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.

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.

Purpose: Posterior spinal fusion (PSF), with or without anterior spinal fusion (ASF), in conjunction with Luque rod instrumentation (LRI) and Galveston technique is a common procedure in neuromuscular spinal deformity. However, few studies have specifically studied the long-term results and complications of Galveston technique. The purpose of this study was to analyze the long-term results of Galveston technique in combination with PSF, with or without ASF, and LRI in the correction of neuromuscular spinal deformity. We were specifically interested in the stability of the distal foundation, lumbosacral fusion, correction of the associated pelvic obliquity, and complications.

Method: Analyzing our Pediatric Orthopaedic Spine Database between 1992–2006, we identified 107 consecutive patients with a neuromuscular spinal deformity who underwent a PSF, with or without ASF, and LRI including Galveston technique, who had a minimum of 2 years postoperative follow-up. There were 55 females and 52 males with a mean age at surgery of 13.5 ± 3.5 years. The mean follow-up was 7.8 ± 3.7 years. We analyzed the coronal and sagittal plane alignment and pelvic obliquity preoperatively, postoperatively, and at last follow-up. We recorded any complications directly related to the Galveston technique.

Results: The mean preoperative major curve was 76 ± 21 degrees. At last postoperative follow-up, this measured 33 ± 16 degrees. The mean preoperative pelvic obliquity was 17 ± 10 degrees and at last follow-up 7 ± 6 degrees. Seven patients (6.5%) had Galveston technique complications: three rod breakages, three implant distal migrations and one patient with both rod breakage and distal migration. These occurred late and only one patient required revision surgery.

Conclusion: The Galveston technique is an excellent procedure for lumbosacral stabilization in patients with neuromuscular spinal deformity. It provides a solid distal foundation for a lumbosacral fusion and for correction of spinal deformity and pelvic obliquity, with minimal complications.

Purpose: Determine the prevalence of complications in neuromuscular scoliosis surgery and to identify risk factors. We hypothesized that patients with smaller pre-operative curve magnitudes would have lower complication rates.

Method: Our Pediatric Orthopaedic Spine Database identified a cohort of 151 consecutive patients with neu-romuscular scoliosis who underwent corrective surgery between 1992 and 2005 and had a minimum of 2 years of follow-up. Twenty-two patients (15%) were excluded; 20 patients with a diagnosis of myelodysplasia and two due to death during the follow-up period. Preoperative, operative, and postoperative factors were analyzed for any association with major complications and length of stay (LOS) utilizing stepwise logistic and multiple regression. Only factors with p-values < 0.05 remained in the analysis models. Odds ratios were calculated for significant dichotomous variables and receiver operator characteristic (ROC) curves were created for significant continuous variables.

Results: There were 79 male and 50 female patients with a mean age at surgery of 13.4 years (range, 6 to 21 years). Eighty-seven patients (68%) underwent posterior spinal fusion (PSF) with segmental spinal instrumentation (SSI). and 42 patients (32%) underwent anterior spinal fusion (ASF) and PSF with SSI. Mean follow-up was 46.4 months (range, 24 to 251 months). There were 45 major complications in 37 patients (29% prevalence). Non-ambulatory status (p < 0.05) and a high preoperative Cobb angle (p < 0.01) were associated with an increasing prevalence of major complications. Non-ambulatory patients were almost four times more likely to have a major complication (OR of 3.8, p < 0.05) in comparison to ambulatory patients. A pre-operative Cobb angle ≥ 60 degrees (p < 0.01) was the most accurate predictor for an increased risk for major complication. Patients undergoing PSF with SSI only or combined ASF and PSF with SSI on the same day who sustained one major (p < 0.05) or two minor (p < 0.01) complications had a significantly increased LOS.

Conclusion: The prevalence of complications following surgery for neuromuscular scoliosis is high. Non-ambulatory status and higher preoperative Cobb curve magnitude are directly associated with an increased risk for major complication and indirectly associated with increased LOS.

Purpose: Determine if one or two pairs of pedicle screws were superior to multiple laminar hooks for the distal foundation segmental in spinal instrumentation (SSI) in the surgical correction of AIS.

Method: We analyzed 108 consecutive patients identi-fied from our Pediatric Orthopaedic Spine Database (1992–2005) that underwent a posterior spinal fusion (PSF) and segmental spine instrumentation (SSI). There were 3 patient groups: Group 1, one pair of pedicle screws for the distal foundation (n=12); Group 2, two or more pairs of pedicle screws (n=44) and Group 3, multiple hooks only (n=52). The mean age at surgery was 13.5 years, 14.1 years, and 13.0 years, respectively. The major curve was measured perioperatively and at one month, 6 months, 12 months, and 24 months postoperatively and the mean percentage of correction, as well as loss of correction determined. We also analyzed the length of surgery (hours), length of hospitalization and complications.

