Purpose of study. The aim is to assess the use of non-fusion instrumentation “growth rods” in early onset scoliosis (EOS). Methods. A retrospective review of 12 consecutive patients who had undergone a growth rod procedure for EOS was performed. Six patients had neuromuscular scoliosis, 5 had juvenile idiopathic scoliosis while one had a congenital aetiology. Growth constructs were predominately constructed from modular commercially available sets using hooks, screws and connection blocks. One VEPTR was used in a severe kyphoscoliosis. Patients returned to theatre at 6 monthly intervals for a lengthening procedure. Patients were assessed with regards to age at presentation, age at surgery, indications for surgery, initial Cobb angle, post- operative Cobb angle, number of lengthening's done, instrumentation used, amount of spine growth achieved and complications. Results. The average age at presentation was 3 yrs 8 months (birth – 7 years 5 months). The average Cobb angle was 55 (38–90). Age at index surgery ranged from 2yrs 9 months to 8 years 2 months. The Cobb angle after the first procedure averaged 37 (range 20–90). The average lengthening over 51 lengthening procedures was 8 mm. Four patients have reached the end of the process and under gone a definitive fusion with pedicle screws and growth rods. Their final Cobb angle averaged 32 (26–48). Definitive surgery was performed earlier than planned in one patient due to repetitive rod breakage. Lengthening was abandoned in one patient whose implants became septic and required removal. Two patients required revision for superior construct failure. Conclusion. The growth rod procedure allows spinal deformity correction and control as well as on-going growth in trunk height. It is a labour intensive process with a significant incidence of complications. There is however very little choice in these patients due to concerns of fusion restricting pulmonary development. NO DISCLOSURES

Scoliosis is estimated to occur between 21–64% of patients with cerebral palsy (CP), where a subset of patients develops early onset scoliosis (EOS) before the age of ten. Traditional growth friendly (TGF) surgeries in the context of traditional growing rods have been shown to be effective in treating scoliosis in this population, however significant complication rates are reported. Currently, no studies have been done to examine the effect of novel growth friendly surgeries such as magnetically controlled growing rods (MCGR) on EOS in CP patients. The objective of this study is to compare MCGR with TGF surgeries in this patient population, specifically by evaluating radiographic measurements and risk of unplanned reoperations (UPRORs). Patients with EOS secondary to CP were prospectively identified from an international database, with data retrospectively analyzed. Scoliosis (primary curve), maximum kyphosis, T1-S1 and T1-T12 height were measured pre-operation, immediate post-operation, and at two-years follow-up. The risk and etiology of UPRORs were compared between MCGR and TGF. P < 0.05 was considered statistically significant for all analyses. Of the 120 patients that met inclusion criteria, 86 received TGF (age 7.5 ± 1.8 years; follow-up 7.0 ± 2.9 years) and 34 received MCGR (age 7.1 ± 2.2 years, follow-up 2.8 ± 0.5 years). Compared to TGF, MCGR resulted in significant improvements in maintenance of scoliosis correction (p=0.04). At final follow-up, UPRORs were 24% for MCGR (8/34 patients) and 43% (37/86 patients) for TGF (p=0.05). To minimize the influence of follow-up period, UPRORs within the first two years post-operation were evaluated: MCGR (21%, 7/34 patients) vs. TGF (14%, 12/86 patients; p=0.37). Within the first two years, etiology of UPROR as a percentage of all patients per group were deep infection (5% TGF, 6% MCGR), implant failure/migration (5% TGF, 9% MCGR), dehiscence (2% TGF, 3% MCGR), and superficial infection (1% TGF, 3% MCGR). The most common etiology of UPROR for TGF was deep infection and implant failure/migration and for MCGR was implant failure/migration. For patients with CP, at final follow-up, MCGR had superior maintenance of scoliosis correction; however, there was no difference in risk of UPROR within the first two years post-operatively (21% MCGR, 14% TGF)

Intrathecal morphine (IM) is a common adjunct in paediatric spinal deformity surgery. We previously demonstrated with idiopathic scoliosis it provides safe and effective analgesia in the immediate postoperative period. This study represents our 25 year experience with IM in all diagnostic groups. Our prospective Pediatric Orthopaedic Spine Database (1993–2018) was reviewed to identify all patients undergoing spinal deformity surgery who received IM and who did not. Patients 21 years of age or less who had a posterior spinal fusion (PSF) with segmental spinal instrumentation (SSI), and received 9–19 mcg/kg (up to 1 mg) of IM were included. Early onset scoliosis surgical patients were excluded. We assessed demographics, pain scores, time to first dose of opioids, diagnoses, surgical time, paediatric intensive care unit (PICU) admission and IM complications (respiratory depression, pruritus, nausea/ vomiting). There were 986 patients who met inclusion criteria. This included 760 patients who received IM and 226 who did not. IM was not used for short procedures (< 3 hrs), respiratory concerns, unsuccessful access of intrathecal space, paraplegia, and anesthesiologist decision. Both groups followed the same strict perioperative care path. The patients were divided into 5 diagnostic groups (IM / non IM patients): idiopathic (578/28), neuromuscular (100/151), syndromic (36/17), and congenital scoliosis (32/21) and kyphosis (14/9). Females predominated over males (697/289). The first dose of opioids after surgery was delayed for a mean of 10.6 hrs in IM group compared to 2.3 hrs in the non-IM group (p=0.001). The postoperative pain scores were significantly lower in the IM groups in the Post Anesthesia Care Unite (p=0.001). Only 17 IM patients (2%) were admitted to the PICU for observation secondary to respiratory depression, none required re-intubation. None of the IM group were re-intubated. Forty-nine patients (6%) experienced pruritus in the IM group compared to 4 of 226 patients (2%) in the non IM group. There were 169 patients (22%) of the IM patients and 21 patients (9%) of the non IM had nausea and vomiting postoperatively. Three patients (0.39%) had a dural leak from the administration of IM but did not require surgical repair. There were no other perioperative complications related to the use of IM. There were no significant group differences. Pre-incision IM is a safe and effective adjunct for pain management in all diagnostic groups undergoing spinal surgery. The IM patients had lower pain scores and a longer time to first administration of post-operative opioids. Although there is an increased frequency of respiratory depression, pruritus, and nausea/vomiting in the IM group, there were no serious complications

