Joshua M. Pahys

Background: Curve-specific risk factors for intraoperative neuromonitoring (IONM) alerts during surgery for adolescent idiopathic scoliosis (AIS) remain unclear. Methods: We identified 5,206 patients with AIS who underwent spinal fusion with multimodal IONM from a prospective database. Alerts were defined as ≥50% amplitude decrease in somatosensory evoked potentials (SSEPs) and/or transcranial motor evoked potentials (TcMEPs), or >10% SSEP latency increase. Demographics, radiographic parameters, surgical variables, triggering events, interventions, and outcomes were compared between the 252 patients with and 4,954 without an alert. Results: IONM alerts occurred in 5% of patients. Alert rates varied by Lenke classification, with Type-4 curves demonstrating the highest risk (8%; relative risk [RR] = 1.61, 95% confidence interval [CI], 1.15 to 2.24) and Type 5 demonstrating the lowest risk (2%; RR = 0.45, 95% CI, 0.25 to 0.82). Patients with an alert had a larger mean preoperative major Cobb angle (66.7° ± 15.0° versus 56.1° ± 12.1°, p < 0.001) and more frequent use of Ponte osteotomies (79% versus 66%, p < 0.001). Multivariable analysis demonstrated the major Cobb angle to be the leading independent risk factor for alerts (p < 0.001). Hypotension was the leading triggering event (23%), and raising blood pressure was the most common intervention overall (52%). Neurologic deficits occurred in 4% of patients with an alert versus <1% of those without an alert (p < 0.001). Only 12 patients (<1%) experienced neurologic deficits, with 2 having permanent deficits. At 2-year follow-up, the major Cobb angle correction did not differ significantly between the groups with and without alerts, alert status did not independently affect correction (p = 0.058), and the groups achieved similar outcomes (73% versus 71% correction, respectively). Conclusions: IONM alerts occurred in 5% of patients with AIS and were independently associated with a larger major Cobb angle. Fewer than 1% of patients sustained a permanent neurologic injury, and alerts did not appear to compromise 2-year correction. Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: Vertebral body tethering (VBT) is a fusionless surgical technique used to treat adolescent idiopathic scoliosis (AIS). It is unclear what the optimal window is for surgical intervention using VBT. The purpose of this study is to report the rate of success following VBT in patients with open triradiate cartilage (OTC) and to report the rate of reoperation. Methods: A retrospective review was performed for patients with early-onset scoliosis (EOS) or AIS with OTC who underwent VBT from 2012 to 2020 with a minimum 2-year follow-up. Success was defined as curves P P P 51 degrees, percent thoracic correction 79 degrees. Overcorrection was associated with an upright preoperative thoracic major curve <46 degrees. Level of Evidence: Level IV.

Background: Understanding outcomes of spinal fusion (SF) in children with cerebral palsy (CP) beyond the short term is important to determine efficacy and durability. This study examined complications, unplanned returns to the operating room (UPROR), and radiographic and clinical outcomes after SF in children with CP. Methods: Patients with GMFCS IV or V CP who had been followed for a minimum of 5 years after SF were identified in a prospective multicenter database and analyzed. The major Cobb angle and pelvic obliquity (PO) were recorded. Data regarding complications and any UPROR were collected prospectively. The Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaire was completed preoperatively and at 2 and 5 years postoperatively. Data were analyzed using a generalized estimating equation (GEE), repeated-measures analysis of variance (RM-ANOVA), and the Kaplan-Meier method. Results: One hundred and eighty-nine patients (mean age, 13.4 ± 2.7 years; 94 male and 95 female; 45% White, 24% Hispanic, 16% Black, and 4% Asian as self-reported) were included in the study. The preoperative Cobb angle (82.8° ± 23.0°) was improved at 2 years (29.9° ± 16.2°; p < 0.001), and the improvement was maintained at 5 years (30.2° ± 17.0°; p = 0.284). The preoperative PO (27.4° ± 15.6°) was improved at 2 years (9.7° ± 9.1°; p < 0.001), and the improvement was maintained at 5 years (9.9° ± 9.8°; p = 0.997). There were 46 patients (24.3%) with major complications and 25 patients (13.2%) who required UPROR, mostly within the first year. The probability of remaining free of major complications and of having no UPROR at 5 years was >75% and >87%, respectively. Improvements in CPCHILD scores were observed at 2 years and remained improved at 5 years compared with baseline. RM-ANOVA demonstrated no significant differences in the change in scores over time in patients with complications or UPROR compared with those who did not. Those with complications or UPROR showed no evidence of a major decline in CPCHILD scores. Conclusions: SF resulted in durable radiographic correction and sustained improvements in caregiver-reported quality of life over a minimum of 5 years. Patients with major complications or UPROR showed no deterioration in CPCHILD scores. These findings support SF as an effective treatment option for appropriately selected patients with GMFCSIV or V CP. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Purpose Anterior vertebral body tethering (VBT) is a viable option for children with idiopathic scoliosis. Treating double major curves with bilateral VBT may allow patients to avoid spinal fusion while improving the coronal Cobb angle. Methods A single center retrospective study was conducted to identify all patients who underwent bilateral VBT (lowest instrumented vertebra L3 or 4) with minimum 2-year follow-up. Clinical and radiographic parameters were collected, including complications and reoperations. Statistical analysis was performed utilizing Students’ t-test. Results Seventy-three patients (67 female, 91.8%) underwent bilateral VBT with mean follow-up of 4.2 ± 1.5 years. Preoperatively, all patients were skeletally immature (age 12.7 ± 1.2 years with a Sanders score of 3.3 ± 0.8 and Risser grade of 0.6 ± 0.8). The preoperative lumbar Cobb angle was 51.1° ± 7.9° which corrected to 20.7° ± 11.3° at most recent follow-up (p < 0.01) and the thoracic Cobb angle measured 52.3° ± 9.0° which corrected to 27.0° ± 11.3° (p < 0.01) at most recent follow-up. At latest follow-up, 51/73 (69.9%) had a thoracic Cobb angle <30°, 59/73 patients (80.8%) had a lumbar Cobb angle <30°, and 47/73 (64.4%) had both thoracic and lumbar Cobb angles <30°. 15 patients (20.5%) underwent 17 reoperations with overcorrection being the most common indication (8/17, 47.1%). Broken tethers led to reoperation in 3/17 instances (17.6%). Five patients (6.8%) eventually required posterior spinal fusion. Conclusions Bilateral VBT is a safe procedure and may be a viable option for patients with double curves, with the majority of curves measuring <30° at most recent follow-up. Surgeons can use these data to help patients and parents make informed decisions regarding treatment options.

