B. Stephens Richards

A comparison between the Boston brace and the Charleston bending brace in adolescent idiopathic scoliosis

Study Design. The authors studied 319 patients with adolescent idiopathic scoliosis treated at the same institution with either a Boston brace or a Charleston bending brace. Objectives. To determine if both orthoses are equally effective in stopping curve progression and preventing the need for surgical correction. Summary of Background Data. Early reports suggest that the Charleston brace may be comparable to the Boston brace in its effectiveness and that both braces positively influence the natural history of idiopathic scoliosis. Methods. Skeletally immature (Risser 0, 1, or 2) patients with idiopathic scoliosis who were 10 years old or older at the time of brace prescription, had curves from 25° to 45°, and had no prior treatment were studied retrospectively. All measurements were collected by a single observer, and all patients were followed up to skeletal maturity. Results. The Boston brace is more effective than the Charleston brace, both in preventing curve progression and in avoiding the need for surgery. These findings were most notable for patients with curves of 36°-45°, in whom 83% of the those treated with a Charleston brace had curve progression of more than 5°, compared with 43% of those treated with the Boston brace (p < 0.0001). Conclusion. When given the choice between these two orthoses in the treatment of adolescent idiopathic scoliosis, the authors recommend use of the Boston brace. The Charleston brace should be considered only in the treatment of smaller single thoracolumbar or single lumbar curves.

A Comparison of Two Nonoperative Methods of Idiopathic Clubfoot Correction: The Ponseti Method and the French Functional (Physiotherapy) Method

BACKGROUND In the treatment of idiopathic clubfeet, the Ponseti method and the French functional method have been successful in reducing the need for surgery. The purpose of this prospective study was to compare the results of these two methods at one institution. METHODS Patients under three months of age with previously untreated idiopathic clubfeet were enrolled. All feet were rated for severity prior to treatment. After both techniques had been described to them, the parents selected the treatment method. Outcomes at a minimum of two years were classified as good (a plantigrade foot with, or without, a heel-cord tenotomy), fair (a plantigrade foot that had or needed to have limited posterior release or tibialis anterior transfer), or poor (a need for a complete posteromedial surgical release). Two hundred and sixty-seven feet in 176 patients treated with the Ponseti method and 119 feet in eighty patients treated with the French functional method met the inclusion criteria. RESULTS The patients were followed for an average of 4.3 years. Both groups had similar severity scores before treatment. The initial correction rates were 94.4% for the Ponseti method and 95% for the French functional method. Relapses occurred in 37% of the feet that had initially been successfully treated with the Ponseti method. One-third of the relapsed feet were salvaged with further nonoperative treatment, but the remainder required operative intervention. Relapses occurred in 29% of the feet that had been successfully treated with the French functional method, and all required operative intervention. At the time of the latest follow-up, the outcomes for the feet treated with the Ponseti method were good for 72%, fair for 12%, and poor for 16%. The outcomes for the feet treated with the French functional method were good for 67%, fair for 17%, and poor for 16%. CONCLUSIONS Nonoperative correction of an idiopathic clubfoot deformity can be maintained over time in most patients. Although there was a trend showing improved results with use of the Ponseti method, the difference was not significant. In our experience, parents select the Ponseti method twice as often as they select the French functional method.

Risk factors for the development of delayed infections following posterior spinal fusion and instrumentation in adolescent idiopathic scoliosis patients.

