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Behrooz A. Akbarnia - One of the best experts on this subject based on the ideXlab platform.
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an initial effort to define an Early Onset Scoliosis graduate the pediatric spine study group experience
Spine deformity, 2020Co-Authors: Christina K Hardesty, Charles E. Johnston, John B Emans, Jeff Pawelek, Robert F Murphy, Michael P Glotzbecker, Pooria Hosseini, Behrooz A. AkbarniaAbstract:Increasingly, patients with Early Onset Scoliosis (EOS) are completing a growth friendly surgical program followed by observation, removal of implants or a definitive spinal fusion. These patients are colloquially referred to as “graduates”. A standardized definition of a graduate is needed for research and comparing the outcomes, family counseling, and a better understanding of the population. A 15-question electronic survey was completed by 39 experienced pediatric spine surgeons to identify factors salient to the definition of a graduate of EOS surgical programs. A Delphi/Nominal group technique session with nine questions was then performed face-to-face with 21 members of the Pediatric Spine Study Group to discuss and refine the definition. A follow-up electronic survey was then distributed to these same 21 members to gain consensus on the final definition. From the initial survey, it was identified that a graduate did not require definitive spinal fusion after a growing program. From the Delphi session, it was determined that skeletal maturity was the most important factor in defining a graduate. A strictly defined minimum length of follow-up was not felt to be a prerequisite for qualification of graduation. After the final electronic version was distributed, > 80% of respondents agreed upon the final definition, thereby achieving consensus. The Pediatric Spine Study Group recommends adoption of the following definition: a “graduate” is a patient who has undergone any surgical program to treat Early Onset Scoliosis, and has reached skeletal maturity and does not have a planned surgical intervention for EOS in the future. V.
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an initial effort to define an Early Onset Scoliosis graduate the pediatric spine study group experience
Spine deformity, 2020Co-Authors: Christina K Hardesty, Charles E. Johnston, John B Emans, Jeff Pawelek, Robert F Murphy, Michael P Glotzbecker, Pooria Hosseini, Behrooz A. AkbarniaAbstract:Purpose Increasingly, patients with Early Onset Scoliosis (EOS) are completing a growth friendly surgical program followed by observation, removal of implants or a definitive spinal fusion. These patients are colloquially referred to as "graduates". A standardized definition of a graduate is needed for research and comparing the outcomes, family counseling, and a better understanding of the population. Methods A 15-question electronic survey was completed by 39 experienced pediatric spine surgeons to identify factors salient to the definition of a graduate of EOS surgical programs. A Delphi/Nominal group technique session with nine questions was then performed face-to-face with 21 members of the Pediatric Spine Study Group to discuss and refine the definition. A follow-up electronic survey was then distributed to these same 21 members to gain consensus on the final definition. Results From the initial survey, it was identified that a graduate did not require definitive spinal fusion after a growing program. From the Delphi session, it was determined that skeletal maturity was the most important factor in defining a graduate. A strictly defined minimum length of follow-up was not felt to be a prerequisite for qualification of graduation. After the final electronic version was distributed, > 80% of respondents agreed upon the final definition, thereby achieving consensus. Conclusion The Pediatric Spine Study Group recommends adoption of the following definition: a "graduate" is a patient who has undergone any surgical program to treat Early Onset Scoliosis, and has reached skeletal maturity and does not have a planned surgical intervention for EOS in the future. Level of evidence V.
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minimum 5 year follow up on graduates of growing spine surgery for Early Onset Scoliosis
Journal of Pediatric Orthopaedics, 2020Co-Authors: Robert F Murphy, George H. Thompson, Behrooz A. Akbarnia, John T Smith, Paul D Sponseller, John B Emans, David L Skaggs, William R Barfield, David S Marks, John M. FlynnAbstract:Introduction After discontinuation of growth friendly (GF) surgery for Early Onset Scoliosis, patients undergo spinal fusion or continued observation. This last planned treatment is colloquially called "definitive" treatment, conferring these patients as "graduates" of a growing program. The 5-year radiographic and clinical outcomes of this cohort are unknown. Methods An international pediatric spine database was queried for patients from a GF program (spine or rib-based) with minimum 5-year follow-up from last planned surgery (GF or spinal fusion). Radiographs and charts were reviewed for main coronal curve angle and maximum kyphosis as well as occurrence of secondary surgery. Results Of 580 graduates, 170 (29%) had minimum 5-year follow-up (37% male). Scoliosis etiology was congenital in 41 (24%), idiopathic 36 (21%), neuromuscular 51 (30%), and syndromic 42 (25%). Index surgery consisted of spine-based growing rods in 122 (71%) and rib-based distraction in 48 (29%). Mean age at index surgery was 6.8 years, and patients underwent an average of 5.4 lengthenings over an average of 4.9 years (range, 6 mo to 11 y). Last planned treatment was at an average age of 11.8 years (range, 7 to 17 years). Last planned treatment consisted of spinal fusion in 114 patients, 47 had growing implants maintained, 9 had implants removed. Average follow-up was 7.3 years (range, 5 to 13 y).When compared from postdefinitive treatment to 2-year follow-up, there was noted progression of the coronal curve angle (46±19 to 51±21 degrees, P=0.046) and kyphosis (48±20 to 57±25 degrees, P=0.03). However, between 2 and 5 years, no further progression occurred in the coronal (51±21 to 53±21 degrees, P=0.26) or sagittal (57±25 to 54±28 degrees, P=0.93) planes. When stratified based on etiology, there was no significant coronal curve progression between 2- and 5-year follow-up. When comparing spinal fusion patients to those who had maintenance of their growing construct, there was also no significant curve progression.Thirty-seven (21%) underwent at least 1 (average, 1.7; range, 1 to 7) revision surgery following graduation, and 15 of 37 (41%) underwent 2 or more revision surgeries. Reason for revision was implant revision (either GF or spinal fusion) in 34 patients, and implant removal in 3. On an average, the first revision was 2.5 years after the definitive treatment plan (range, 0.02 to 7.4 y). In total, 15 of 37 (41%) revisions occurred over 2 years following the final decision for treatment plan, and 7 of 37 (19%) occurred 5 or more years after the definitive treatment.Patients who underwent spinal fusion as a definitive treatment strategy were more likely to undergo revision surgery (27%) than patients who had their GF implants maintained (11%) (P=0.04). Conclusions Five years following "graduation" from growing surgery for Early Onset Scoliosis, there is progression of curve magnitude in both the coronal and sagittal planes up to 2 years, with no further progression at 5 years. A total of 21% of patients undergo at least 1 revision surgery, and average time to revision surgery is over 2 years from last planned surgery. Risk of revision surgery was higher in patients who underwent a spinal fusion as their definitive treatment strategy. Level evidence Level III-retrospective comparative. Type of evidence Therapeutic.
