgery and underwent Magnetically Controlled Growing Rod (MCGR) implantation. Methods We reviewed surgical, radiographic, and UPROR outcomes for EOS patients treated with the MCGR implant < 12 years + 11 months of age, had complete preop/postop major curve measurements, and had complete MCGR details. Results 376 patients underwent MCGR implantation at a mean age of 7.7 years (1.8–12.9). Diagnoses included 106 (28%) idiopathic, 84 (22%) syndromic, 153 (41%) neuromuscular, and 33 (9%) congenital. The mean preop-cobb was 76.7° (9–145°), and an immediate postop correction was 41% (0–84%). We found that 38% (142/376) of patients experienced an UPROR prior to the maximal actuator length being achieved. UPROR occurred at mean 2 years (3 days–5 years) after initial implantation. Of the 142 patients who experienced UPROR there were 148 complications that lead to an UPROR. The most common reason for UPROR was anchor (55/148: 37%) or MCGR implant related (33/148: 22%). Wound related (22/148:15%), Neuro related 4/148: 3%), and other (34/148: 23%) accounted for the remaining UPROR occurrences. Conclusion In conclusion, the MCGR UPROR rate was 142/376 (38%) after an average of 2 years post implantation. At 2-year follow-up, only 20% of MCGR patients had experienced an UPROR. However, between 2 and 5 years, the development of an UPROR increased precipitously with only 39% of MCGR patients remaining UPROR free at 5 years post MCGR implantation. The most common reason for UPROR was related to anchor or MCGR implant-related complications. This information can be utilized to set realistic expectations about the need and timing of future surgical procedures with patients and their families.

Background Neuromuscular and syndromic (NMS) scoliosis patients are at higher risk of acute surgical site infections (SSIs). Despite following POSNA’s endorsed consensus-based guidelines for SSI prevention, our institutional rates of acute SSI have varied dramatically. This variability drove simultaneous strategies to lower SSI rates: the creation of a preoperative Medical Optimization Clinic (MOC) and use of antibiotic-impregnated (Abx-I) calcium sulfate beads. Methods Patients undergoing index PSF at a single institution between 2016 and 2022 were retrospectively reviewed. Patients with ≥ 2 risk factors were included: (1) BMI < 18.5 or > 25; (2) incontinence; (3) instrumentation to pelvis; (4) non-verbal; (5) GMFCS IV/V. SSI was defined as deep infection within 90 days. We compared patients who attended MOC and received Abx-I (MOC + Abx-I) to those receiving neither intervention (control) nor a single intervention. Results 282 patients were included. The overall infection rate was 4.26%. Higher GMFCS (p = 0.0147), non-verbal status (p = 0.0048), and longer fusions (p = 0.0298) were independently associated with infection rate. Despite the MOC + Abx-I group having larger Cobb angles (88° ± 26°), higher GMFCS levels (4.5 ± 0.9), ASA class (3 ± 0.4), and more frequent instrumentation to the pelvis (85%), they had the lowest infection rate (2.13%) when compared to the control (4.2%) or single intervention groups (5.7%, 4.6%) (p = 0.9). Conclusion The study examined the modern infection rate of NMS patients following the implementation of two interventions: MOC and Abx-I. Despite having higher risk factors (curves (88°), GMFCS level (4.5), ASA class (3), higher % instrumentation to the pelvis (85%)), the patients treated with both interventions demonstrated the lowest infection rate (2.13%).

Purpose Determine peri-operative risk factors predictive for prematurely stopping surgery prior to completion of deformity correction due to intra-operative neuromonitoring changes. Methods A single institution retrospective review of adolescent idiopathic scoliosis (AIS) patients that underwent spinal fusion for curves greater than 70°. Cases aborted due to persistent loss of IONM were compared to completed cases. Demographic, radiographic, neurologic, and surgical information was reviewed. Results There were 453 total cases. Nine (9/453: (2%)) cases were aborted due to persistent loss of IONM, and 4 (4/453; (0.88%)) awoke with a neurologic deficit. Comparing to the 444 completed cases, pre-operative risk factors associated with case abortion were older age (15.3 vs. 13.8 years; p = 0.02), sex (male) (66.7% vs. 20.3%, p = 0.004), and larger cobb angles (87.6° vs. 79.2°; p = 0.01). Being male increased the risk of case abortion: 7.9X. Intraoperative risk factors associated with case abortion were combined anterior/posterior approach (ASF/PSF) (44.4% vs. 7.2%; p = 0.003) and increased index procedure EBL (1127 vs. 769 mL; p = 0.043). ASF/PSF increased the risk: 10.3X. Four (4/9;44%) of the aborted cases awoke with neurologic deficit. Motor strength returned at 2.3 days (0–18). Aborted cases returned to the OR after 12.6 ± 7.0 days (1–23) which was related to time to regain motor strength. Conclusion Pre-operative risk factors for AIS case abortion due to persistent loss of IOMN are older age, males, with larger Cobb angles. Intraoperative risk factors are combined ASF/PSF and increased index procedure EBL. Independent risk factors were sex (male) and ASF/PSF which increased the risk 7.9X and 10.3X, respectively.