Object: Several studies have characterized the relationship among postoperative thoracic, lumbar, and pelvic alignment in the sagittal plane. However, little is known of the relationship between postoperative thoracic kyphosis and sagittal cervical alignment in patients with adolescent idiopathic scoliosis (AIS) treated with all pedicle screw constructs. The authors examined this relationship and associated factors. Methods: A prospective database of pediatric patients with AIS undergoing spinal fusion between 2003 and 2005 was reviewed for those who received predominantly pedicle screw constructs for Lenke Type 1 or Type 2 curves. Parameters analyzed on pre- and postoperative radiographs were the fusion levels; cervical, thoracic, and lumbar sagittal balance; and C-2 and C-7 plumb lines. Results: Preoperatively, 6 (Group A) of the 22 patients included in the study had frank cervical kyphosis (mean angle 13.0°) with mean associated thoracic kyphosis of 27.2° (range 16°–37°). Postoperatively, cervical kyphosis (13.0°) remained in the patients in Group A along with mean thoracic kyphosis of 17.7° (range 4°–26°, p < 0.05). Preoperatively, the remaining 16 of 22 patients had neutral to lordotic cervical alignment (mean −13.8°) with thoracic kyphosis (mean 45°, range 30°–76°). Postoperatively, 8 (Group B) of these 16 patients demonstrated cervical sagittal decompensation (> 5° kyphosis), with 6 showing frank cervical kyphosis (10.5°, p < 0.05). In Group B, the mean postoperative thoracic kyphosis was 25.6° (range 7°–49°, p < 0.05). The other 8 patients (Group C) had mean postoperative thoracic kyphosis of 44.1° (range 32°–65°), and there was no cervical decompensation (p < 0.05). Conclusions: The sagittal profile of the thoracic spine is related to that of the cervical spine. The surgical treatment of Lenke Type 1 and 2 curves by using all pedicle screw constructs has a significant hypokyphotic effect on thoracic sagittal plane alignment (19 [86%] of 22 patients). If postoperative thoracic kyphosis is excessively decreased (mean 25.6°, p < 0.05), the cervical spine may decompensate into significant kyphosis.

Adolescent idiopathic scoliosis (AIS) is a 3D spinal deformity affecting children between the ages of 11 and 18, without an identifiable etiology. The authors here reviewed the available literature to provide spine surgeons with a summary and update on current management options. Smaller thoracic and thoracolumbar curves can be managed conservatively with observation or bracing, but corrective surgery may be indicated for rapidly growing or larger curves. The authors summarize the atypical features to look for in patients who may warrant further investigation with MRI during diagnosis and review the fundamental principles of the surgical management of AIS. Patients with AIS can be managed very well with a combination of conservative and surgical options. Outcomes for these children are excellent with sustained longer-term results.

