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

Background:. Spinal deformity surgery carries the risk of loss of neurological function which may be permanent. Although the overall the incidence is low it is much higher in complex congenital deformities or those with pre-existing myelopathy. Intra-operative spinal cord monitoring allows this risk to be reduced by providing feedback to the surgeon while the corrective manoeuvres are performed. Although ideally a trained technician with multimodal monitoring is recommended, it is often not an option in a resource limited environment and surgeon operated technology is used. Aim:. to evaluate the use of surgeon operated trans-cranial motor evoked potentials (tcMEP) in spinal deformity surgery. Methods:. A retrospective review was conducted on a single surgeon series of 108 consecutive cases utilising the NIM system (Medtronic). Percutaneous needles were employed in the scalp, both hands and feet to allow the upper limbs to act as controls. Forty-nine patients were 13 years old or less, 47 were 14–18, and 12 adults. The cohort consisted of 54 AIS, 27 neuromuscular scoliosis, 14 congenital, 2 old TB and 11 miscellaneous. The vast majority were posterior based procedures. Results:. In 4 cases initial traces could not be obtained. One was a severe myelopathy and further efforts to monitor were abandoned. In one case the anaesthetist had broken protocol and once converted to TIVA the traces improved. Two others were poor initially but improved as the case progressed. In 8 cases intra-operative traces were lost. One was thought to be due to hypothermia and the patient woke intact. Two were unrelated to surgical intervention and recovered spontaneously with patients waking intact. Four cases deteriorated during the corrective manoeuvre (one delayed) and recovered with reduction of correction. One case required removal of instrumentation after repeated loss each time rods were inserted and awoke with a weak leg but recovered and was re-operated two weeks later. Conclusion:. Surgeon operated tcMEP's allows feedback in terms of safety of deformity correction with a 100% negative predictive value and an 8% incidence of signal loss during correction allowing immediate remedial action

Introduction. Somatosensory evoked potential (SSEP) monitoring allows for assessment of the spinal cord and susceptible structures during complex spinal surgery. It is well validated for the detection of potential neurological injury but little is known of surgeon's responses to an abnormal trace and its effect on neurological outcome. We aimed to investigate this in spinal deformity patients who are particularly vulnerable during their corrective surgery. Methods. Our institutional neurophysiology database was analysed between 1. st. October 2005 and 31. st. March 2010. Monitoring was performed by a team of trained neurophysiology technicians who were separate from the surgical team. A significant trace was defined as a 50% reduction in trace amplitude or a 10% increase in signal latency. Patients suffering a significant trace event were examined post-operatively by a Consultant Neurologist who was separate from the surgical team. Results. 2386 consecutive operations (F:1719, M:667 median age 16 yrs) were performed in the time period and 72 operations reported a significant trace event (‘red alert’). From these cases 47 (65%) had a clearly documented intervention by the surgeon and 7 patients overall suffered a lasting neurological deficit (0.3%). The most common timing events were during instrumentation (50%) and during correction/distraction (16%). Most common responses were optimisation of patient/monitoring set-up (23%) and adjustment of metalwork (22%). There were 18 wake-up tests performed. We found SSEP monitoring to have a sensitivity of 100%, specificity 97.4%, positive predictive value 14% and negative predictive value 100%. A Chi-square test (p=0.016) was significant suggesting intervention had a beneficial effect on neurological outcome. Conclusion. We would advocate the use of SSEP monitoring in all patients undergoing spinal deformity surgery. These patients tend to be young, neurologically intact pre-operatively and are particularly vulnerable to the large corrective forces their surgery requires

Summary. Optimum position of pedicle screws can be determined preoperatively by CT based planning. We conducted a comparative study in order to analyse manually determined pedicle screw plans and those that were obtained automatically by a computer software and found an agreement in plans between both methods, yet an increase in fastening strengths was observed for automatically obtained plans. Hypothesys. Automatic planning of pedicle screw positions and sizing is not inferior to manual planning. Design. Prospective comparative study. Introduction. Preoperative planning in spinal deformity surgery starts by a proper selection of implant anchors throughout the instrumented spine, where pedicle screws provide the optimum choice for bone fixation. In the case of severe spinal deformities, dysplastic pedicles can limit screw usage, and therefore studying the anatomy of vertebrae from preoperative images can aid in achieving the safest screw position through optimal fastening strength. The purpose of this study is to compare manually and automatically obtained preoperative pedicle screw plans. Materials and Methods. CT scans of 17 deformed thoracic spines were studied by two experienced spine deformity surgeons, who placed 316 pedicle screws in 3D using a software positioning tool by aiming for the safest trajectory that permitted the largest possible screw sizes. The resulting manually obtained screw sizes, trajectory angles, entry points and normalised fastening strengths were compared to those obtained automatically by a dedicated computer software that, basing on vertebral anatomy and bone density in 3D, determined optimal screw sizes and trajectories. Results. Statistically significant differences were observed between manually and automatically obtained plans for screw sizes (p < 0.05) and trajectory angles (p < 0.001). However, for automatically obtained plans, screws were not smaller in diameter (p < 0.05) or shorter in length (p < 0.001), while screw normalised fastening strengths were higher (p < 0.001). Conclusions. In comparison to manual planning, automatically obtained plans did not result in smaller screw diameters or shorter screw lengths, which is in agreement with the definition of the pull-out strength, but in different screw trajectory angles, which is reflected by higher normalised fastening strengths. Captions. Fig. 1. Visual comparison among automatically obtained (green colour) and manually defined pedicle screw placement plans by two experienced spine surgeons (red and blue colour) for three different patients with adolescent idiopathic scoliosis, shown from top to bottom in a three-dimensional view, left sagittal, right sagittal and coronal view. Fig. 2. Histograms of differences between observers and (left column), between observer and automated method (middle column), and between observer and automated method (right column), shown from top to bottom for differences in pedicle screw pedicle screw diameter, sagittal inclination, and normalised fastening strength. For figures/tables, please contact authors directly.

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

Aims

Medical comorbidities are a critical factor in the decision-making process for operative management and risk-stratification. The Hierarchical Condition Categories (HCC) risk adjustment model is a powerful measure of illness severity for patients treated by surgeons. The HCC is utilized by Medicare to predict medical expenditure risk and to reimburse physicians accordingly. HCC weighs comorbidities differently to calculate risk. This study determines the prevalence of medical comorbidities and the average HCC score in Medicare patients being evaluated by neurosurgeons and orthopaedic surgeon, as well as a subset of academic spine surgeons within both specialities, in the USA.