Double major curvature treated with vertebral body tethering of both curves: how do outcomes compare to posterior spinal fusion?

PURPOSE

Vertebral body tethering (VBT) is a non-fusion alternative to posterior spinal fusion (PSF). There have been few reports on VBT of two curvatures. We aim to compare the radiographic outcomes between VBT and PSF in patients with double curvatures in which both curves were instrumented.

METHODS

29 AIS patients matched by Lenke, age (± 2 years), triradiate cartilage closure status, major Cobb angle (± 8°), and T5-T12 kyphosis (± 10°). Variables were compared using Wilcoxon rank-sum tests, Student's t tests, and chi-Square. Clinical success was defined as major curve < 35°.

RESULTS

Group baseline demographics were similar. Major thoracic (T) curve types had significantly better major (VBT 51.5 ± 7.9° to 31.6 ± 12.0° [40%] vs. PSF 54.3 ± 7.4° to 17.4 ± 6.5° [68%]; p = 0.0002) and secondary curve correction in the PSF group. 71% of major T VBT patients were clinically successful versus 100% of PSF. Major thoracolumbar (TL) curve types experienced comparable major (VBT 52.3 ± 7.0° to 18.3 ± 11.4° (65%) vs. PSF 53.0 ± 5.2° to 23.8 ± 10.9° (56%); p = 0.2397) and secondary curve correction. 92% of major TL VBT patients were clinically successful versus 75% in the PSF group. There was no difference in T5-12 kyphosis or lumbar lordosis between groups for any curve type. There were 4 patients (13.8%) with major complications in the VBT group compared to 0 (0%) in the PSF.

CONCLUSION

Patients with double major AIS who underwent VBT with major T curve types had less correction than PSF; however, those with major TL curves experienced similar radiographic outcomes regardless of procedure. Complications were greater for VBT.

A New Look at Vertebral Body Tethering (VBT): Through the Modified Clavien-Dindo-Sink (mCDS) Classification

INTRODUCTION

Anterior vertebral body tethering (AVBT) is increasingly popular as an option for surgical treatment of idiopathic scoliosis (IS). While the technology remains new, it is important for families and patients to be able to compare it to the current standard of care, posterior spinal fusion (PSF). The purpose of this study is to describe the complication rate of AVBT in IS using the mCDS and to compare it to the recently reported complication rate of PSF in IS.

METHODS

A multicenter pediatric spine deformity database was queried for all idiopathic scoliosis patients who underwent vertebral body tethering. There were 171 patients with a minimum 9-month follow-up included in this study. Complications were retrospectively graded by 2 attending pediatric spine surgeons using the mCDS classification system.

RESULTS

Data from 171 patients with idiopathic scoliosis was available for analysis, with 156/171 (91%) of patients being female and an average age of 12.2 years old at surgery. There were 156 thoracic tethers (1 with an LIV below L2), 5 lumbar tethers, 9 staged double tethers, and only 1 patient with same-day double tether. Fifty-five (55) (32%) patients experienced a total of 69 complications. The most common complication type for VBT by mCDS was Grade IIIb, encompassing 29/69 (42%) of complications. The second most frequent complication grade was Grade I at 23/69 (33%). Thirty-four (34) out of 69 (49%) of the VBT complications reported required either procedural/surgical intervention or admission to the ICU.

CONCLUSIONS

This is the first study to directly compare the complication profile of VBT to PSF using the mCDS. Forty-nine percent (49%) of the VBT complications reported were at least Grade III, while only 7% of complications in the control PSF cohort from the literature were Grade III or higher. The mCDS complication classification brings light to the early learning experience of a new technique compared to the widely accepted standard of PSF for IS.

LEVEL OF EVIDENCE

III - Retrospective comparative study.

The Effect of Implant Density on Adolescent Idiopathic Scoliosis Fusion: Results of the Minimize Implants Maximize Outcomes Randomized Clinical Trial

BACKGROUND

Severe adolescent idiopathic scoliosis (AIS) can be treated with instrumented fusion, but the number of anchors needed for optimal correction is controversial.