Results: The mean preoperative major curve was 52.5 degrees in Group 1, 52. degrees in Group 2, and 48.8 degrees in Group 3. The mean percent postoperative correction (POC%) at 1 month was 67.2, 65.2, and 63.4 % in the 3 groups, respectively (p=0.531). The mean percent post-operative correction (POC%) at 24 month was 55.6% for Group 1, 56.6% for Group 2 and 51.5% for Group 3 (p=0.478). The mean percent loss of correction (LOC%) at 24 months was 3.1%, 2.25%, and 2.9% respectively(p=0.648). One-way ANOVA demonstrated no significant differences in patient age, number of levels fused, length of surgery, or length of hospital stay. There were no implant related complications.

Conclusion: Hybrid constructs with one or more pairs of pedicle screws and all-hook constructs for distal foundations in SSI provided similar major curve correction, percentage postoperative correction, and are associated with a minimal loss of correction postoperatively. There was no significant difference between length of surgery, hospital stay or complications.

Purpose: Postoperative pain is common following posterior spinal fusion (PSF) and segmental spinal instrumentation (SSI) for idiopathic scoliosis (IS). It is often treated with intravenous morphine patient controlled analgesia (PCA), but no studies have examined continuous morphine infusion. The purpose of this study was to identify the safety and efficacy of continuous morphine infusion without PCA for post-operative pain management in these patients.

Method: We retrospectively reviewed 338 consecutive patients from 1992 to 2006 who received continuous morphine infusion. Following induction of general anesthesia and prior to surgical incision, patients received intrathecal morphine for preemptive analgesia. Anesthesia was maintained with 50% nitrous oxide and up to 0.6% isoflurane, with minimal or no intravenous opioids. Following surgery, pre-ordered morphine infusion (0.01 mg/kg/hr) began when patients first reported pain. The infusion rate was titrated using a strict protocol based on frequent assessment of vital signs, Wong-Baker visual analog pain scores (VAS), and clinical status. The infusion continued until patients were able to take oral analgesics at postoperative day 2–3. Factors analyzed included patient demographics, intrathecal morphine dosage, intraoperative intravenous opioid dosage, pain scores through the third postoperative day, interval to start of morphine infusion, total morphine requirement in the first 48 postoperative hours, and postoperative complications.

Results: Mean intrathecal morphine dose was 15.45 mcg/kg and mean interval to start of morphine infusion was 15:45 hours. Mean VAS pain scores were 3.05, 4.48, 4.48, and 4.60 at 12 hours, 1, 2, and 3 days postoperatively. The total mean dosage of morphine in the first 48 hours postoperatively was 0.03 mg/kg/hr. Nausea/vomiting, pruritis, respiratory depression, and PICU admissions related to the morphine drip occurred in 13.3%, 4.1%, 0%, and 0% of the patients during the same time period.

Conclusion: A low frequency of adverse events and a mean postoperative pain score of 5 or less demonstrates that continuous postoperative morphine infusion is a safe and effective method of pain management in children following PSF and SSI for IS. Continuous morphine infusion without PCA is a safe, alternative method of pain control for postoperative patients with IS.

Purpose: Do children from different gender or racial groups receive different analgesic doses for the same acute pain condition? We previously reported on intra-thecal morphine for preemptive analgesia in children undergoing posterior spinal fusion (PSF) and segmental spinal instrumentation (SSI) for idiopathic scoliosis (IS). We determined the optimal dose range to maximize analgesia while minimizing adverse effects. The purpose is to ensure this adopted protocol is equally effective across gender and racial groups.

Method: We studied 407 intrathecal morphine patients. Those given a moderate dose of 9–19 mcg/kg (n=293) had the most effective and safe postoperative pain relief. This group consisted of 246 female and 47 male patients. There were 224 Caucasian (CA) and 63 African-American (AA) patients. Other ethnicities were excluded. Factors analyzed included postoperative Wong-Baker visual analog pain scores (VAS), time to first opioid rescue dose, total morphine dose over the first 48 hours, and postoperative complications.

Results: For female and male gender, mean VAS pain scores in post-anesthesia care unit (PACU) were 0.48 and 0.56, mean times to first opioid rescue dose were 999.1 and 1003.3 minutes, and total morphine over the first 48 hours were 1.5mg/kg in both groups, respectively. Respiratory depression and PICU admission occurred in 2 (4.2.%) and 4 (1.6%) patients, respectively. For CA and AA patients, mean VAS pain scores in PACU were 0.48 and 0.46, mean times to first opioid rescue dose were 991.7 and 1031.9 minutes, and total morphine over the first 48 hours were 1.5mg/kg and 1.3mg/kg, respectively. Respiratory depression occurred in 5 (2.2.%) and 2 (3.2%) patients and PICU admission occurred in 4 (1.8.%) and 4 (6.3%) patients, respectively. StudentÂ’s t-test and Fisher exact test demonstrated no significant differences between genders for all variables, and no significant differences between races except less total morphine for AA patients over the first 48 hours (p=0.0024).