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idiopathic Early Onset Scoliosis growing rods versus vertically expandable prosthetic titanium ribs at 5 year follow up
Journal of Pediatric Orthopaedics, 2020Co-Authors: Malick Bachabi, George H. Thompson, Behrooz A. Akbarnia, Michael G. Vitale, John T Smith, Anna Mcclung, Jeff Pawelek, Ron El Hawary, Paul D SponsellerAbstract:BACKGROUND Distraction-based techniques allow spinal growth until skeletal maturity while preventing curve progression. METHODS Two multicenter Early-Onset Scoliosis databases were used to identify patients with idiopathic spine abnormalities treated with traditional growing rods (TGR) or vertically expandable titanium ribs (VEPTR). Patients underwent at least 4 lengthenings and had at least 5-year follow-up. Significance was set at P<0.05. RESULTS In total, 50 patients treated with TGR and 22 treated with VEPTR were included. Mean (±SD) age at surgery was 5.5 (±2.0) years for the TGR group versus 4.3 (±1.9) years for the VEPTR group (P=0.044); other demographic parameters were similar. VEPTR patients had more procedures (mean 15±4.2) than TGR patients (mean 10±4.0) (P=0.001). Unilateral constructs were present in 18% (4 of 22) of VEPTR and 16% (8 of 50) of TGR patients. Bilateral constructs spanned a mean 2.1 additional surgical levels and exposed patients to 1.6 fewer procedures than unilateral constructs. Curve correction was similar between bilateral and unilateral constructs. TGR patients experienced greater curve correction (50%) than VEPTR patients (27%) (P<0.001) and achieved a greater percentage of thoracic height gain (24%) than VEPTR patients (12%) (P=0.024). At latest follow-up, TGR patients had better maintenance of curve correction, less kyphosis, and 15% greater absolute gain in thoracic height versus VEPTR patients. TGR patients had a lower rate of wound complications (14%) than VEPTR patients (41%) (P=0.011). CONCLUSIONS In patients with idiopathic Early-Onset Scoliosis, TGRs produced greater initial curve correction, greater thoracic height gains, less kyphosis, and lower incidence of wound complications compared with VEPTR. LEVEL OF EVIDENCE Level III.
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surgical and health related quality of life outcomes of growing rod graduates with severe versus moderate Early Onset Scoliosis
Spine, 2019Co-Authors: Ilkka Helenius, George H. Thompson, Charles E. Johnston, Muharrem Yazici, Anna Mcclung, Paul D Sponseller, John B Emans, Suken A Shah, Jeff Pawelek, Behrooz A. AkbarniaAbstract:STUDY DESIGN A retrospective review of a prospective, multicenter database. OBJECTIVE The aim of this study was to compare surgical and quality-of-life outcomes at the end of growing rod treatment in patients with severe versus moderate Early-Onset Scoliosis (EOS). SUMMARY OF BACKGROUND DATA Knowledge of the outcomes of severe EOS after growth-friendly treatment is limited because this condition is uncommon. METHODS We identified 40 children with severe EOS (major curve ≥90°) treated with growing rods before age 10 with minimum 2-year follow-up after last lengthening or final fusion. From the same registry, we matched 40 patients with moderate EOS (major curve < 90°). Twenty-seven patients in the severe group and 12 in the moderate group underwent final fusion (P < 0.001). RESULTS Mean preoperative curves were 102° (range, 90°-139°) in the severe group and 63° (range, 33°-88°) in the moderate group (P < 0.001). At final follow-up, mean curves were 56° (range, 10°-91°) and 36° (range, 12°-89°), respectively (P < 0.001). Fourteen (35%) children in the severe group and 32 (80%) in the moderate group had Scoliosis of < 45° at final follow-up [risk ratio (RR), 0.44; 95% confidence interval (95% CI), 0.20-0.57]. At final follow-up, 30 (75%) children in the severe group and 35 (88%) in the moderate group had achieved T1-T12 length of ≥18 cm (RR, 0.86; 95% CI, 0.70-1.09). Thirty-five children in the severe group and 26 in the moderate group had at least one complication (RR, 1.35; 95% CI, 1.05-1.73). Mean 24-Item Early-Onset Scoliosis Questionnaire scores were similar between groups at final follow-up. CONCLUSION Delaying surgery until the major curve has progressed beyond 90° is associated with larger residual deformity and more complications than treating at a lesser curve magnitude. Quality-of-life outcomes were similar between those with severe and moderate EOS. LEVEL OF EVIDENCE 3.
John B Emans - One of the best experts on this subject based on the ideXlab platform.
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an initial effort to define an Early Onset Scoliosis graduate the pediatric spine study group experience
Spine deformity, 2020Co-Authors: Christina K Hardesty, Charles E. Johnston, John B Emans, Jeff Pawelek, Robert F Murphy, Michael P Glotzbecker, Pooria Hosseini, Behrooz A. AkbarniaAbstract:Increasingly, patients with Early Onset Scoliosis (EOS) are completing a growth friendly surgical program followed by observation, removal of implants or a definitive spinal fusion. These patients are colloquially referred to as “graduates”. A standardized definition of a graduate is needed for research and comparing the outcomes, family counseling, and a better understanding of the population. A 15-question electronic survey was completed by 39 experienced pediatric spine surgeons to identify factors salient to the definition of a graduate of EOS surgical programs. A Delphi/Nominal group technique session with nine questions was then performed face-to-face with 21 members of the Pediatric Spine Study Group to discuss and refine the definition. A follow-up electronic survey was then distributed to these same 21 members to gain consensus on the final definition. From the initial survey, it was identified that a graduate did not require definitive spinal fusion after a growing program. From the Delphi session, it was determined that skeletal maturity was the most important factor in defining a graduate. A strictly defined minimum length of follow-up was not felt to be a prerequisite for qualification of graduation. After the final electronic version was distributed, > 80% of respondents agreed upon the final definition, thereby achieving consensus. The Pediatric Spine Study Group recommends adoption of the following definition: a “graduate” is a patient who has undergone any surgical program to treat Early Onset Scoliosis, and has reached skeletal maturity and does not have a planned surgical intervention for EOS in the future. V.
