Faculty Bibliography

BACKGROUND CONTEXT: Adolescent idiopathic scoliosis (AIS) is largely an asymptomatic condition with little impact on function in a young, active population. Little is known about the level of activity of the postoperative AIS patient other than from non-descriptive patient outcome questionnaires. PURPOSE: The purpose of this study was to assess return to sports participation in operatively treated AIS patients. STUDY DESIGN/SETTING: Retrospective questionnaires were administered to consecutively enrolled operative AIS patients. PATIENT SAMPLE: Operative AIS patients. OUTCOME MEASURES: Intensity and time spent in the sport after surgery for AIS. METHODS: A retrospective study of consecutive operative AIS patients presenting for their 1- or 2-year postoperative visits and who were engaged in a sport or dance regularly before surgery were administered the SRS-22, Activity Questionnaire for Adults and Adolescents (AQuAA) and a customized questionnaire on return to sport. The intensity and time spent in the sport were compared pre- and postsurgery using Wilcoxon signed-rank tests. RESULTS: 38 patients were enrolled (age 14.2 yrs; 84.2% female; 36 PSF, 2 combined approaches; levels fused 9.5; mean FU 1.5 yrs). 36/38 (94.7%) returned to their sports after surgery. Median times to begin training after surgery was 3-6 months and to fully return to sport was 6-12 months. Among these 36 patients, 29 (80.6%) were able to return to their previous or a higher level of competition. Nine (25%) patients had reduced intensity of participating sport (p=0.0005). Most frequently played sports after surgery were: in Contact category Football (5.3%), in Light Contact category: Baseball/Softball (23.7%), Soccer (15.8%) and Volleyball (15.8%); in Noncontact category: Swimming/Diving (26.3%), Dance (23.7%) and Track & Field (13.2%); and in Recreational category: Running/Jogging (44.7%), Swimming (noncompetitive, 28.9%) and Strength training (23.7%) (please note that patients may participate in multiple sports within and!

BACKGROUND: Standardized pediatric hospitalist and orthopaedic co-management of spinal fusion patients may improve quality processes and outcomes. This approach has not been studied in a general academic center. OBJECTIVE: Estimate relative effects and feasibility of the interventions on quality outcomes, length of stay (LOS), catheter-acquired urinary tract infections (CAUTI), medica- tion errors, and pain scores. DESIGN AND SETTING: Retrospective cohort using inter- rupted time series, analyzing data from 83 patients aged 5 to 18 years admitted for posterior spinal fusion (PSF) in 2009 (N = 27), 2010 (N = 28), and 2011 (N = 28) on a children's service at a general academic tertiary care center. INTERVENTIONS: Multimodal approach to standardizing pediatric PSF postoperative care with interdepartmental development of order sets, clinical care guidelines, and routine pediatric hospitalist co-management of all pediatric PSF patients. MEASUREMENTS: Chi-square analysis of order set use, guideline use measured by proxy medication and documenta- tion data. ANOVA for comparison of CAUTI and medication error rate and multivariate linear regression of LOS and pain scores. RESULTS: Pediatric hospitalist co-management documen- tation increased from 64% to 80%. Guideline use increased from 40% to 79%, and order set use was < 15%. CAUTI and medication error ratios remained low. Adjusted mean LOS decreased by 0.8 days (p = 0.039, 95% CI 0.7, 1.1). Pain scores did not differ. CONCLUSION: Interdisciplinary, clinical guideline devel- opment and postoperative co-management significantly decreased hospital LOS in pediatric PSF patients. In a general academic medical center, this change may be at- tributed to a pediatric hospitalist academic team, a universal co-management process with well-communicated roles, and a pediatric hospital-based physician development of and adherence to standardized practice.

Objective. The purpose of this study was to evaluate a new questionnaire to assess outcomes related to the midline anterior lumbar approach and to identify risk factors for negative patient responses. Methods. A retrospective review of 58 patients who underwent anterior lumbar surgery at a single institution for either degenerative disc disease or spondylolisthesis in 2009 was performed. The outcome measures included our newly developed Anterior Lumbar Surgery Questionnaire (ALSQ), ODI, and EQ-5D. Results. There were 58 patients available for followup, 27 women and 31 men. The average age at surgery was 50.8 years, with an average followup of 2.92 years. The average change in ODI was 34.94 (22.7) and EQ-5D was 0.28 (0.29). The rate of complications with the anterior approach was 10.3% and there was one male patient (3.2%) with retrograde ejaculation. Determination of the effectiveness of the new ALSQ revealed that it significantly correlated to the EQ-5D and ODI (P < 0.05). Smoking was associated with a negative response on thirteen questions. BMP use was not associated with a negative response on any sexual function questions. Conclusions. Our new Anterior Lumbar Surgery Questionnaire determines patient perceived complications related to the midline anterior lumbar surgical approach.

Anterior removal of a lumbar total disc replacement implant is often a very technically demanding procedure. The anterior retroperitoneal anatomy is prone to scarring, limiting remobilization and making a direct anterior exposure above the L5-S1 level difficult if not impossible to achieve safely. Anterolateral approach strategies can be more safely achieved at L4-L5 and above, but may require vertebral osteotomy in order to remove a keeled prosthesis. Successful conversion to a fusion with implant removal can be achieved, even when osteotomy is needed for implant removal. This Grand Rounds case presentation involves an unusual late retroperitoneal abscess following two-level TDR with direct extension to one of the implants, and the subsequent nonoperative and operative management. Removal of a well-fixed keeled implant at the L4-L5 level following nonoperative treatment of a surrounding retroperitoneal abscess and conversion to fusion represents close to, if not a 'worst-case' scenario for revision TDR. However, with proper preoperative planning and surgical experience, a safe and successful procedure can be the end result

STUDY DESIGN: A prospective, randomized study. OBJECTIVE: To compare the clinical results of posterior spinal fusion (PSF) with allograft augmentation versus no graft for patients with adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: The use of allograft has become a standard means of augmenting a PSF. Many studies have shown equal rates of fusion when comparing allograft with autogenous iliac crest. There have been no studies to directly compare the results obtained with allograft with those achieved without the use of any bone graft at all. METHODS: Ninety-one patients with AIS were randomized into two treatment groups. Seventy-six patients had greater than 2-year follow-up and are included in this review. The Allograft Group consisted of 37 patients who underwent a standard PSF using a multisegmented hook-screw and rod system with the use of corticocancellous allograft for augmentation. The No Graft Group included 39 patients with AIS who underwent the same procedure without any bone graft. All autogenous bone resulting from a thoracoplasty and any local bone (for example, that removed from spinous processes) was discarded in both groups. Patients with at least 2 years of radiographic and clinical follow-up were evaluated using established criteria for possible or definite pseudarthrosis. Treatment groups were similar with respect to age, preoperative deformity, and correction obtained. RESULTS: The overall definitive pseudarthrosis rate for this study was 1.3% (1 of 76 patients). The 1 patient with pseudarthrosis was in the Allograft Group (1 of 37, or 2.7%, P = 0.98 as defined by our criteria), versus none of 39 in the No Graft Group. Two patients in each group (5.4% in the Allograft Group and 5.1% in the No Graft Group) met the radiographic criteria for possible pseudarthrosis. This establishes a P value of 0.65 comparing risk of possible pseudarthrosis in the two groups. CONCLUSION: Our results suggest that a PSF using newer-generation multisegmented hook-screw and rod systems can be successful with allograft and/or local bonegraft without the use of supplemental autogenous bone graft (from the iliac crest or ribs) in patients with AIS