Conclusion: An optimal intrathecal morphine dose range of 9–19 mcg/kg provides effective and safe postoperative pain relief in children undergoing PSF and SSI for IS, regardless of gender or race. Intrathecal morphine can be given with the assurance that it does not discriminate against gender or provide less optimal analgesia to AA patients.

Introduction. Prospective evaluation of fibrinogen levels preoperatively and postoperatively in patients with idiopathic scoliosis undergoing posterior spinal fusion (PSF) and segmental spinal instrumentation (SSI) who received Amicar to decrease perioperative blood loss. Our previous randomized, double-blind (Amicar and control) study demonstrated a rise in fibrinogen levels on the first postoperative day in the Amicar group, but not in the control group. Fibrinogen levels were not measured on the remaining postoperative days.

Methods. We analyzed fibrinogen levels preoperatively and on all postoperative days (4 or 5 days) until discharge in 51 consecutive patients with idiopathic scoliosis, who received Amicar and underwent a PSF and SSI.

Results. There were 41 females and 10 males with a mean age at surgery of 14.2±1.8 years. Their mean hospitalization was 4.6±0.8 days. Their mean estimated intraoperative blood loss was 766±308ml and postoperative suction drainage 532±186ml for a total perioperative blood loss of 1297±311ml. The perioperative transfusion requirements were 0.5±0.6 units per patient. The preoperative fibrinogen was 255.5±58.3 mg/dl, and it rose steadily throughout the postoperative period to 680.9±111.9 mg/dl on the fifth postoperative day. There were no complications related to the use of Amicar.

Conclusions. Fibrinogen levels rise steadily throughout the postoperative period. The significance of this increase is unknown. Was it due to the use of Amicar or just the effects of surgery itself? Further investigations will be necessary.

Introduction: A comparison of the success of the thoracolumbosacral orthosis (TLSO) and the Providence orthosis in the treatment of adolescent idiopathic scoliosis (AIS) using the new Scoliosis Research Society’s (SRS) Committee on Bracing and Nonoperative Management inclusion and assessment criteria for bracing studies.

Methods: A retrospective study of brace patients with AIS between 1992 and 2004. We have used a custom TLSO (22 hour/day) and the Providence orthosis (8–10 hour/night) to control progressive curves. A total of 83 patients met the new inclusion criteria: 10 years of age and older at initiation of bracing; initial curve of 25 to 40 degrees; Risser sign 0–2; females, premenarchal or less than one year post menarchal; and no prior treatment. There were 48 patients in the TLSO group and 35 in the Providence group. The new SRS assessment criteria of effectiveness included the percentage of patients who had 5 degrees or less and 6 degrees or more of curve progression at maturity; the percentage of patients whose curve progressed beyond 45 degrees; the percentage of patients who had surgery recommended or undertaken; and a minimum of two years of follow-up beyond maturity in those patients who were felt to have been successfully treated. All patients are analyzed irregardless of compliance (“intent to treat”).

Results: There were no significant differences in age at brace initiation, initial primary curve magnitude, gender, or initial Risser sign between the two groups. In the TLSO group, only 7 patients (15%) did not progress (5 degrees or less), while 41 patients progressed 6 degrees or more (85%), including 30 patients that exceeded 45 degrees. Thirty-eight patients (79%) ultimately required surgery. In the Providence group, 11 patients (31%) did not progress, while 24 patients (69%) progressed 6 degrees or more, including 15 patients that exceeded 45 degrees. Twenty-one patients (60%) required surgery. However, when the initial curve at initiation of bracing was 25 to 35 degrees, the results improved. Five of 34 patients (15%) in the TLSO group and 10 of 24 patients (42%) in the Providence group did not progress, while 29 patients (85%) and 14 patients (58%) progressed 6 degrees or more and 26 patients (76%) and 11 patients (46%) required surgery, respectively.

Conclusions: Using the new SRS criteria, the Providence orthosis was more effective for avoiding surgery and preventing curve progression than the TLSO when the primary initial curves were 35 degrees or less. However, the overall success in both groups was inferior to previous studies. Our results raises the question of the effectiveness of orthotic management in AIS and supports the need for a multicenter, randomized study utilizing the new SRS inclusion and assessment criteria.

Introduction: Retrospective review of patients with idiopathic scoliosis who underwent same-day or staged anterior (ASF) and posterior spinal fusion (PSF) and segmental spinal instrumentation (SSI). We evaluated our learning curve with video-assisted thoracoscopic surgery (VATS) with respect to operative time, blood loss, and complications in patients with idiopathic scoliosis. An increased or steep learning curve has been described in the initial application of VATS.