Study Design. Retrospective comparison study of patients who had a delayed infection following a posterior spinal fusion and instrumentation (PSFI) for adolescent idiopathic scoliosis (AIS). Objective. To define risk factors for the development of delayed infections following PSFI for AIS by comparing those patients who developed this complication to a randomly selected group of patients who did not. Summary of Background Data. Despite studies reporting the incidence and treatment of delayed infection following PSFI for AIS, there are no studies analyzing risk factors for its occurrence. Methods. All patients who required treatment for delayed infections following PSFI for AIS were identified (infection group, n = 36). A random selection of patients who did not develop a delayed infection (no infection, n = 90) was made in a ratio of 3:1 (no infection/infection). The 2 groups were compared using statistical methods. Results. Parameters associated with the infection group included: presence of a significant medical history, surgeon, less surgical time, a more distal fusion level (16% infection rate with a thoracic LIV vs. 33% infection rate with a lumbar LIV), not using postoperative drains, and increased drainage when drains were used. Other factors associated with infection were use of a blood transfusion and when increasing units of transfusion were used. Multivariate logistic regression analysis identified 3 factors that remained statistically significant: 1) significant medical history, 2) receiving a blood transfusion, and 3) not using a postoperative drain. Factors that were not associated with delayed infection included body mass index, the number of anchor points used, use of allograft bone, and the total number of levels instrumented and antibiotic regimen. Conclusion. The occurrence of a delayed infection is most likely multifactorial and is related to a positive past medical history and the use of blood transfusions. Postoperative use of a drain may be important to avoid delayed infection.

Building consensus: development of a Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high-risk pediatric spine surgery.

Background: Perioperative surgical site infection (SSI) after pediatric spine fusion is a recognized complication with rates between 0.5% and 1.6% in adolescent idiopathic scoliosis and up to 22% in “high risk” patients. Significant variation in the approach to infection prophylaxis has been well documented. The purpose of this initiative is to develop a consensus-based “Best Practice” Guideline (BPG), informed by both the available evidence in the literature and expert opinion, for high-risk pediatric patients undergoing spine fusion. For the purpose of this effort, high risk was defined as anything other than a primary fusion in a patient with idiopathic scoliosis without significant comorbidities. The ultimate goal of this initiative is to decrease the wide variability in SSI prevention strategies in this area, ultimately leading to improved patient outcomes and reduced health care costs. Methods: An expert panel composed of 20 pediatric spine surgeons and 3 infectious disease specialists from North America, selected for their extensive experience in the field of pediatric spine surgery, was developed. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were as follows: (1) surveyed for current practices; (2) presented with a detailed systematic review of the relevant literature; (3) given the opportunity to voice opinion collectively; and (4) asked to vote regarding preferences privately. Round 1 was conducted using an electronic survey. Initial results were compiled and discussed face-to-face. Round 2 was conducted using the Audience Response System, allowing participants to vote for (strongly support or support) or against inclusion of each intervention. Agreement >80% was considered consensus. Interventions without consensus were discussed and revised, if feasible. Repeat voting for consensus was performed. Results: Consensus was reached to support 14 SSI prevention strategies and all participants agreed to implement the BPG in their practices. All agreed to participate in further studies assessing implementation and effectiveness of the BPG. The final consensus driven BPG for high-risk pediatric spine surgery patients includes: (1) patients should have a chlorhexidine skin wash the night before surgery; (2) patients should have preoperative urine cultures obtained; (3) patients should receive a preoperative Patient Education Sheet; (4) patients should have a preoperative nutritional assessment; (5) if removing hair, clipping is preferred to shaving; (6) patients should receive perioperative intravenous cefazolin; (7) patients should receive perioperative intravenous prophylaxis for gram-negative bacilli; (8) adherence to perioperative antimicrobial regimens should be monitored; (9) operating room access should be limited during scoliosis surgery (whenever practical); (10) UV lights need NOT be used in the operating room; (11) patients should have intraoperative wound irrigation; (12) vancomycin powder should be used in the bone graft and/or the surgical site; (13) impervious dressings are preferred postoperatively; (14) postoperative dressing changes should be minimized before discharge to the extent possible. Conclusions: In conclusion, we present a consensus-based BPG consisting of 14 recommendations for the prevention of SSIs after spine surgery in high-risk pediatric patients. This can serve as a tool to reduce the variability in practice in this area and help guide research priorities in the future. Pending such data, it is the unsubstantiated opinion of the authors of the current paper that adherence to recommendations in the BPG will not only decrease variability in practice but also result in fewer SSI in high-risk children undergoing spinal fusion. Level of Evidence: Not applicable.