METHODS

We conducted a multicenter, randomized study that included patients undergoing spinal fusion for single thoracic curves between 45° and 65°, the most common form of operatively treated AIS. Of the 211 patients randomized, 108 were assigned to a high-density screw pattern and 103, to a low-density screw pattern. Surgeons were instructed to use ≥1.8 implants per spinal level fused for patients in the high-implant-density group or ≤1.4 implants per spinal level fused for patients in the low-implant-density group. The primary outcome measure was the percent correction of the coronal curve at the 2-year follow-up. The power analysis for this trial required 174 patients to show equivalence, defined as a 95% confidence interval (CI) within a ±10% correction margin with a probability of 90%.

RESULTS

In the intention-to-treat analysis, the mean percent correction of the coronal curve was equivalent between the high-density and low-density groups at the 2-year follow-up (67.6% versus 65.7%; difference, -1.9% [95% CI: -6.1%, 2.2%]). In the per-protocol cohorts, the mean percent correction of the coronal curve was also equivalent between the 2 groups at the 2-year follow-up (65.0% versus 66.1%; difference, 1.1% [95% CI: -3.0%, 5.2%]). A total of 6 patients in the low-density group and 5 patients in the high-density group required reoperation (p = 1.0).

CONCLUSIONS

In the setting of spinal fusion for primary thoracic AIS curves between 45° and 65°, the percent coronal curve correction obtained with use of a low-implant-density construct and that obtained with use of a high-implant-density construct were equivalent.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Machine Learning for Benchmarking Adolescent Idiopathic Scoliosis Surgery Outcomes

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

Design a risk-stratified benchmarking tool for adolescent idiopathic scoliosis (AIS) surgeries.

SUMMARY OF BACKGROUND DATA

Machine learning (ML) is an emerging method for prediction modeling in orthopedic surgery. Benchmarking is an established method of process-improvement and is an area of opportunity for ML methods. Current surgical benchmark tools often use ranks and no "gold standards"for comparisons exist.

METHODS

Data from 6076 AIS surgeries were collected from a multicenter registry and divided into three datasets: encompassing surgeries performed (1) during the entire registry, (2) the past 10 years, and (3) during the last 5 years of the registry. We trained three ML regression models (baseline linear regression, gradient boosting [GB], and XGBoost [XGB]) on each data subset to predict each of the five outcome variables, length of stay (LOS), estimated blood loss (EBL), operative time, SRS-Pain and -Self-image. Performance was categorized as "below expected" if performing worse than one standard deviation of the mean, "as expected" if within one standard deviation, and "better than expected" if better than one standard deviation of the mean.

RESULTS

Ensemble ML methods classified performance better than traditional regression techniques for LOS, EBL, and operative time. The best performing models for predicting LOS and EBL were trained on data collected in the last 5 years, while operative time used the entire 10-year dataset. No models were able to predict SRS-Pain or -Self-image in any useful manner. Point-precise estimates for continuous variables were subject to high average errors.

CONCLUSIONS

Classification of benchmark outcomes is improved with ensemble ML-techniques and may provide much needed case-adjustment for a surgeon performance program. Precise estimates of health-related quality of life scores and continuous variables were not possible, suggesting that performance classification is a better method of performance evaluation.

SRS-22r Self-Image After Surgery for Adolescent Idiopathic Scoliosis at 10-year Follow-up

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To examine SRS-Self Image scores at up to 10 years after surgery for adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Self-image is complex with implications for surgical and patient-reported outcomes after AIS surgery. Surgically modifiable factors that impact self-image are inconsistently reported in the literature with few longer-term reports. We examined the rate and durability of self-image improvement.

MATERIALS AND METHODS

An AIS registry was queried for patients with up to 10 years of follow-up after AIS surgery. A mixed effects model estimated change in SRS-22 Self Image from baseline to 6 weeks, 1 year, 2 years, 5 years, and 10 years. All enrolled patients contributed data to the mixed effects models. A sub-analysis of patients with 1-year and 10-year follow-up evaluated worsening/static/improved SRS-22 Self Image scores examined stability of scores over that timeline. Baseline demographic data and 1-year deformity magnitude data were compared between groups using parametric and nonparametric tests as appropriate.