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an initial effort to define an Early Onset Scoliosis graduate the pediatric spine study group experience
Spine deformity, 2020Co-Authors: Christina K Hardesty, Charles E. Johnston, John B Emans, Jeff Pawelek, Robert F Murphy, Michael P Glotzbecker, Pooria Hosseini, Behrooz A. AkbarniaAbstract:Purpose Increasingly, patients with Early Onset Scoliosis (EOS) are completing a growth friendly surgical program followed by observation, removal of implants or a definitive spinal fusion. These patients are colloquially referred to as "graduates". A standardized definition of a graduate is needed for research and comparing the outcomes, family counseling, and a better understanding of the population. Methods A 15-question electronic survey was completed by 39 experienced pediatric spine surgeons to identify factors salient to the definition of a graduate of EOS surgical programs. A Delphi/Nominal group technique session with nine questions was then performed face-to-face with 21 members of the Pediatric Spine Study Group to discuss and refine the definition. A follow-up electronic survey was then distributed to these same 21 members to gain consensus on the final definition. Results From the initial survey, it was identified that a graduate did not require definitive spinal fusion after a growing program. From the Delphi session, it was determined that skeletal maturity was the most important factor in defining a graduate. A strictly defined minimum length of follow-up was not felt to be a prerequisite for qualification of graduation. After the final electronic version was distributed, > 80% of respondents agreed upon the final definition, thereby achieving consensus. Conclusion The Pediatric Spine Study Group recommends adoption of the following definition: a "graduate" is a patient who has undergone any surgical program to treat Early Onset Scoliosis, and has reached skeletal maturity and does not have a planned surgical intervention for EOS in the future. Level of evidence V.
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minimum 5 year follow up on graduates of growing spine surgery for Early Onset Scoliosis
Journal of Pediatric Orthopaedics, 2020Co-Authors: Robert F Murphy, George H. Thompson, Behrooz A. Akbarnia, John T Smith, Paul D Sponseller, John B Emans, David L Skaggs, William R Barfield, David S Marks, John M. FlynnAbstract:Introduction After discontinuation of growth friendly (GF) surgery for Early Onset Scoliosis, patients undergo spinal fusion or continued observation. This last planned treatment is colloquially called "definitive" treatment, conferring these patients as "graduates" of a growing program. The 5-year radiographic and clinical outcomes of this cohort are unknown. Methods An international pediatric spine database was queried for patients from a GF program (spine or rib-based) with minimum 5-year follow-up from last planned surgery (GF or spinal fusion). Radiographs and charts were reviewed for main coronal curve angle and maximum kyphosis as well as occurrence of secondary surgery. Results Of 580 graduates, 170 (29%) had minimum 5-year follow-up (37% male). Scoliosis etiology was congenital in 41 (24%), idiopathic 36 (21%), neuromuscular 51 (30%), and syndromic 42 (25%). Index surgery consisted of spine-based growing rods in 122 (71%) and rib-based distraction in 48 (29%). Mean age at index surgery was 6.8 years, and patients underwent an average of 5.4 lengthenings over an average of 4.9 years (range, 6 mo to 11 y). Last planned treatment was at an average age of 11.8 years (range, 7 to 17 years). Last planned treatment consisted of spinal fusion in 114 patients, 47 had growing implants maintained, 9 had implants removed. Average follow-up was 7.3 years (range, 5 to 13 y).When compared from postdefinitive treatment to 2-year follow-up, there was noted progression of the coronal curve angle (46±19 to 51±21 degrees, P=0.046) and kyphosis (48±20 to 57±25 degrees, P=0.03). However, between 2 and 5 years, no further progression occurred in the coronal (51±21 to 53±21 degrees, P=0.26) or sagittal (57±25 to 54±28 degrees, P=0.93) planes. When stratified based on etiology, there was no significant coronal curve progression between 2- and 5-year follow-up. When comparing spinal fusion patients to those who had maintenance of their growing construct, there was also no significant curve progression.Thirty-seven (21%) underwent at least 1 (average, 1.7; range, 1 to 7) revision surgery following graduation, and 15 of 37 (41%) underwent 2 or more revision surgeries. Reason for revision was implant revision (either GF or spinal fusion) in 34 patients, and implant removal in 3. On an average, the first revision was 2.5 years after the definitive treatment plan (range, 0.02 to 7.4 y). In total, 15 of 37 (41%) revisions occurred over 2 years following the final decision for treatment plan, and 7 of 37 (19%) occurred 5 or more years after the definitive treatment.Patients who underwent spinal fusion as a definitive treatment strategy were more likely to undergo revision surgery (27%) than patients who had their GF implants maintained (11%) (P=0.04). Conclusions Five years following "graduation" from growing surgery for Early Onset Scoliosis, there is progression of curve magnitude in both the coronal and sagittal planes up to 2 years, with no further progression at 5 years. A total of 21% of patients undergo at least 1 revision surgery, and average time to revision surgery is over 2 years from last planned surgery. Risk of revision surgery was higher in patients who underwent a spinal fusion as their definitive treatment strategy. Level evidence Level III-retrospective comparative. Type of evidence Therapeutic.