The Spinal Appearance Questionnaire: Results of reliability, validity, and responsiveness testing in patients with idiopathic scoliosis

Study Design. Prospective, sequential enrollment. Objective. We report the development and testing of the Spinal Appearance Questionnaire (SAQ) for reliability, validity, and responsiveness in patients with idiopathic scoliosis. Summary of Background Data. The SAQ was designed to measure patients’ and their parents’ perception of their spinal deformity’s appearance using standardized drawings and questions. This study was designed to test the instrument’s psychometric properties. Methods. The SAQ was administered as a test-retest to idiopathic scoliosis patients and parents for reliability and initial validity assessment (Group I). It was then administered to patients before surgery and 1 year after surgery (Group II) for responsiveness and further validity testing. Finally, both the SAQ and SRS instruments were administered to adolescent idiopathic patients before surgery and 1 year after surgery (Group III) for comparison of the 2 instruments. Results. Group I: The individual scale items had good to excellent reliability (Spearman’s rho, 0.57–0.99) and high internal scale consistency (Cronbach’s alpha >0.7). The mean scale scores differentiated between curves greater than 30° and lesser curves (P < 0.01). Surgery improved scores compared with those with “surgery recommended.” Group II: The domains correlated with clinical and radiographic aspects of the deformity before surgery. All of the domains showed significant difference after surgery (P < 0.0001) and large effect size for all domains except for the patient chest domain. Group III: Both the SAQ and the SRS instruments had significant improvement in all of their domains except for the SRS Activity scale. The relative efficiency of the SAQ domains to the SRS appearance domain (the most responsive SRS domain) was greater for 5 SAQ domains. Conclusion. The SAQ is reliable, responsive to curve improvement, and shows strong evidence of validity. It provides more detail than the SRS in the appearance domain, and provides explanation of spinal deformity’s concerns and improvements.

Screening for idiopathic scoliosis in adolescents: An information statement

Many states mandate school screening to identify children at risk for scoliosis, though recent studies have cast some controversy on the effectiveness of routine scoliosis screening. Previous studies have both supported and discouraged routine screening. Prevention of severe scoliosis is a major commitment of physicians caring for children with spinal deformities. For this reason, the American Academy of Orthopaedic Surgeons (AAOS), the Scoliosis Research Society (SRS), the Pediatric Orthopaedic Society of North America (POSNA), and the American Academy of Pediatrics (AAP) convened a task force to examine issues related to scoliosis screening and to put forth the present information statement. The societies acknowledge the important role of a systematic review of the literature as well as the role of consensus expert opinion in the common situation where the available evidence does not yet exist to speak definitely for, or against, an evaluation or intervention. Costs involved with scoliosis screening are relatively low on a societal level and may justify the possibility of preventing surgery in adolescents with scoliosis. Adolescents without significant spinal deformity who are referred to a specialist for evaluation often do not require radiographs. For those who do need radiographic evaluation, it is important to know that the radiation exposure using current-day radiographic techniques, including digital radiography, is significantly smaller than in the past. Opponents to scoliosis screening have focused on concerns about a low predictive value of screening and the cost-effectiveness of referral. There have also been concerns about the possibility of unnecessary treatment, including brace use, and the effect of exposure to radiation when radiographs are obtained. With regard to early treatment in those adolescents detected with moderate scoliosis, the available data neither definitively support nor refute the efficacy of bracing. To most effectively answer this, a well-organized level I study is needed. Such a study, …

Analysis of patient and parent assessment of deformity in idiopathic scoliosis using the Walter Reed Visual Assessment Scale.