RESULTS

Data from 4608 patients contributed data to the longitudinal model; 162 had 1-year and 10-year data. Mean SRS-Self Image improvement at 10-year follow-up was 1.0 (95% CI: 0.9-1.1) point. No significant changes in Self-Image domain scores were estimated from 1-year to 10-year (all P >0.05) postoperative. Forty (25%) patients had SRS-Self Image worsening from 1 year to 10 years, 36 (22%) improved, and 86 (53%) were unchanged. Patients who worsened over 10 years had lower SRS-Self Image at baseline than those unchanged at enrollment (3.3 vs. 3.7, P =0.007). Neither radiographic parameters nor SRS-Mental Health were different at baseline for the enrolled patients.

CONCLUSION

Ten years after surgery, 75% of patients reported similar or better SRS-Self Image scores than one year after surgery. Nearly 25% of patients reported worsening self-image at 10 years. Patients who worsened had lower baseline SRS-Self Image scores, without radiographic or mental health differences at baseline or follow-up.

The Reliability of the AO Spine Upper Cervical Classification System in Children: Results of a Multi-Center Study

BACKGROUND

There is no uniform classification system for traumatic upper cervical spine injuries in children. This study assesses the reliability and reproducibility of the AO Upper Cervical Spine Classification System (UCCS), which was developed and validated in adults, to children.

METHODS

Twenty-six patients under 18 years old with operative and nonoperative upper cervical injuries, defined as from the occipital condyle to the C2-C3 joint, were identified from 2000 to 2018. Inclusion criteria included the availability of computed tomography and magnetic resonance imaging at the time of injury. Patients with significant comorbidities were excluded. Each case was reviewed by a single senior surgeon to determine eligibility. Educational videos, schematics describing the UCCS, and imaging from 26 cases were sent to 9 pediatric orthopaedic surgeons. The surgeons classified each case into 3 categories: A, B, and C. Inter-rater reliability was assessed for the initial reading across all 9 raters by Fleiss's kappa coefficient (kF) along with 95% confidence intervals. One month later, the surgeons repeated the classification, and intra-rater reliability was calculated. All images were de-identified and randomized for each read independently. Intra-rater reproducibility across both reads was assessed using Fleiss's kappa. Interpretations for reliability estimates were based on Landis and Koch (1977): 0 to 0.2, slight; 0.2 to 0.4, fair; 0.4 to 0.6, moderate; 0.6 to 0.8, substantial; and >0.8, almost perfect agreement.

RESULTS

Twenty-six cases were read by 9 raters twice. Sub-classification agreement was moderate to substantial with α κ estimates from 0.55 for the first read and 0.70 for the second read. Inter-rater agreement was moderate (kF 0.56 to 0.58) with respect to fracture location and fair (kF 0.24 to 0.3) with respect to primary classification (A, B, and C). Krippendorff's alpha for intra-rater reliability overall sub-classifications ranged from 0.41 to 0.88, with 0.75 overall raters.

CONCLUSION

Traumatic upper cervical injuries are rare in the pediatric population. A uniform classification system can be vital to guide diagnosis and treatment. This study is the first to evaluate the use of the UCCS in the pediatric population. While moderate to substantial agreement was found, limitations to applying the UCCS to the pediatric population exist, and thus the UCCS can be considered a starting point for developing a pediatric classification.

LEVEL OF EVIDENCE

Level III.

Post-operative steroids in patients with patients with severe cerebral palsy undergoing posterior spinal fusion

INTRODUCTION

Posterior spinal fusion (PSF) represents a large physiologic challenge for children with neuromuscular scoliosis (NMS). Perioperative complications are numerous with many occurring in the post-operative period due to pain and relative immobilization. This study assessed the impact of steroids on patients undergoing PSF for NMS.

METHODS

A retrospective review of consecutive patients managed at a single center with PSF for NMS was reviewed. Clinical and radiographic analysis was used to evaluate baseline demographics, curve characteristics, and post-operative course.