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mri utilization and rates of abnormal pretreatment mri findings in Early Onset Scoliosis review of a global cohort
Spine deformity, 2020Co-Authors: Brendan A Williams, Peter Sturm, Laurel C. Blakemore, Anna Mcclung, Paul D Sponseller, John B Emans, Suken A Shah, Jeff Pawelek, Stefan Parent, Burt YaszayAbstract:Retrospective review To report the frequency of pretreatment magnetic resonance imaging (MRI) utilization and rates and types of intra-spinal abnormalities identified on MRI in patients with Early-Onset Scoliosis (EOS). MRI can help identify spinal cord abnormalities in patients with EOS. We reviewed data from patients enrolled from 1993–2018 in an international EOS registry. Patients with incomplete/unverifiable data and those with spinal deformities secondary to infection or tumor were excluded, leaving 1343 patients for analysis. Demographic characteristics, pretreatment major curve magnitude, treatment type, and MRI findings were analyzed. Patients were categorized by EOS type (congenital, idiopathic, neuromuscular, syndromic), pretreatment MRI utilization, and presence of intra-spinal abnormality on MRI. Univariate testing and multivariate logistic regression were performed to identify demographic, radiographic, and clinical predictors of MRI utilization and abnormal MRI findings. MRI was used in 836 patients (62%). Pretreatment MRI utilization rates ranged from 42% in neuromuscular EOS to 74% in congenital EOS. Prevalence of abnormal MRI findings was 24% overall, ranging from 13% in patients with idiopathic EOS to 39% in neuromuscular EOS. Compared with white/Caucasian patients, Asian/Asian-American patients had higher odds of MRI utilization and abnormal MRI findings. Treatment type, pretreatment major curve magnitude, age at MRI, and age at treatment were not associated with abnormal MRI findings. Overall, 249 abnormalities were identified in 197 patients. The most common findings were syrinx and tethered cord. Syrinx with Chiari malformation was the most frequent combination of abnormal findings. In the two-thirds of patients who underwent MRI before EOS treatment, findings were abnormal in 24%. EOS type and race/ethnicity were associated with both MRI utilization and abnormal findings. The most frequent abnormalities were syrinx and tethered cord, and the type of abnormalities appeared to differ by EOS type. Prognostic, Level III.
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surgical and health related quality of life outcomes of growing rod graduates with severe versus moderate Early Onset Scoliosis
Spine, 2019Co-Authors: Ilkka Helenius, George H. Thompson, Charles E. Johnston, Muharrem Yazici, Anna Mcclung, Paul D Sponseller, John B Emans, Suken A Shah, Jeff Pawelek, Behrooz A. AkbarniaAbstract:STUDY DESIGN A retrospective review of a prospective, multicenter database. OBJECTIVE The aim of this study was to compare surgical and quality-of-life outcomes at the end of growing rod treatment in patients with severe versus moderate Early-Onset Scoliosis (EOS). SUMMARY OF BACKGROUND DATA Knowledge of the outcomes of severe EOS after growth-friendly treatment is limited because this condition is uncommon. METHODS We identified 40 children with severe EOS (major curve ≥90°) treated with growing rods before age 10 with minimum 2-year follow-up after last lengthening or final fusion. From the same registry, we matched 40 patients with moderate EOS (major curve < 90°). Twenty-seven patients in the severe group and 12 in the moderate group underwent final fusion (P < 0.001). RESULTS Mean preoperative curves were 102° (range, 90°-139°) in the severe group and 63° (range, 33°-88°) in the moderate group (P < 0.001). At final follow-up, mean curves were 56° (range, 10°-91°) and 36° (range, 12°-89°), respectively (P < 0.001). Fourteen (35%) children in the severe group and 32 (80%) in the moderate group had Scoliosis of < 45° at final follow-up [risk ratio (RR), 0.44; 95% confidence interval (95% CI), 0.20-0.57]. At final follow-up, 30 (75%) children in the severe group and 35 (88%) in the moderate group had achieved T1-T12 length of ≥18 cm (RR, 0.86; 95% CI, 0.70-1.09). Thirty-five children in the severe group and 26 in the moderate group had at least one complication (RR, 1.35; 95% CI, 1.05-1.73). Mean 24-Item Early-Onset Scoliosis Questionnaire scores were similar between groups at final follow-up. CONCLUSION Delaying surgery until the major curve has progressed beyond 90° is associated with larger residual deformity and more complications than treating at a lesser curve magnitude. Quality-of-life outcomes were similar between those with severe and moderate EOS. LEVEL OF EVIDENCE 3.
Jeff Pawelek - One of the best experts on this subject based on the ideXlab platform.
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an initial effort to define an Early Onset Scoliosis graduate the pediatric spine study group experience
Spine deformity, 2020Co-Authors: Christina K Hardesty, Charles E. Johnston, John B Emans, Jeff Pawelek, Robert F Murphy, Michael P Glotzbecker, Pooria Hosseini, Behrooz A. AkbarniaAbstract:Purpose Increasingly, patients with Early Onset Scoliosis (EOS) are completing a growth friendly surgical program followed by observation, removal of implants or a definitive spinal fusion. These patients are colloquially referred to as "graduates". A standardized definition of a graduate is needed for research and comparing the outcomes, family counseling, and a better understanding of the population. Methods A 15-question electronic survey was completed by 39 experienced pediatric spine surgeons to identify factors salient to the definition of a graduate of EOS surgical programs. A Delphi/Nominal group technique session with nine questions was then performed face-to-face with 21 members of the Pediatric Spine Study Group to discuss and refine the definition. A follow-up electronic survey was then distributed to these same 21 members to gain consensus on the final definition. Results From the initial survey, it was identified that a graduate did not require definitive spinal fusion after a growing program. From the Delphi session, it was determined that skeletal maturity was the most important factor in defining a graduate. A strictly defined minimum length of follow-up was not felt to be a prerequisite for qualification of graduation. After the final electronic version was distributed, > 80% of respondents agreed upon the final definition, thereby achieving consensus. Conclusion The Pediatric Spine Study Group recommends adoption of the following definition: a "graduate" is a patient who has undergone any surgical program to treat Early Onset Scoliosis, and has reached skeletal maturity and does not have a planned surgical intervention for EOS in the future. Level of evidence V.