To evaluate the efficacy of VEPTR in preventing further progression of scoliosis without impeding spinal growth in the treatment of children with progressive early onset scoliosis (EOS) without rib abnormalities. Prospective, multi-center, observational cohort study on patients with EOS treated with VEPTR with 2-year follow up. Data were analysed based on measurements done pre-implant, immediate post-op and at 2-yr f/u. Sixty-three patients met inclusion: 35 males and 28 females. Mean age at time of implantation was 6.1±2.4 yrs. Etiologies included congenital (n=6), neuromuscular (n=36), syndromic (n=4), and idiopathic (n=17). Mean follow up was 2.2±0.4 yrs. Scoliosis (72o±18o) decreased after implant surgery (47o±17o) followed by slight increase at 2-yr f/u (57o±18o), p<0.0001. At 2-yr f/u, VEPTR was effective in treating EOS without rib abnormalities with 86% of patients having an improvement in scoliosis and 94% of patients having an increased spinal height as compared to pre-operatively. VEPTR provided greater than 100% of expected age-matched spine growth and the instrumented spinal segment continued to grow during distraction phase. This large prospective, multicentre study demonstrated the ability of VEPTER to effectively treat EOS without rib abnormalities. Goals of preventing further scoliosis progression and of maintaining normal spine growth were achieved

Introduction. Originally, the vertical expandable titanium rib (VEPTR™) was developed to treat children with Thoracic insufficiency syndrome secondary to fused ribs and congenital scoliosis. Over the years its usage has widen and is currently being used to treat all etiology of early onset scoliosis (EOS). A major draw back remains the size of the titanium VEPTR™ implant. In keeping with the new trend of chrome-cobalt alloy (CoCr). spinal implants, we set out to explore if redesigning the VEPTR™ was mechanically sound. The aim of this study was twofold. Firstly, we investigate the mechanical properties of a VEPTR™ made with CoCr alloy compared to that of titanium alloy. Secondly we investigated how much we could down size the VEPTR™. Materials & Methods. Finite element analyses were performed on 3 different VEPTR™ designs (rod diameter of 6mm, 5mm and 4mm) subjected to a compressive load of 500N (equivalent to a 50Kg child). For each configuration, two materials, titanium alloy and chrome-cobalt alloy, were used. Maximum Von Mises stress distribution (VMSD), plastic strain (PS) and total displacement (TD) of the VEPTR™ were measured as indicators of mechanical properties of the implant. Results. Results for the maximum Von Mises stress distribution (VMSD), plastic strain and total displacement (TD) can be seen on the table 1. Discussion. Results confirm that yield strength of titanium material is greater than that of Co-Cr, while Plastic strain (PS) is greater for a CoCr VEPTR™ than for titanium VEPTR™. As expected a 6 mm CoCr VEPTR resist displacement almost twice as a 6 mm titanium VEPTR. Little difference is noted in plastic strain and VonMises stress at 6mm. Down sizing the implant to 5 mm in titanium or CoCr may runs the risk of implant failure as both exceeds their failure point and they both deform 0.29% and 6.6% respectively, placing the 5mm CoCr at higher risk of failure. Our results suggest that the VEPTR™ design could be reduced to 5mm however requires a new design to minimize the risk of failure. 4mm rods will not withstand a 50kg load

Purpose. Management of early onset scoliosis (EOS) can be very challenging. Surgery is indicated when orthotics and casting fail. Growing rod instrumentation has become an effective approach in controlling the deformity while allowing spinal growth. However, as with any surgery, there are known complications including failure of the proximal foundation. We analyzed our patients who underwent growing rod instrumentation and identified factors that were correlated with proximal foundation failure. Method. Our Pediatric Orthopaedic Spine Database (1992–2010) was reviewed for all patients who underwent growing rod instrumentation. Sixty-six patients with EOS were identified and divided into two groups: Group 1 – proximal foundation failure; and Group 2 – no incidents of proximal failure. The two groups were evaluated for differences in age, sex, weight, upper vertebral level in construct, presence of apical fusion, and pre-operative curve magnitude. Results. Eight of the 66 patients (12%) had proximal foundation failure. When comparing Group 1 and Group 2, only age, pre-operative kyphosis, and presence of apical fusion were significant differences between the two groups. The mean age of Group 1 patients was 4.9 years (range, 2.6 to 9.2 years) and the mean age of Group 2 patients was 7.5 years (range, 2.4 to 11.6 years) (p <0.006). The mean pre-operative kyphosis in Group 1 was 71 degrees compared to 50 degrees in Group 2 (p=0.049). Among the 12 patients with apical fusion, four (33%) had proximal failure. The presence of apical fusion was also a significant difference between the groups (p=0.003). Linear regression demonstrated a significant correlation between kyphosis and failure (k=0.005, p-value 0.016) as well as age and pullout (k=−0.005, p-value <0.01). Conclusion. Our data indicates that younger patients with increased pre-operative kyphosis are at a higher risk for proximal failure of their growing rods resulting in increased incidence of unplanned surgeries. The presence of an apical fusion was also correlated to increased failure rates possibly due to stress at the proximal construct. Further research is needed to determine if stronger constructs decrease the pullout rate in the at-risk patients