RESULTS

Eighty-nine patients who underwent PSF for NMS were included. Fifty-seven of these patients did not receive post-operative steroids (NS) while 32 patients were treated with post-operative steroids (dexamethasone, WS) for a median of 3 doses (median 6.0 mg/dose every 8 h after surgery). The demographic variables of the cohorts were similar with no difference in curve magnitude, number of vertebrae fused, number of osteotomies, or EBL between groups. A 70% decrease in the median post-operative morphine equivalents was observed in the steroid cohort (0.50 mg/kg WS vs 1.65 mg/kg NS, p value < 0.001). There was an association between post-operative morphine equivalents and length of stay (Spearman's rho = 0.22, p value = 0.04). There was no difference in wound healing, infection, and pulmonary or gastrointestinal complications between groups. No difference was found in pain at discharge, 30-day ED returns, or 30-day OR returns between groups.

CONCLUSIONS

Post-operative dexamethasone resulted in a 70% decrease in morphine equivalent use after PSF for NMS without any increase in perioperative wound infections.

LEVEL OF EVIDENCE

Level 3: case-control series.

Modified Clavien-Dindo-Sink system is reliable for classifying complications following surgical treatment of early-onset scoliosis

PURPOSE

Appropriately measuring and classifying surgical complications is a critical component of research in vulnerable populations, including children with early-onset scoliosis (EOS). The purpose of this study was to assess the inter- and intra-rater reliability of a modified Clavien-Dindo-Sink system (CDS) classification system for EOS patients among a group of pediatric spinal deformity surgeons.

METHODS

Thirty case scenarios were developed and presented to experienced surgeons in an international spine study group. For each case, surgeons were asked to select a level of severity based on the modified CDS system to assess inter-rater reliability. The survey was administered on two occasions to allow for assessment of intra-rater reliability. Weighted Kappa values were calculated, with 0.61 to 0.80 considered substantial agreement and 0.81 to 1.00 considered nearly perfect agreement.

RESULTS

11/12 (91.7%) surgeons completed the first-round survey and 8/12 (66.7%) completed the second. Inter-observer weighted kappa values for the first and second survey were 0.75 [95% CI 0.56-0.94], indicating substantial agreement, and 0.84 [95% CI 0.70-0.98], indicating nearly perfect agreement, respectively. Intra-observer reliability was 0.86 (range 0.74-0.95) between the first and second surveys, indicating nearly perfect agreement .

CONCLUSION

The modified CDS classification system demonstrated substantial to nearly perfect agreement between and within observers for the evaluation of complications following the surgical treatment of EOS patients. Adoption of this reliable classification system as a standard for reporting complications in EOS patients can be a valuable tool for future research endeavors, as we seek to ultimately improve surgical practices and patient outcomes.

LEVEL OF EVIDENCE

Level V.

Avoiding PICU admission following PSF for neuromuscular scoliosis in non-ambulatory cerebral palsy managed with ERAS protocol

PURPOSE

Children with neuromuscular scoliosis (NMS) undergoing posterior spinal fusion (PSF) have historically been managed post-operatively in the pediatric intensive care unit (PICU) due to institutional tendencies. This study sought to define risk factors for PICU admission when using an enhanced recovery after surgery (ERAS) pathway.

METHODS

A retrospective review of children with non-ambulatory (GMFCS 4 or 5) cerebral palsy undergoing PSF for NMS performed at two institutions by 5 surgeons. Both institutions have a pre-existing ERAS pathway for NMS patients consisting of post-surgical transfer to the hospital floor with early reinstitution of feeding and mobilization. PICU admission is used at the discretion of the surgeon and anesthesiologist rather than by institutional decree. Patient and surgical factors were assessed for risk factors of PICU admission.

RESULTS

A total of 103 children were included (84% GMFCS 5, mean 14.52 years (± 3.4 years)). Forty children (38.8%) required postoperative PICU admission. PICU admission was associated with seizure disorder (P = 0.09), pre-existing feeding tube (P = 0.003), tracheostomy (P = 0.03), and modified GMFCS-5 subclassification (P = 0.003). Independent predictors of PICU admission include pre-existing feeding (Odd's ratio = 2.9, P = 0.02) and length of surgery (Odd's ratio = 2.6, P < 0.001), with surgery lasting ≥ 5.0 h having an 82.5% sensitivity and 63.5% specificity (AUC 0.8, P < 0.001) for post-operative PICU admission.