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an initial effort to define an Early Onset Scoliosis graduate the pediatric spine study group experience
Spine deformity, 2020Co-Authors: Christina K Hardesty, Charles E. Johnston, John B Emans, Jeff Pawelek, Robert F Murphy, Michael P Glotzbecker, Pooria Hosseini, Behrooz A. AkbarniaAbstract:Increasingly, patients with Early Onset Scoliosis (EOS) are completing a growth friendly surgical program followed by observation, removal of implants or a definitive spinal fusion. These patients are colloquially referred to as “graduates”. A standardized definition of a graduate is needed for research and comparing the outcomes, family counseling, and a better understanding of the population. A 15-question electronic survey was completed by 39 experienced pediatric spine surgeons to identify factors salient to the definition of a graduate of EOS surgical programs. A Delphi/Nominal group technique session with nine questions was then performed face-to-face with 21 members of the Pediatric Spine Study Group to discuss and refine the definition. A follow-up electronic survey was then distributed to these same 21 members to gain consensus on the final definition. From the initial survey, it was identified that a graduate did not require definitive spinal fusion after a growing program. From the Delphi session, it was determined that skeletal maturity was the most important factor in defining a graduate. A strictly defined minimum length of follow-up was not felt to be a prerequisite for qualification of graduation. After the final electronic version was distributed, > 80% of respondents agreed upon the final definition, thereby achieving consensus. The Pediatric Spine Study Group recommends adoption of the following definition: a “graduate” is a patient who has undergone any surgical program to treat Early Onset Scoliosis, and has reached skeletal maturity and does not have a planned surgical intervention for EOS in the future. V.
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characterizing use of growth friendly implants for Early Onset Scoliosis a 10 year update
Journal of Pediatric Orthopaedics, 2020Co-Authors: Richard E. Mccarthy, James O Sanders, David L Skaggs, Suken A Shah, Jeff Pawelek, Scott J Luhmann, Walter Klyce, Stuart L Mitchell, Peter SturmAbstract:BACKGROUND Growth-friendly treatment of Early-Onset Scoliosis (EOS) has changed with the development and evolution of multiple devices. This study was designed to characterize changes in the use of growth-friendly implants for EOS from 2007 to 2017. METHODS We queried the Pediatric Spine Study Group database for patients who underwent index surgery with growth-friendly implants from July 2007 to June 2017. In 1298 patients, we assessed causes of EOS; preoperative curve magnitude; age at first surgery; patient sex; construct type; lengthening interval; incidence of "final" fusion for definitive treatment; and age at definitive treatment. α=0.05. RESULTS From 2007 to 2017, the annual proportion of patients with idiopathic EOS increased from 12% to 33% (R=0.58, P=0.006). Neuromuscular EOS was the most common type at all time points (range, 33% to 44%). By year, mean preoperative curve magnitude ranged from 67 to 77 degrees, with no significant temporal changes. Mean (±SD) age at first surgery increased from 6.1±2.9 years in 2007 to 7.8±2.5 years in 2017 (R=0.78, P<0.001). As a proportion of new implants, magnetically controlled growing rods increased from <5% during the first 2 years to 83% in the last 2 years of the study. Vertically expandable prosthetic titanium ribs decreased from a peak of 48% to 6%; growth-guidance devices decreased from 10% to 3%. No change was seen in mean surgical lengthening intervals (range, 6 to 9 mo) for the 614 patients with recorded lengthenings. Final fusion was performed in 88% of patients who had undergone definitive treatment, occurring at a mean age of 13.4±2.4 years. CONCLUSIONS From 2007 to 2017, neuromuscular EOS was the most common diagnosis for patients treated with growth-friendly implants. Patient age at first surgery and the use of magnetically controlled growing rods increased during this time. Preoperative curve magnitude, traditional growing rod lengthening intervals, and rates of final fusion did not change. LEVEL OF EVIDENCE Level II.
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mri utilization and rates of abnormal pretreatment mri findings in Early Onset Scoliosis review of a global cohort
Spine deformity, 2020Co-Authors: Brendan A Williams, Peter Sturm, Laurel C. Blakemore, Anna Mcclung, Paul D Sponseller, John B Emans, Suken A Shah, Jeff Pawelek, Stefan Parent, Burt YaszayAbstract:Retrospective review To report the frequency of pretreatment magnetic resonance imaging (MRI) utilization and rates and types of intra-spinal abnormalities identified on MRI in patients with Early-Onset Scoliosis (EOS). MRI can help identify spinal cord abnormalities in patients with EOS. We reviewed data from patients enrolled from 1993–2018 in an international EOS registry. Patients with incomplete/unverifiable data and those with spinal deformities secondary to infection or tumor were excluded, leaving 1343 patients for analysis. Demographic characteristics, pretreatment major curve magnitude, treatment type, and MRI findings were analyzed. Patients were categorized by EOS type (congenital, idiopathic, neuromuscular, syndromic), pretreatment MRI utilization, and presence of intra-spinal abnormality on MRI. Univariate testing and multivariate logistic regression were performed to identify demographic, radiographic, and clinical predictors of MRI utilization and abnormal MRI findings. MRI was used in 836 patients (62%). Pretreatment MRI utilization rates ranged from 42% in neuromuscular EOS to 74% in congenital EOS. Prevalence of abnormal MRI findings was 24% overall, ranging from 13% in patients with idiopathic EOS to 39% in neuromuscular EOS. Compared with white/Caucasian patients, Asian/Asian-American patients had higher odds of MRI utilization and abnormal MRI findings. Treatment type, pretreatment major curve magnitude, age at MRI, and age at treatment were not associated with abnormal MRI findings. Overall, 249 abnormalities were identified in 197 patients. The most common findings were syrinx and tethered cord. Syrinx with Chiari malformation was the most frequent combination of abnormal findings. In the two-thirds of patients who underwent MRI before EOS treatment, findings were abnormal in 24%. EOS type and race/ethnicity were associated with both MRI utilization and abnormal findings. The most frequent abnormalities were syrinx and tethered cord, and the type of abnormalities appeared to differ by EOS type. Prognostic, Level III.
