Jeffrey Cassidy

Blood management in pediatric spinal deformity surgery: review of a 2‐year experience

BACKGROUND: Pediatric scoliosis surgery is associated with considerable blood loss and allogenic transfusions. Transfusions contribute to morbidities and cost. A perioperative pediatric blood management program was implemented at our institution. Patients received preoperative evaluation, cell salvage, topical hemostasis, antifibrinolytics, and hypotensive anesthesia.

Do multilevel Ponte osteotomies in thoracic idiopathic scoliosis surgery improve curve correction and restore thoracic kyphosis

Background: To compare the routine use of posterior-based (Ponte) osteotomies to complete inferior facetectomies in thoracic idiopathic scoliosis. Hypokyphosis is common in thoracic adolescent idiopathic scoliosis. The use of pedicle screw fixation in deformity correction can exacerbate this hypokyphosis. We hypothesized that by utilizing posterior-based Ponte osteotomies rather than facetectomies, we could improve coronal plane correction and decrease the loss of kyphosis during curve correction. Methods: The radiographs and clinical charts of patients with idiopathic scoliosis (Lenke types I, II) who underwent isolated thoracic posterior spinal fusion utilizing primarily pedicle screw constructs from January 2008 to August 2010 were reviewed. Maximum preoperative Cobb angle, thoracic kyphosis (T5-T12), levels instrumented, number of posterior-based osteotomies, operative time, estimated blood loss, and postoperative residual coronal Cobb angle and kyphosis were recorded. Operative time per level, blood loss per level, percent main curve correction, and change in thoracic kyphosis was calculated. Patients having undergone complete inferior facetectomies and those with multilevel Ponte osteotomies were then compared. Results: Eighteen patients underwent posterior spinal fusion with osteotomies and 19 patients had complete inferior facetectomies during this time period. The osteotomy cohort had a larger preoperative Cobb angle [59±10 vs. 52±8 (mean±SD); P=0.03]. No difference was observed in the preoperative kyphosis (22±15 vs. 25±12) or in levels fused (9±1 vs. 8±1). Patients with routine osteotomies had them performed at 76% of the levels instrumented. No significant difference was found in terms of percentage of coronal plane correction (84% in both groups), average postoperative kyphosis 28±8 versus 25±7, or the change in kyphosis 6±14 versus 0±2 degrees, in the osteotomy and the facetectomy groups, respectively. Estimated blood loss per level was significantly higher in the osteotomy group (97±42 mL vs. 66±25 mL; P=0.01) as was time per level 31±5 versus 23±3 minutes/level (P<0.001). Conclusions: This study shows a significantly higher blood loss and operative time associated with the use of routine posterior osteotomies in the thoracic spine without a significant improvement in coronal or sagittal correction.

Acetabular Retroversion in Military Recruits with Femoral Neck Stress Fractures

Acetabular retroversion (AR) alters load distribution across the hip and is more prevalent in pathologic conditions involving the hip. We hypothesized the abnormal orientation and mechanical changes may predispose certain individuals to stress injuries of the femoral neck. We retrospectively reviewed the anteroposterior (AP) pelvic radiographs of 54 patients (108 hips) treated for a femoral neck stress fracture (FNSF) and compared these radiographs with those for a control group of patients with normal pelvic radiographs. We determined presence of a crossover sign (COS), femoral neck abnormalities, and neck shaft angle. The prevalence of a positive COS was greater in patients with stress fractures than in the control subjects (31 of 54 [57%] versus 17 of 54 [31%], respectively) and higher than for control subjects reported in the literature. Thirteen patients had radiographic changes of the femoral neck consistent with femoroacetabular impingement (FAI). These radiographic abnormalities were seen more commonly in retroverted hips. A greater incidence of AR was noted in patients with FNSF. Potential implications include more aggressive screening of military recruits with AR and the new onset of hip pain. Finally, we present an algorithm we use to diagnose and treat these relatively rare FNSFs.Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Risser sign inter-rater and intra-rater agreement: is the Risser sign reliable?

BackgroundStudies directly evaluating the reliability of the Risser sign are few in number, possess small sample sizes, and offer conflicting results. This study establishes the reliability of the Risser sign on a large sample size in an effort to provide clarification on the subject.MethodsTwo years’ worth of AP pelvis radiographs from patients age 8–20 were downloaded from our institution’s digital imaging system. One hundred of these images were selected for inclusion by an independent reviewer whose goal was to capture a spread of radiographs that included all Risser stages. Risser grading occurred in two rounds. In each round, three examiners randomly reviewed the 100 radiographs on three different occasions. The full AP pelvis radiograph was graded in Round 1 while only the iliac apophysis was visible in Round 2. Kappa coefficients and their confidence bounds are reported to indicate intra- and inter-observer reliability. The contrast between the rates of agreement about Risser stages in Rounds 1 versus 2 was assessed by McNemar’s test. The signed-rank test was used to evaluate differences in intra-observer values between rounds.ResultsRound 1 inter-observer kappa was 0.76. Round 2 inter-observer kappa was 0.51. In Round 1, 63 radiographs showed perfect agreement within the same Risser stage for all observations compared to 44 radiographs with perfect agreement within the same Risser stage in Round 2 (p = 0.004). Round 1 intra-observer kappa values were 0.92, 0.86, and 0.88. Round 2 intra-observer kappa values were 0.91, 0.77, and 0.88. Intra-observer value differences between rounds were not significant for two observers (p = 0.074, 0.061) but was significant for the third observer (p = 0.002).ConclusionThe reliability of the Risser sign is acceptable and can be further improved when other markers of skeletal maturity on the pelvis radiograph are used to assist in grading.