CONCLUSION

The majority of children with non-ambulatory cerebral palsy can be successfully managed on the hospital floor following PSF. The extent of central neuromotor impairment is significantly associated with PICU admission along with surgery lasting longer than 5 h.

Outcomes of Posterior Spinal Fusion in Pediatric Patients with Down Syndrome

BACKGROUND

Trisomy 21 or Down syndrome is associated with multiple orthopaedic manifestations. Although cervical instability is the most common spinal condition associated with Down syndrome, the prevalence of scoliosis has been estimated at 4.8% to 8.7%. Very few prior studies have documented the role of spinal fusion in this population, and all have included ≤10 patients.

METHODS

An institutional review board-approved multicenter retrospective analysis of patients with Down syndrome treated with spinal fusion between January 2009 and December 2019 was performed by cross-referencing Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth and Tenth Revisions (ICD-9 and ICD-10) codes. Patients were followed for ≥2 years, with a mean follow-up of 3.77 years. Clinical and radiographic outcomes were collected, and complications were documented using the Clavien-Dindo-Sink (CDS) classification.

RESULTS

A total of 23 patients were included: 96% had ≥1 medical comorbidities, including 16 (70%) with congenital heart disease, of whom 88% had previous cardiac surgery, and 10 (44%) with thyroid disorders. All 23 patients underwent posterior spinal fusion. The mean estimated blood loss was 617 ± 459 mL, the mean length of the surgical procedure was 290 ± 92.7 minutes, and the mean length of hospital stay was 6.03 ± 2.91 days. The major Cobb angle measured 61.7° ± 17.6°, which corrected to 19.4° ± 14.8° (68.6% correction; p < 0.001), with well-maintained correction at 2 years of 22.0° ± 10.3° (64.3% correction; p = 0.158). Thirteen (57%) of 23 patients had a change in curve of >5°. There were no intraoperative complications; however, 12 patients (52%) sustained postoperative complications (e.g., need for reoperation, implant failure, and pulmonary complications), including 6 patients with CDS type 3 or 4 (e.g., wound dehiscence, late superficial abscess, pleural effusion, pseudarthrosis, and readmission for hypoxia). Four patients (17%) required a revision surgical procedure. One patient (4%) required an unplanned intensive care unit admission.

CONCLUSIONS

Although instrumented spinal fusion can effectively correct spinal deformity in these patients, complications are more frequent than in children with adolescent idiopathic scoliosis, with over half of patients sustaining a complication.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

1- vs. 2-year follow-up after posterior spinal fusion for AIS: what additional information is gained?

PURPOSE

Traditionally, 2-year follow-up data have been the established standard for reporting clinical outcomes following spinal deformity surgery. However, previous studies indicate that 2-year follow-up does not represent long-term outcomes. Currently, there is no clear data that demonstrate a difference in outcomes between the 1 and 2 years postoperative time-periods following posterior spinal fusions (PSF) for adolescent idiopathic scoliosis (AIS).

METHODS

A multi-center, prospective database was queried for AIS patients treated with PSF. Clinical outcome scores, assessed by SRS-22, coronal and sagittal radiographic parameters were assessed at time periods: 6 months, 1 year, and 2 years post operatively. Complications and reoperation rates were also assessed. Statistical analysis compared outcomes variables across time-points to assess for significant differences.

RESULTS

694 patients (82.6% female, mean age at surgery 14.9 ± 2.13 years) were identified. Between post-operative year 1 and 2, significant difference in SRS-22 domain scores were present for function domain (4.5 vs. 4.6; p < 0.001), mental health domain (4.3 vs. 4.2; p < 0.001), and total domain score (4.4 vs. 4.4; p = 0.03) but were below the minimal clinically important difference threshold. New complication development was significantly higher within the first year following surgery than the 1-2 year follow-up period (p < 0.001) with greater complication severity within the 0-1 year follow-up period (P = 0.03).

CONCLUSION

There are no clinically important changes in SRS-22 domain scores between 1 and 2 years following PSF for AIS, with higher complications in the first year following PSF. Two-year follow-up data provide little added clinical information while under-estimating the cumulative complication and reoperation rates at long-term follow-up.