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idiopathic Early Onset Scoliosis growing rods versus vertically expandable prosthetic titanium ribs at 5 year follow up
Journal of Pediatric Orthopaedics, 2020Co-Authors: Malick Bachabi, George H. Thompson, Behrooz A. Akbarnia, Michael G. Vitale, John T Smith, Anna Mcclung, Jeff Pawelek, Ron El Hawary, Paul D SponsellerAbstract:BACKGROUND Distraction-based techniques allow spinal growth until skeletal maturity while preventing curve progression. METHODS Two multicenter Early-Onset Scoliosis databases were used to identify patients with idiopathic spine abnormalities treated with traditional growing rods (TGR) or vertically expandable titanium ribs (VEPTR). Patients underwent at least 4 lengthenings and had at least 5-year follow-up. Significance was set at P<0.05. RESULTS In total, 50 patients treated with TGR and 22 treated with VEPTR were included. Mean (±SD) age at surgery was 5.5 (±2.0) years for the TGR group versus 4.3 (±1.9) years for the VEPTR group (P=0.044); other demographic parameters were similar. VEPTR patients had more procedures (mean 15±4.2) than TGR patients (mean 10±4.0) (P=0.001). Unilateral constructs were present in 18% (4 of 22) of VEPTR and 16% (8 of 50) of TGR patients. Bilateral constructs spanned a mean 2.1 additional surgical levels and exposed patients to 1.6 fewer procedures than unilateral constructs. Curve correction was similar between bilateral and unilateral constructs. TGR patients experienced greater curve correction (50%) than VEPTR patients (27%) (P<0.001) and achieved a greater percentage of thoracic height gain (24%) than VEPTR patients (12%) (P=0.024). At latest follow-up, TGR patients had better maintenance of curve correction, less kyphosis, and 15% greater absolute gain in thoracic height versus VEPTR patients. TGR patients had a lower rate of wound complications (14%) than VEPTR patients (41%) (P=0.011). CONCLUSIONS In patients with idiopathic Early-Onset Scoliosis, TGRs produced greater initial curve correction, greater thoracic height gains, less kyphosis, and lower incidence of wound complications compared with VEPTR. LEVEL OF EVIDENCE Level III.
Colin Nnadi - One of the best experts on this subject based on the ideXlab platform.
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a six year observational study of 31 children with Early Onset Scoliosis treated using magnetically controlled growing rods with a minimum follow up of two years
Journal of Bone and Joint Surgery-british Volume, 2018Co-Authors: T Subramanian, D Mayers, A Ahmad, D M Mardare, David C Kieser, Colin NnadiAbstract:Aims Magnetically controlled growing rod (MCGR) systems use non-invasive spinal lengthening for the surgical treatment of Early-Onset Scoliosis (EOS). The primary aim of this study was to evaluate ...
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systematic review of the complications associated with magnetically controlled growing rods for the treatment of Early Onset Scoliosis
European Spine Journal, 2018Co-Authors: Chrishan Thakar, Jeremy Fairbank, David C Kieser, Mihai Mardare, Shahnawaz Haleem, Colin NnadiAbstract:To analyse the complication profile of magnetically controlled growing rods (MCGRs) in Early Onset Scoliosis (EOS). This is a systematic review using PUBMED, Medline, Embase, Google Scholar and the Cochrane Library (keywords: MAGEC, Magnetically controlled growing rods and EOS) of all studies written in English with a minimum of five patients and a 1-year follow-up. We evaluated coronal correction, growth progression (T1–S1, T1–T12) and complications. Fifteen studies (336 patients) were included (42.5% male, mean age 7.9 years, average follow-up 29.7 months). Coronal improvement was achieved in all studies (pre-operative 64.8°, latest follow-up 34.9° p = 0.000), as was growth progression (p = 0.001). Mean complication rate was 44.5%, excluding the 50.8% medical complication rate. The unplanned revision rate was 33%. The most common complications were anchor pull-out (11.8%), implant failure (11.7%) and rod breakage (10.6%). There was no significant difference between primary (39.8%) and conversion (33.3%) procedures (p = 0.462). There was a non-statistically significant increased complication rate with single rods (40 vs. 27% p = 0.588). MCGRs improve coronal deformity and maintain spinal growth, but carry a 44.5% complication and 33% unplanned revision rate. Conversion procedures do not increase this risk. Single rods should be avoided. These slides can be retrieved under Electronic Supplementary material.
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an nihr approved two year observational study on magnetically controlled growth rods in the treatment of Early Onset Scoliosis
Journal of Bone and Joint Surgery-british Volume, 2018Co-Authors: Colin Nnadi, Chrishan Thakar, James Wilsonmacdonald, P Milner, A Rao, D Mayers, Jeremy Fairbank, T SubramanianAbstract:Aims The primary aim of this study was to evaluate the performance and safety of magnetically controlled growth rods in the treatment of Early Onset Scoliosis. Secondary aims were to evaluate the clinical outcome, the rate of further surgery, the rate of complications, and the durability of correction. Patients and Methods We undertook an observational prospective cohort study of children with Early Onset Scoliosis, who were recruited over a one-year period and followed up for a minimum of two years. Magnetically controlled rods were introduced in a standardized manner with distractions performed three-monthly thereafter. Adverse events which were both related and unrelated to the device were recorded. Ten children, for whom relevant key data points (such as demographic information, growth parameters, Cobb angles, and functional outcomes) were available, were recruited and followed up over the period of the study. There were five boys and five girls. Their mean age was 6.2 years (2.5 to 10). Results The m...
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radiological and clinical assessment of the distraction achieved with remotely expandable growing rods in Early Onset Scoliosis
European Spine Journal, 2016Co-Authors: D J Rolton, James Wilsonmacdonald, Chrishan Thakar, Colin NnadiAbstract:Magnetically controlled growing rods (MCGR) allow controlled distraction of the immature spine for the treatment of Early Onset Scoliosis. This study’s primary aim was to determine the disparity between ‘true’ (TD) and ‘intended’ (ID) distraction. The secondary aim was to assess truncal growth and development during sequential lengthening. Twenty-one patients with a maximum follow up of 37 months were included in the study. Patients in the study underwent three monthly distractions. The amount of TD was determined by measuring the expansion gap on dedicated fluoroscopic images of the actuator. The total TD to date was compared to the ID measurement reported on the external adjustment device (EAD). Weight, sitting and standing heights were recorded at each distraction. The average number of three monthly distractions was 8. The true to intended distraction ratio was calculated as 0.33. Patients who had undergone previous surgery gained less distraction with a ratio of 0.30 compared to patients undergoing MCGR as a primary procedure with a ratio of 0.35. Weight, sitting and standing heights increased in all patients by an average of 3.1 kg, 2.3 and 5.2 cm per year. The Cobb angle following surgical correction was maintained in 19 of 21 patients at the latest follow-up. The TI ratio of 0.33 suggests that for every unit of distraction registered on the EAD approximately 33 % of true distraction occurs in vivo. Increases in sitting and standing heights were observed in all patients in the study.