Methods: We began performing VATS in 1998. We compared our first 25 consecutive VATS patients (Group 2) and subsequent 28 consecutive VATS patients (Group 3) to 16 consecutive patients (Group 1) with a thora-cotomy (1991–1998) for idiopathic scoliosis. Training at a sponsored regional course was obtained prior to our first VATS procedure.

Results: VATS allowed more discs to be excised in Group 2 (4.5±1, 5.7±1 and 4.4±1 discs in the 3 groups, respectively) and significantly decreased the anterior operative time (215±33, 260±56 and 177±47 minutes) and time per individual disc excision (50±13, 47±12 and 41±12 minutes), while providing comparable correction of the thoracic deformity (67±12, 66±10 and 70±13% correction). There was no increase in estimated intra-operative anterior blood loss (228±213, 183±136 and 211±158ml), estimated blood loss per disc excised (51±42, 34±29 and 48±37ml), or complications in the VATS groups. Complications were primarily pulmonary and resolved with medical therapy. Postoperative chest tube drainage (855±397, 462±249 and 561±26lml) and total perioperative anterior blood loss (1083±507, 647±309 and 773±308ml) were significantly decreased in the VATS groups, but this was attributed to the use of Amicar.

Conclusions: VATS is an effective procedure for ASF in idiopathic scoliosis. The learning curve is short, provided appropriate training is obtained.

Introduction: This is a retrospective study of the effectiveness of Amicar in decreasing perioperative blood loss and the need for transfusion in same-day anterior (ASF) and posterior spinal fusion (PSF) with segmental spinal instrumentation (SSI) in idiopathic scoliosis. Preliminary prospective, prospective randomized double-blind and fibrinogen studies have demonstrated Amicar to be effective in decreasing perioperative blood loss in idiopathic scoliosis surgery. Increased fibrinogen secretion is a possible explanation.

Methods. Amicar is administered at 100mg/kg over 15 min not to exceed 5 grams at anesthesia induction. Maintenance is 10mg/kg/hr until wound closure. There were three study groups: Group 1, (n=15), no Amicar; Group 2, (n=27), Amicar for the PSF only; and Group 3, (n=16), Amicar for both ASF and PSF.

Results. The total perioperative blood loss (estimated intraoperative blood loss for the ASF and PSF procedures, measured suction drainage and measured chest tube drainage) and the transfusion (autologous and bank blood) requirements were: Group 1, 3807±105ml and 3.1±1.5 units; Group 2 2080±659ml and 1.9±0.9 units; and Group 3 2183±851ml and 1.0±0.8 units.

Conclusions. Amicar appears highly effective in decreasing perioperative blood loss and transfusion requirements in same-day ASF, PSF, with SSI in idiopathic scoliosis. This results in less preoperative autologous blood donation, blood transfusion, costs, and potential transfusion-related complications. It appears to be most effective in decreasing intraoperative PSF blood loss and chest tube drainage. It had no effect during the ASF. We now recommend that it be used for the posterior procedure only.

Introduction and Aims: Evaluate the efficacy of epsilon aminocaproic acid (Amicar) in decreasing peri-operative blood loss in patients with idiopathic scoliosis.

Method: Thirty-six patients participated in this prospective, randomised, double blind, IRB-approved study. The patients who received Amicar were unknown until the completion of the study. All patients were 11–18 years of age, had idiopathic scoliosis, and underwent a posterior spinal fusion and segmental spinal instrumentation using standard hypotensive anesthesia. Factors analysed included age, gender, curve severity, number of vertebrae fused, operating time, hemoglobin and hematocrit pre-operatively and post-operatively, number of autologous units donated, pre-operative and post-operative fibrinogen levels, height, weight, estimated blood volume, estimated intra-operative blood loss, post-operative suction drainage, total peri-operative blood loss, and the autologous transfusion requirements.

Results: Nineteen patients received Amicar and 17 patients were controls. There was no statistical difference between the two groups pre-operatively. Total peri-operative blood loss was statistically less in the Amicar group (p=.036). This was 1,391±212ml in the Amicar group compared to 1,716±513ml in the control group. The decrease was predominantly in the post-operative suction drainage – 605±253ml compared to 939±455ml. The hemoglobin and hematocrits were higher postoperatively in the Amicar group. Interestingly, the fibrinogen levels rose post-operatively in the Amicar group. Total autologous blood transfusions were less in the Amicar group at 1.0±0.8 units compared to 1.7±1.2 units (p=.061). No patient required homologous blood. There were no post-operative complications.

Conclusions: Amicar is a safe, effective, and inexpensive pharmacologic agent that decreases peri-operative blood loss, particularly post-operative suction drainage, in patients with idiopathic scoliosis. This is probably due to increased fibrinogen levels. It results in a significantly decreased need for autologous blood donations pre-operatively and the associated costs.