Scoliosis correction surgery is one of the longest and most complex procedures of all orthopedic surgery. The complication rate is therefore not negligible and is particularly high when the surgery is performed in patients with neuromuscular or connective tissue disease or complex genetic syndromes. In fact, these patients have various comorbidities and organ deficits (respiratory capacity, swallowing / nutrition, heart function, etc.), which can compromise the outcome of the surgery. In these cases, an accurate assessment and preparation for surgery is essential, also making use of external consultants. To make this phase simpler, more effective and homogeneous, a multidisciplinary path of peri-operative optimization is being developed in our Institute, which also includes the possibility of post-operative hospitalization for rehabilitation and recovery. The goal is to improve the basic functional status as much as possible, in order to ensure faster functional recovery and minimize the incidence of peri-operative complications, to be assessed by clinical audit. The path model and the preliminary results on the first patients managed according to the new modality are presented here.

The multidisciplinary path involves the execution of the following assessments / interventions: • Pediatric visit with particular attention to the state of the upper airways and the evaluation of chronic or frequent inflammatory states • Cardiological Consultation with Echocardiogram. • Respiratory Function Tests, Blood Gas Analysis and Pneumological Consultation to evaluate indications for preoperative respiratory physiotherapy cycles, Non-Invasive Ventilation (NIV) cycles, Cough Machine. Possible Polysomnography. • Nutrition consultancy to assess the need for nutritional preparation in order to improve muscle trophism. • Consultation of the speech therapist in cases of dysphagia for liquids and / or solids. • Electroencephalogram and Neurological Consultation in epileptic patients. • Physiological consultation in patients already being treated with a cough machine and / or NIV. • Availability of postoperative hospitalization in the rehabilitation center (with skills in respiratory and neurological rehabilitation) for the most complex cases. When all the appropriate assessments have been completed, the anesthetist in charge at our Institute examines the clinical documentation and establishes whether the path can be considered complete and whether the patient is ready for surgery. At the end of the surgery, the patient is admitted to the Post-operative Intensive Care Unit of the Institute. If necessary, a new program of postoperative rehabilitation (respiratory, neuromotor, etc.) is programmed in a specialist reference center.

To date, two patients have been referred to the preoperative optimization path: one with Ullrich Congenital Muscular Dystrophy, and one with 6q25 Microdeletion Syndrome. In the first case, the surgery was performed successfully, and the patient was discharged at home. In the second case, after completing the optimization process, the surgery was postponed due to the finding of urethral malformation with the impossibility of bladder catheterization, which made it necessary to proceed with urological surgery first.

The preliminary case series presented here is still very limited and does not allow evaluations on the impact of the program on the clinical practice and the complication rate. However, these first experiences made it possible to demonstrate the feasibility of this complex multidisciplinary path in which a network of specialists takes part.

Recently, there is ongoing evidence regarding rapid recovery after orthopaedic surgery, with advantages for the patient relative to post operative pain, complications and functional recovery. The aim of this study is to present our experience in rapid recovery for adolescent idiopathic scoliosis in the last 2 years.

Retrospective study of 36 patients with adolescent idiopathic scoliosis, (age range 11 to 18 years) treated with spinal thoraco-lumbar posterior fusion with rapid post-operative recovery, compared with a similar group, treated with traditional protocol.

We found a statistically significant difference in terms of length-of-stay, patient-controlled-analgesia and use of oppioid and post operative blood transfusions. There was no difference in post operative infection rate.

Our experience shows better functional recovery, satisfactory controlled analgesia and reduction in costs of hospitalization with the use of ERAS protocols.

Purpose: There is very little evidence to guide treatment of patients with spinal surgical site infection (SSI) who require irrigation and debridement (I& D) with respect to need for single or multiple I& D’s. The purpose of this study is to build a predictive model which stratifies patients with spinal SSI to determine which patients will go on to need single versus multiple I& D.

Method: A consecutive series of 128 patients from a tertiary spine center (collected from 1999–2005) who required I& D for spinal SSI, were studied based on data from a prospectively collected outcomes database. Over 30 variables were identified by extensive literature review as possible risk factors for SSI, and tested as possible predictors of risk for multiple I& D. Logistic regression was conducted to assess each variable’s predictability by a “bootstrap” statistical method. Logistic regression was applied using outcome of I& D – single or multiple as the “response”.

Results: 24/128 patients required multiple I& D. Primary spine diagnosis was approximately represented by ¼ trauma, ¼ deformity, ¼ degenerative and ¼ oncology/inflammatory/other. Six predictors: spine location, medical comorbidities, microbiology of the SSI, presence of distant site infection (ie. UTI or bacteremia), presence of instrumentation and bone graft type, proved to be the most reliable predictors of need for multiple I& D. Internal validation of the predictive model yielded area under the curve (AUC) of .84

Conclusion: Infection factors played an important role in need for multiple I& D. Patients with +MRSA culture or those with distant site infection such as bacteremia with or without UTI or pneumonia, were strong predictors of need for multiple I& D. Presence of instrumentation, location of surgery in the posterior lumbar spine and use of non-autograft bone predicted multiple I& D. Diabetes also proved to be the most significant medical comorbidity for multiple I& D.

Most of the studies in the literature identify spondylodiscitis as a challenge for the physician: symptoms are not specific and sub-acute/chronic presentation is common. The question of when surgery is indicated is a frequent matter of debate. We want to present and validate our flow chart for spinal infections diagnosis and treatment.

A retrospective review of 128 cases of spinal infections presenting over a 10-year period was performed. Medical records, imaging (X-Rays, MRI with gadolinium, Ga-67 and Tc-99 bone scan), laboratory test and bacteriology results of 128 patients from 1997 to 2006 were reviewed.

The average age of presentation was 55 years (median age: 61 years, range: between 1 and 88 years) of 53 females and 75 males. Only one level was interested in 22% of the cases. The cervical spine was affected in 6% of cases, the thoracic spine in 37%, and the lumbosacral spine in 57%. Soft tissues have been affected in 16% of the patients. CT guided trocar biopsies were performed in 80 patients, incisional biopsies in 10 patients, and excisional biopsy in 1 case. No complication occurred. The most represented microorganisms which were identified were Staphylococcus Aureus and Mycobacterium Tuberculosis. Conservative treatment alone (antibiotic therapy and bracing) was performed in 84 cases out of 128 (66%); Forty-four patients with either neurologic compromise or mechanical instability or those who were unresponsive to drugs and immobilisation were submitted to surgical treatment.

Late diagnosis may lead to spinal deformities, prolonged hospital stay and more expensive management of the patient. Appropriate treatment usually brings to resolution even if spinal infections are rare and often misdiagnosed. We suggest an easy-to-follow flow-chart for the diagnosis and treatment of spinal infections.