Objectives. This study evaluates the Walter Reed Visual Assessment Scale (WRVAS) compared with clinical parameters and written descriptions of the deformity from idiopathic scoliosis patients and their parents. Summary of Background Data. The WRVAS demonstrates seven visible aspects of spinal deformity in an analogue scale. Higher scores reflect worsening deformity. Materials and Methods. The WRVAS was administered to 182 idiopathic scoliosis patients at four centers in conjunction with open-ended questions about patients’ and their parents’ perceptions of their spinal deformity. The open-ended responses were categorized as either “deformity noted” or “no deformity noted.” Results. WRVAS scores strongly correlate with curve magnitude (P = 0.01) and clearly differentiates curves of 30° or more from lesser curves. Among treatment groups, patients with surgery recommended had significantly higher scores than that of other patients. The instrument differentiated those noting no deformity from those noting a deformity. The correlation between patients’ and parents’ scores was high (Spearman’s rho = 0.8). When a deformity was noted, parents gave higher scores than did their children for rib prominence, shoulder level, scapular rotation, and the total score, but not for the other dimensions. Conclusions. Increasing scores of the WRVAS are strongly correlated with curve magnitude lending construct validity to this type of assessment tool. Patients with “surgery recommended” report more visible deformity on the scale than observed, braced, and postoperative patients, supporting the hypothesis that surgery improves the perceived appearance. Parents perceive more deformity of the ribs and shoulders more than did the patients, but other aspects of the deformity are identified equally. WRVAS scores correlate significantly with curve magnitude and treatment. Parents and patients have similar scores, but with parents perceiving more deformity of the ribs and shoulders than patients.

Pediatric pedicle screws: Comparative effectiveness and safety - A systematic literature review from the Scoliosis Research Society and the Pediatric Orthopaedic Society of North America task force

BACKGROUND Pedicle screws are widely used in spinal surgery. There is extensive published literature concerning the use of pedicle screw instrumentation for spinal surgery in adults. Now there is a trend to use pedicle screws in pediatric patients, including the very young. A systematic review of the current English-language literature on the use of pedicle screw instrumentation in the pediatric age group was performed to specifically determine (1) the pedicle screw placement accuracy in patients with spine deformity and (2) the effect size of all-pedicle screw constructs compared with other methods of spinal instrumentation in terms of the percentage of scoliosis correction. METHODS English-language studies of pedicle screw use in pediatric patients (defined as those younger than eighteen years of age) were included. Descriptive statistics synthesized the accuracy of pedicle screw placement. Accuracy rates were compared between pediatric and adult patients. The effect of pedicle screw instrumentation on scoliosis correction was calculated with use of Cobb angle measurements. RESULTS On the basis of the literature search, 1181 articles were screened, 320 abstracts were examined, and ninety full-text articles representing 5761 patients were reviewed in detail. Seventeen studies met the inclusion criteria for the analysis of pedicle screw placement accuracy. A total of 13,536 pedicle screws were placed in 1353 pediatric patients. The overall placement accuracy rate in pediatric patients was 94.9%, which was higher than the rate of 91.5% reported for adults. The weighted, geometric, and 5% trimmed mean accuracy rates of pedicle screw placement were 91.9%, 88.5%, and 89.1%, respectively (standard deviation = 10%; interquartile range = 10%). Sixteen comparative studies met the inclusion criteria for the analysis of the effect of pedicle screw instrumentation on scoliosis correction. Pedicle screw constructs had a significantly larger percentage of Cobb angle correction compared with hooks (Cohens d = 1.14) and hybrid constructs (Cohens d = 0.49). CONCLUSIONS The accuracy of pedicle screw placement in the pediatric spine exceeds the accuracy rate reported in adults. Pedicle screw instrumentation constructs are significantly more effective for scoliosis correction, as determined on the basis of Cobb angle measurements, than are hook constructs and hybrid constructs.

Comparison of reliability between the Lenke and King classification systems for adolescent idiopathic scoliosis using radiographs that were not premeasured.