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the use of magnetically controlled growing rods to treat children with Early Onset Scoliosis Early radiological results in 19 children
Journal of Bone and Joint Surgery-british Volume, 2016Co-Authors: W Thompson, James Wilsonmacdonald, Chrishan Thakar, D J Rolton, Colin NnadiAbstract:Aims We undertook a prospective non-randomised radiological study to evaluate the preliminary results of using magnetically-controlled growing rods (MAGEC System, Ellipse technology) to treat children with Early-Onset Scoliosis. Patients and Methods Between January 2011 and January 2015, 19 children were treated with magnetically-controlled growing rods (MCGRs) and underwent distraction at three-monthly intervals. The mean age of our cohort was 9.1 years (4 to 14) and the mean follow-up 22.4 months (5.1 to 35.2). Of the 19 children, eight underwent conversion from traditional growing rods. Whole spine radiographs were carried out pre- and post-operatively: image intensification was used during each lengthening in the outpatient department. The measurements evaluated were Cobb angle, thoracic kyphosis, proximal junctional kyphosis and spinal growth from T1 to S1. Results The mean pre-, post-operative and latest follow-up Cobb angles were 62° (37.4 to 95.8), 45.1° (16.6 to 96.2) and 43.2° (11.9 to 90.5), respectively (p < 0.05). The mean pre-, post-operative and latest follow-up T1-S1 lengths were 288.1 mm (223.2 to 351.7), 298.8 mm (251 to 355.7) and 331.1 mm (275 to 391.9), respectively (p < 0.05). In all, three patients developed proximal pull-out of their fixation and required revision surgery: there were no subsequent complications. There were no complications of outpatient distraction. Conclusions Our study shows that MCGRs provide stable correction of the deformity in Early-Onset Scoliosis in both primary and revision procedures. They have the potential to reduce the need for multiple operations and thereby minimise the potential complications associated with traditional growing rod systems. Cite this article: Bone Joint J 2016;98-B:1240–47.
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minimum 5 year follow up on graduates of growing spine surgery for Early Onset Scoliosis
Journal of Pediatric Orthopaedics, 2020Co-Authors: Robert F Murphy, George H. Thompson, Behrooz A. Akbarnia, John T Smith, Paul D Sponseller, John B Emans, David L Skaggs, William R Barfield, David S Marks, John M. FlynnAbstract:Introduction After discontinuation of growth friendly (GF) surgery for Early Onset Scoliosis, patients undergo spinal fusion or continued observation. This last planned treatment is colloquially called "definitive" treatment, conferring these patients as "graduates" of a growing program. The 5-year radiographic and clinical outcomes of this cohort are unknown. Methods An international pediatric spine database was queried for patients from a GF program (spine or rib-based) with minimum 5-year follow-up from last planned surgery (GF or spinal fusion). Radiographs and charts were reviewed for main coronal curve angle and maximum kyphosis as well as occurrence of secondary surgery. Results Of 580 graduates, 170 (29%) had minimum 5-year follow-up (37% male). Scoliosis etiology was congenital in 41 (24%), idiopathic 36 (21%), neuromuscular 51 (30%), and syndromic 42 (25%). Index surgery consisted of spine-based growing rods in 122 (71%) and rib-based distraction in 48 (29%). Mean age at index surgery was 6.8 years, and patients underwent an average of 5.4 lengthenings over an average of 4.9 years (range, 6 mo to 11 y). Last planned treatment was at an average age of 11.8 years (range, 7 to 17 years). Last planned treatment consisted of spinal fusion in 114 patients, 47 had growing implants maintained, 9 had implants removed. Average follow-up was 7.3 years (range, 5 to 13 y).When compared from postdefinitive treatment to 2-year follow-up, there was noted progression of the coronal curve angle (46±19 to 51±21 degrees, P=0.046) and kyphosis (48±20 to 57±25 degrees, P=0.03). However, between 2 and 5 years, no further progression occurred in the coronal (51±21 to 53±21 degrees, P=0.26) or sagittal (57±25 to 54±28 degrees, P=0.93) planes. When stratified based on etiology, there was no significant coronal curve progression between 2- and 5-year follow-up. When comparing spinal fusion patients to those who had maintenance of their growing construct, there was also no significant curve progression.Thirty-seven (21%) underwent at least 1 (average, 1.7; range, 1 to 7) revision surgery following graduation, and 15 of 37 (41%) underwent 2 or more revision surgeries. Reason for revision was implant revision (either GF or spinal fusion) in 34 patients, and implant removal in 3. On an average, the first revision was 2.5 years after the definitive treatment plan (range, 0.02 to 7.4 y). In total, 15 of 37 (41%) revisions occurred over 2 years following the final decision for treatment plan, and 7 of 37 (19%) occurred 5 or more years after the definitive treatment.Patients who underwent spinal fusion as a definitive treatment strategy were more likely to undergo revision surgery (27%) than patients who had their GF implants maintained (11%) (P=0.04). Conclusions Five years following "graduation" from growing surgery for Early Onset Scoliosis, there is progression of curve magnitude in both the coronal and sagittal planes up to 2 years, with no further progression at 5 years. A total of 21% of patients undergo at least 1 revision surgery, and average time to revision surgery is over 2 years from last planned surgery. Risk of revision surgery was higher in patients who underwent a spinal fusion as their definitive treatment strategy. Level evidence Level III-retrospective comparative. Type of evidence Therapeutic.