The Efficacy of Amicar Versus Tranexamic Acid in Pediatric Spinal Deformity Surgery: A Prospective, Randomized, Double-Blinded Pilot Study

STUDY DESIGN Single-center, prospective, randomized, double-blinded trial. OBJECTIVES To compare blood loss, allogenic transfusion requirements, and coagulation parameters between pediatric spinal deformity patients receiving aminocaproic acid (Amicar) or tranexamic acid (TXA) during posterior spinal fusion. SUMMARY OF BACKGROUND DATA Amicar and TXA have been shown to decrease blood loss in pediatric spinal deformity cases compared with controls. The difference in efficacy between these medications in this population has not been reported. METHODS Enrolled patients were randomized to receive either Amicar or TXA during scoliosis surgery. Baseline demographic and deformity comparisons were collected. Intraoperative comparisons included estimated and calculated blood loss, number of levels instrumented, number of osteotomies, operative time, and allogenic transfusion requirements. Preoperative and postoperative hemoglobin, platelets, prothrombin time, partial prothrombin time (PTT), international normalized ratio (INR), and fibrinogen were recorded. RESULTS A total of 47 patients were enrolled with data available for review (N = 25, Amicar; N = 22, TXA). No difference in cohorts was found in demographics, preoperative hemoglobin, platelets, prothrombin time, PTT, INR, initial Cobb angle, average number of: levels fused, patients with osteotomies and osteotomies, operative time, and final Cobb angles. Estimated blood loss was significantly less (about 221 mL) than the calculated blood loss in both groups (p = .003). Estimated blood loss (1,088 vs. 726 mL; p = .055) and calculated blood loss (1,366 vs. 903 mL; p = .13) trended higher in the Amicar group. Although no difference in allogenic transfusion rates (20% vs. 14%) was observed, average volumes transfused were significantly higher in the Amicar cohort (1,014 vs. 461 mL; p = .03). The TXA cohort demonstrated a statistically significant smaller change in INR, a lower PTT, and greater fibrinogen levels postoperatively. CONCLUSIONS Compared with Amicar, TXA use was associated with a lower allogenic transfusion requirement, less alteration in postoperative clotting studies, and a trend toward lower blood loss in pediatric posterior spinal fusion patients.

Chondromyxoid Fibroma of the Lumbar Spine in a Pediatric Patient

Chondromyxoid fibroma is a rare nonmalignancy that comprises <1% of all bone tumors. It typically presents with pain, swelling, and tenderness to palpation. The lesion has a predilection for the metaphysis of long bones of the lower extremity, most commonly in the proximal tibial metaphysis. Patients often present in their second or third decade of life, although some reports have included a younger average age. Sporadic reports of chondromyxoid fibroma in the spine are found in the literature. This article presents the second case of a chondromyxoid fibroma of the lumbar spine in a pediatric patient, along with a literature review with emphasis on recurrence rates and malignant transformation.

Cervical spinal cord injury after thoracic spinal instrumentation: a case series.

Study Design. Retrospective case report of 2 cases. Objective. To describe 2 cases of cervical spinal cord injury/vascular insult after posterior instrumentation of thoracic/thoracolumbar scoliosis. Summary of Background Data. Spinal cord injury is an uncommon but well-documented complication associated with spinal deformity surgery. The midthoracic spinal cord is most vulnerable to these presumed vascular insults. Injuries above the level of instrumentation are rare. Methods. In this report, we review the clinical histories of 2 adolescent females undergoing posterior spinal fusion with subsequent cervical spinal cord injuries. Results. In both cases, intraoperative cervical alignment appeared neutral and all hardware appeared appropriately positioned. Spinal cord monitoring demonstrated changes in 1 patient but not in the other. With time, both patients improved clinically. Conclusion. Cervical spinal cord injuries may occur after distal deformity correction.

Treatment of Iatrogenic Chyloretroperitoneum with Octreotide Following Spinal Deformity Correction

Chylous fluid leakage is a rare but well-described complication of anterior spinal surgery1-6. Conservative treatment, including a drainage tube and a low-fat diet or total parenteral nutrition supplemented with oral medium-chain triglycerides, has had varying success. Treatment is often prolonged, requiring continuous drainage for up to six months in some reported series7. The use of octreotide, a somatostatin analogue, was first described in the general surgery literature for the treatment of chylothorax resulting from a ruptured thoracic duct2,4,5. Numerous reports have confirmed the success of octreotide in the treatment of chylous accumulations in the chest, peritoneal cavity, and retroperitoneum, although, to the best of our knowledge, there is no mention of its use in the orthopaedic literature. We report a case of chyloretroperitoneum following lumbar hemivertebrectomy that was successfully treated with octreotide. The patient and his parents were informed that data concerning the case would be submitted for publication, and they provided consent. No patient identifiers were used in the course of this investigation in accordance with Health Insurance Portability and Accountability Act regulations. A five-year-old boy with a midlumbar hemivertebra had undergone convex hemiepiphysiodesis from a combined anterior and posterior approach when he was three years old. The curve continued to progress, and he subsequently underwent a hemivertebrectomy with anterior spinal fusion and posterior spinal instrumentation and fusion two years later (Figs. 1 through 4⇓⇓⇓). During the left-sided anterior approach, we noted substantial scarring from the initial surgical procedure. The ureter was identified and protected. A steady accumulation of clear fluid was noted after the approach was completed. The fluid formed fat droplets when irrigated and appeared to be chyle. The source could not be identified, …