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: 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.