Background: Anterior vertebral body tethering (aVBT) has emerged as a novel treatment option for patients with idiopathic scoliosis. We present the results from the first U.S. Food and Drug Administration (FDA) Investigational Device Exemption (IDE) study on aVBT. Methods: In this prospective review of a retrospective data set, eligible patients underwent aVBT at a single center from August 2011 to July 2015. Inclusion criteria included skeletally immature patients with Lenke type-1A or 1B curves between 30° and 65°. Clinical and radiographic parameters were collected, with the latter measured by an independent reviewer. Results: Fifty-seven patients (49 girls and 8 boys), with a mean age (and standard deviation) of 12.4 ± 1.3 years (range, 10.1 to 15.0 years), were enrolled in the study. The patients had a mean of 7.5 ± 0.6 levels tethered, the mean operative time was 223 ± 79 minutes, and the mean estimated blood loss was 106 ± 86 mL. The patients were followed for an average of 55.2 ± 12.5 months and had a mean Risser grade of 4.2 ± 0.9 at the time of the latest follow-up. The main thoracic Cobb angle was a mean of 40.4° ± 6.8° preoperatively and was corrected to 18.7° ± 13.4° at the most recent follow-up. In the sagittal plane, T5-T12 kyphosis measured 15.5° ± 10.0° preoperatively, 17.0° ± 10.1° postoperatively, and 19.6° ± 12.7° at the most recent follow-up. Eighty percent of patients had curves of <30° at the most recent follow-up. The most recent Scoliosis Research Society (SRS) scores averaged 4.5 ± 0.4, and scores on the self-image questionnaire averaged 4.4 ± 0.7. No major neurologic or pulmonary complications occurred. Seven (12.3%) of 57 patients had a revision: 5 were done for overcorrection and 2, for adding-on. Conclusions: Anterior VBT is a promising technique that has emerged as a treatment option for patients with immature idiopathic scoliosis. We present the results from the first FDA-approved IDE study on aVBT, which formed the basis for the eventual Humanitarian Device Exemption approval. The findings affirm the safety and efficacy of this technique and suggest opportunities for improvement, particularly with respect to reoperation rates. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE: Postoperative complications are one of the most significant concerns in surgeries of the spine, especially in higher-risk cases such as neuromuscular scoliosis. Neuromuscular scoliosis is a classification of multiple diseases affecting the neuromotor system or musculature of patients leading to severe degrees of spinal deformation, disability, and comorbidity, all likely contributing to higher rates of postoperative complications. The objective of this study was to evaluate deformity correction of patients with neuromuscular scoliosis over a 12-year period (2004–2015) by looking at changes in postsurgical complications and management. METHODS: The authors queried the Scoliosis Research Society (SRS) Morbidity and Mortality (M&M) database for neuromuscular scoliosis cases from 2004 to 2015. The SRS M&M database is an international database with thousands of self-reported cases by fellowship-trained surgeons. The database has previously been validated, but reorganization in 2008 created less-robust data sets from 2008 to 2011. Consequently, the majority of analysis in this report was performed using cohorts that bookend the 12-year period (2004–2007 and 2012–2015). Of the 312 individual fields recorded per patient, demographic analysis was completed for age, sex, diagnosis, and preoperative curvature. Analysis of complications included infection, bleeding, mortality, respiratory, neurological deficit, and management practices. RESULTS: From 2004 to 2015, a total of 29,019 cases of neuromuscular scoliosis were reported with 1385 complications, equating to a 6.3% complication rate when excluding the less-robust data from 2008 to 2011. This study shows a 3.5-fold decrease in overall complication rates from 2004 to 2015. A closer look at complications shows a significant decrease in wound infections (superficial and deep), respiratory complications, and implant-associated complications. The overall complication rate decreased by approximately 10% from 2004–2007 to 2012–2015. CONCLUSIONS: This study demonstrates a substantial decrease in complication rates from 2004 to 2015 for patients with neuromuscular scoliosis undergoing spine surgery. Decreases in specific complications, such as surgical site infection, allow us to gauge our progress while observing how trends in management affect outcomes. Further study is needed to validate this report, but these results are encouraging, helping to reinforce efforts toward continual improvement in patient care.

OBJECTIVE: High rates of perioperative complications are associated with deformity correction in neuromuscular scoliosis. The current study aimed to evaluate complications associated with surgical correction of neuromuscular scoliosis and to characterize potential risk factors.METHODS: Data were retrospectively collected from a single-center cohort of 102 consecutive patients who underwent spinal fusions for neuromuscular scoliosis between January 2008 and December 2016 and who had a minimum of 6 months of follow-up. A subgroup analysis was performed on data from patients who had at least 2 years of follow-up. Univariate and multivariate regression analyses, as well as binary correlational models and Student t-tests, were employed for further statistical analysis.RESULTS: The present cohort had 53 boys and 49 girls with a mean age at surgery of 14.0 years (± 2.7 SD, range 7.5–19.5 years). The most prevalent diagnoses were cerebral palsy (26.5%), spinal cord injury (24.5%), and neurofibromatosis (10.8%). Analysis reflected an overall perioperative complication rate of 27% (37 complications in 27 patients), 81.1% of which constituted major complications (n = 30) compared to a rate of 18.9% for minor complications (n = 7). Complications were predicted by nonambulatory status (p = 0.037), increased intraoperative blood loss (p = 0.012), increased intraoperative time (p = 0.046), greater pelvic obliquity at follow-up (p = 0.028), and greater magnitude of sagittal profile at follow-up (p = 0.048). Pulmonary comorbidity (p = 0.001), previous operations (p = 0.013), history of seizures (p = 0.046), diagnosis of myelomeningocele (p = 0.046), increase in weight postoperatively (p < 0.005), and increased lumbar lordosis at follow-up (p = 0.015) were identified as risk factors for perioperative infection.CONCLUSIONS: These results suggest that in neuromuscular scoliosis, patients with preexisting pulmonary compromise and greater intraoperative blood loss have the greatest risk of experiencing a major perioperative complication following surgical deformity correction.