Study Design. Multisurgeon comparison of two radiographic scoliosis curve classification systems was performed. Objective. To determine the reliability of the King and Lenke classifications systems for adolescent idiopathic scoliosis using radiographs that had not been premeasured. Summary of Background Data. Recent studies introducing the new Lenke classification system for idiopathic scoliosis have reported reliability improved over that of the King classification system. This newer classification system evaluates three different parameters (curve type, lumbar modifier, and sagittal thoracic modifier) and then combines them. The reliability of both classification systems had been determined using radiographs in which all of the curves had been premeasured (recorded on the radiographs) before review by examiners. However, in a normal clinical situation, spine surgeons need to determine the Cobb angles independently, thus introducing another variable. Methods. On two separate occasions, four orthopedic surgeons independently evaluated preoperative radiographs (standing posteroanterior, lateral, and two supine side-bending views) of 50 patients with adolescent idiopathic scoliosis. All measurements had been removed on every radiograph before each evaluation. The results were determined by calculating the average percentage of intraobserver and interobserver agreement. Reliability was quantified using kappa statistics. Results. The King classification demonstrated good intraobserver and fair interobserver reliability. Intraobserver percentage of agreement averaged 83.5% (kappa coefficient, 0.81). Interobserver percentage of agreement averaged 68.0% (kappa coefficient, 0.61). All three parameters of the overall Lenke curve classification demonstrated fair reliability. Intraobserver percentage of agreement averaged 65.0% (kappa coefficient, 0.60). Interobserver percentage of agreement averaged 55.5% (kappa coefficient, 0.50). When the Lenke curve type was examined separately, intraobserver percentage of agreement averaged 81.5% (kappa coefficient, 0.76) and interobserver percentage of agreement averaged 71.5% (kappa coefficient, 0.64). The results for this variable (curve type) were similar to those for the King classification. For the Lenke lumbar modifier, the percentage of agreement and reliability were excellent. For the sagittal thoracic modifier, the percentage of agreement was good, but the kappa values were low because of an extreme imbalance in the grouping of hypokyphotic, normal, and hyperkyphotic spines. Conclusions. In this study, with each investigator performing the radiographic measurements, the King classification was found to be better than had been reported recently. The Lenke classification system for adolescent idiopathic scoliosis was found to be less reliable than previously reported when the radiographs were premeasured. This was particularly true when all three parameters of this new classification system were combined. This difference in reliability of the Lenke classification between studies can be attributed to the additional variable of determining the Cobb measurements on each of the unmarked radiographs. Although this new classification system has limitations with respect to interobserver and intraobserver reliability, for planning operative treatment, it offers a more comprehensive radiographic evaluation of patients with adolescent idiopathic scoliosis than previous systems.

Correlation of preoperative deformity magnitude and pulmonary function tests in adolescent idiopathic scoliosis

Study Design. Clinical study correlating preoperative pulmonary function tests (PFTs) to radiographic measures of thoracic deformity severity in adolescent idiopathic scoliosis (AIS) patients. Objective. To determine (1) the incidence of clinically relevant (<65% predicted value) pulmonary impairment in AIS patients; (2) if patients with more severe deformity have greater impairment of PFTs than those with lesser deformity; (3) the effect, if any, of juvenile onset deformity (onset <age 10) on preoperative PFTs. Summary of Background Data. Patients with late-onset (adolescent) spinal deformity are generally believed to have no respiratory morbidity except in severe curves exceeding 100°. Methods. A large multicenter database of surgically treated AIS patients with Lenke 1 to Lenke 4 curves was queried to report preoperative PFTs and correlate them with radiographic measures of coronal, sagittal, and axial plane deformities. Results. Nineteen percent of 858 patients had <65% predicted forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) before surgery, and had larger main thoracic (MT) curves and greater axial rotation than those with predicted PFT values >65%. Patients with MT curves >70°, and especially >80°; proximal thoracic (PT) curves which were >30° or structural; or T5–T12 kyphosis <10° had significantly (P ⩽ 0.001) lower FEV1 or FVC compared to those with less deformity. Axial plane deformity did not correlate with PFT impairment. Juvenile-onset patients had greater PFT impairment than AIS patients, along with slightly larger MT curves. Patients who were braced before surgery had worse PFTs than those had no treatment before surgery. Conclusion. Preoperative PFTs are clinically impaired in 19% of AIS patients, and correlate significantly with the MT and sagittal plane deformity severity, and with PT curve severity to a lesser degree. PFTs do not correlate with degree of axial deformity. From a purely pulmonary standpoint, attention directed to coronal and sagittal plane deformity correction appears warranted, to address the specific deformities which are associated with PFT impairment.