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serial casting in neuromuscular and syndromic Early Onset Scoliosis eos can delay surgery over 2 years
Journal of Pediatric Orthopaedics, 2020Co-Authors: George H. Thompson, Peter Sturm, Kim W. Hammerberg, Scott M Lavalva, Alexander J Adams, Elle M Macalpine, Purnendu Gupta, Sumeet GargAbstract:Background The primary goal in managing Early-Onset Scoliosis (EOS) is delaying/preventing surgical intervention while allowing improved spinal growth and chest wall and lung development to improve life expectancy. The effectiveness of serial casting for patients with neuromuscular and syndromic EOS is unclear. Methods Patients from 2 multicenter registries who underwent serial casting for nonidiopathic Scoliosis (NIS) were reviewed retrospectively. Comparisons were made between precasting and postcasting major and compensatory curves and spine height. The need for surgical intervention and any treatment complications were documented. Risk factors for major curve progression from baseline to casting cessation were evaluated via univariate analysis. Results Forty-four patients (23 females; 21 males) with NIS (26 syndromic, 18 neuromuscular) and a mean age of 3.2 years at baseline were included. Mean follow-up and casting duration was 3.9 and 2.0 years, respectively. There were no statistically significant differences between mean precasting and postcasting major curve (55 vs. 60 degrees; P=0.348), minor curve (31 vs. 33 degrees; P=0.510), or rib-vertebra angle difference (18 vs. 29 degrees; P=0.840). However, thoracic height (15.5 vs. 16.8 cm; P=0.031) and lumbar height (8.9 vs. 9.8 cm; P=0.013) were significantly greater upon casting cessation. Currently, 13 patients (30%) have had successful casting (improvement of major curve ≥10 degrees) while 24 patients (55%) experienced major curve progression (worsening), and 19 patients (43%) required surgical intervention. Mean time from first casting to surgery was 34.5±15.1 months. There were no statistically significant predictors for major curve progression on univariate analysis. Conclusions Spinal deformity progression despite casting and the subsequent need for surgical intervention for NIS were significantly higher compared with those reported for idiopathic EOS. However, serial casting did afford a substantial delay in surgical intervention. Ultimately, serial casting for neuromuscular or syndromic EOS is an effective strategy for delaying surgical intervention, despite suboptimal radiographic outcomes. Level of evidence Level III.
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growth preserving instrumentation in Early Onset Scoliosis patients with multi level congenital anomalies
Spine deformity, 2020Co-Authors: Carter R Clement, George H. Thompson, Anna Mcclung, Paul D Sponseller, David L Skaggs, Burt Yaszay, Carrie E Bartley, Naveed Nabizadeh, Ohenaba Boachieadjei, Suken A ShahAbstract:Retrospective. To assess final outcomes in patients with Early-Onset Scoliosis (EOS) who underwent growth-preserving instrumentation (GPI). Various types of growth-preserving instrumentation (GPI) are frequently employed, but until recently had not been utilized long enough to assess final outcomes. GPI “graduates” with multi-level congenital curves were identified. Graduation was defined as a final fusion or 5 years of follow-up without planned future surgeries. Outcomes included radiographic parameters and complications. 26 patients were included. 11 had associated diagnoses; eight had fused ribs. 17 were treated with traditional growing rods, seven with vertically expandable prosthetic ribs, and two with Shilla procedures. The mean GPI spanned 12.3 levels including 10.7 motion segments, age at index surgery was 5.5 years, treatment spanned 7.5 years, and follow-up was 9.2 years. 24 patients underwent final fusion. Mean major curve decreased from 73° to 49° with index surgery (p 60° in 6 patients (23%). None worsened throughout treatment. Mean T1–T12 height increased 2.4 cm with index surgery (p = 0.02) and 5.4 cm total (p 22 cm in 6 patients (23%). On average, there were 2.6 complications per patient, including 1.7 implant failures. 12 patients (46%) experienced ≥ 3 complications; four patients (15%) experienced none. We observed successful prevention of deformity progression but substantial residual deformity among GPI graduates with multi-level congenital EOS. Most coronal curve correction was attained during GPI implantation; thoracic height improved throughout treatment. While some favorable results were found, treatment strategies allowing improved deformity correction would be valuable for this challenging population. Therapeutic-III.
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idiopathic Early Onset Scoliosis growing rods versus vertically expandable prosthetic titanium ribs at 5 year follow up
Journal of Pediatric Orthopaedics, 2020Co-Authors: Malick Bachabi, George H. Thompson, Behrooz A. Akbarnia, Michael G. Vitale, John T Smith, Anna Mcclung, Jeff Pawelek, Ron El Hawary, Paul D SponsellerAbstract:BACKGROUND Distraction-based techniques allow spinal growth until skeletal maturity while preventing curve progression. METHODS Two multicenter Early-Onset Scoliosis databases were used to identify patients with idiopathic spine abnormalities treated with traditional growing rods (TGR) or vertically expandable titanium ribs (VEPTR). Patients underwent at least 4 lengthenings and had at least 5-year follow-up. Significance was set at P<0.05. RESULTS In total, 50 patients treated with TGR and 22 treated with VEPTR were included. Mean (±SD) age at surgery was 5.5 (±2.0) years for the TGR group versus 4.3 (±1.9) years for the VEPTR group (P=0.044); other demographic parameters were similar. VEPTR patients had more procedures (mean 15±4.2) than TGR patients (mean 10±4.0) (P=0.001). Unilateral constructs were present in 18% (4 of 22) of VEPTR and 16% (8 of 50) of TGR patients. Bilateral constructs spanned a mean 2.1 additional surgical levels and exposed patients to 1.6 fewer procedures than unilateral constructs. Curve correction was similar between bilateral and unilateral constructs. TGR patients experienced greater curve correction (50%) than VEPTR patients (27%) (P<0.001) and achieved a greater percentage of thoracic height gain (24%) than VEPTR patients (12%) (P=0.024). At latest follow-up, TGR patients had better maintenance of curve correction, less kyphosis, and 15% greater absolute gain in thoracic height versus VEPTR patients. TGR patients had a lower rate of wound complications (14%) than VEPTR patients (41%) (P=0.011). CONCLUSIONS In patients with idiopathic Early-Onset Scoliosis, TGRs produced greater initial curve correction, greater thoracic height gains, less kyphosis, and lower incidence of wound complications compared with VEPTR. LEVEL OF EVIDENCE Level III.
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results of growth friendly management of Early Onset Scoliosis in children with and without skeletal dysplasias a matched comparison
Journal of Bone and Joint Surgery-british Volume, 2019Co-Authors: Ilkka Helenius, Joshua M Pahys, George H. Thompson, Charles E. Johnston, Muharrem Yazici, Klane K White, Sumeet Garg, Anna Mcclung, Antti J Saarinen, Michael G. VitaleAbstract:Aims The aim of this study was to compare the surgical and quality-of-life outcomes of children with skeletal dysplasia to those in children with idiopathic Early-Onset Scoliosis (EOS) undergoing g...