Purpose Neurofibromatosis type 1 (NF-1) is a genetic disease with many clinical manifestations, including early onset scoliosis (EOS). There has been increasing interest in the use of growing rod constructs in these patients. Our study seeks to understand the complication rates of these procedures in patients with NF-1. Methods In this multicenter retrospective study, demographic data, radiologic measurements, type of surgical construct, complication information, and deformity outcomes were obtained. This information was then summarized using descriptive statistics in order to evaluate complication rates in the total cohort, between different types of curves, and between different surgical constructs. Results Thirteen patients (8 males and 5 females) were included in the study, eight with dystrophic and five with non-dystrophic scoliosis. The mean preoperative major Cobb angle was 67.8° (median 75°, interquartile range [IQR] 53–83°). Four types of growth-friendly constructs were employed: seven vertical expandable prosthetic titanium rib (VEPTR), four traditional growing rod (TGR), one magnetically controlled growing rod (MCGR), and one Shilla. Major complications occurred in 11/13 patients (85%). Three patients (23%) had surgical site infections, nine (69%) had instrumentation complications, four (31%) had an unplanned surgical intervention other than for fusion, two (15%) had neurological complications, three (23%) had other complications, and seven (54%) required early surgical fusion. Two patients (15%) had additional complications after definitive fusion. The rate of overall complication rates was similar for dystrophic versus non-dystrophic curves (88% versus 80%). Discussion There is a high rate of complications associated with growth-friendly constructs in patients with NF-1 dystrophic and non-dystrophic scoliosis. These complications must be weighed against the advantages of these procedures when deciding on the optimal procedure for patients with NF-1 EOS.

Introduction Management of early onset scoliosis (EOS) patients can require growth-friendly surgery to manage spinal deformity in children too immature for a definitive fusion. There is limited literature on outcomes for patients with failed growing constructs requiring removal of implants (ROI). Methods We studied EOS patients from an international registry undergoing removal of growth-friendly implants, comparing early re-implantation (within 12 months of ROI) to observation-only. We examined demographic data and radiographic measurements with a significance level of p < 0.05. Results Sixty-four patients met the inclusion criteria for radiographic analysis: 53 had early re-implantation and 11 were observed. There were no significant differences between the groups in age at index, ROI, or etiology. Pre-ROI, observation and re-implantation groups had similar coronal Cobb angles (55° vs 47°, p = 0.35) and similar time from index procedure to ROI. However, at two years post-ROI, the observation group had a larger coronal Cobb angle than the re-implantation (81° vs 53°, p = 0.003). In the re-implantation group, 16 (30%) patients progressed ≥ 5° vs 7 (64%) in the observation group (p = 0.04). The re-implantation group had a smaller difference in major Cobb angle between post-ROI and two years post-ROI (−2° vs 12°, p = 0.01). The re-implantation group had no significant progression in the major Cobb angle at two years post-ROI compared to immediate post-ROI (55° vs 53°, p = 0.36), while the observation group increased by about 13° (68° vs 81°, p = 0.03), resulting in a total increase of more than 25° from pre-ROI. Conclusion Our interim data strongly suggest that promptly replacing removed implants stabilizes curves in this population of EOS patients. Timely re-implantation should be a priority, when possible, to enhance outcomes, despite technical challenges for some patients.

Case: Monozygotic 19-year-old female twins with Treacher Collins syndrome presented with progressive scoliosis; their primary thoracic curves measured 73° in Twin 1 and 52° in Twin 2. Both patients underwent posterior spinal fusion with low-density pedicle screw constructs and, at 1 year, demonstrated marked radiographic correction and improved quality of life. Conclusion: Although often overshadowed by craniofacial findings, extracraniofacial manifestations, such as spinal deformity, in Treacher Collins syndrome can cause severe morbidity. Early detection and timely fusion with low-density constructs provide safe, durable correction in severe cases. Level of Evidence: IV.