Risk factors for the development of DJK in AIS patients undergoing posterior spinal instrumentation and fusion

PURPOSE

Typically, selection of lowest instrumented vertebra (LIV) in Adolescent Idiopathic Scoliosis (AIS) is based on the coronal radiograph; however, increasing evidence suggests that fusions proximal to the stable sagittal vertebrae (SSV) on the lateral radiograph can result in distal junctional kyphosis (DJK). The purpose of this study is to compare rates of DJK in patients with AIS that have a discordance between the Lowest Touched Vertebra (LTV) and the SSV and to identify risk factors for developing DJK.

METHODS

Patients with AIS Lenke type 1, 2 and 3 curves treated with a posterior spinal fusion were separated into two groups. Group 1 had SSV that was proximal to the LTV whereas group 2 had SSV that was distal to the LTV. Comparisons were made for patients that were fused to the SSV(a), LTV(b) or between(c). Distal junctional angle (DJA) > 5° and increasing kyphosis at the end of the fusion construct were evaluated as risk factors for DJK.

RESULTS

The rate of DJK was 0.0% in group 1a, 1b, and 1c compared to 4.3%, 18.5% and 10.0% in groups 2a, 2b and 2c, respectively(p < 0.001). The rate of DJK was 22.9% when the distal junctional angle(DJA) > 5° versus 1.4% when the DJA < 5°(p < 0.001).

CONCLUSION

There was a low risk for progression of DJK when the SSV was proximal to the LTV, however, those with SSV distal to the LTV represent a high-risk group. Importantly, the development of DJK occurred almost exclusively in patients with LIV at the thoracolumbar junction which demonstrates that surgeons need to be cautious when ending fusions at T11, T12, and L1 in patients at high risk for DJK. Furthermore, having a distal junctional angle 5° or greater increased the risk of developing DJK by roughly 16-fold. At a minimum of 5-year follow-up, the development of DJK did not appear to adversely impact SRS outcomes or revision rates.

Slipped Capital Femoral Epiphysis Associated with Endocrinopathy: A Narrative Review

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Slipped capital femoral epiphysis (SCFE) has a well-documented association with underlying endocrine conditions, including thyroid hormone aberrations and parathyroid dysfunction.

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Recombinant growth hormone therapy has also been identified as a risk factor for the development of SCFE.

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Presentation before their 10th birthday or after their 16th birthday along with height of <10th percentile are reliable risk factors for identifying children with an SCFE who are at a heightened risk for an underlying endocrinopathy and can been used to guide selective laboratory testing.

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Patients with unilateral SCFE presentations with an underlying endocrinopathy are at a heightened risk for contralateral slip development and should be treated with prophylactic fixation.

Modified Clavien-Dindo-sink classification system for adolescent idiopathic scoliosis

PURPOSE

The Clavien-Dindosink (CDS) classification system provides more treatment-focused granularity than subjective methods of describing surgical complications; however, it has not been validated in posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). The purpose of this study was to modify the CDS system for application in patients with AIS undergoing PSF to assess its inter- and intra-rater reliability for describing complications faced by this population.

METHODS

A review of all complications specific to patients with AIS captured in a large multicenter international database was performed. All complications were classified according to CDS, modified by addition of "prolonged initial hospital stay" as a criterion for Grade II. A survey of this complication list and an additional 20 clinical vignettes (sent out on two occasions) was sent to nine spinal deformity surgeons. Weighted kappa values were used to determine inter- and intra-rater reliability.

RESULTS

The Fleiss κ value for interrater reliability among 5 respondents grading all AIS complications was 0.8 (very good). For each grade, interrater reliability was very good, with an overall range of 0.8-1. The overall kappa value for intrarater reliability among eight respondents grading 20 vignettes was between 0.6 (good) and 0.9 (very good).

CONCLUSION

The modified CDS classification system has very good interrater and intrarater reliability in describing complications following PSF in patients with AIS. This system may be of greater utility for reporting outcomes than a "major" versus "minor" complication system and can serve as a valuable tool for improving surgical practices and patient outcomes in this population.

LEVEL OF EVIDENCE

IV case series.

Comparative cost-utility analysis of postoperative discharge pathways following posterior spinal fusion for scoliosis in non-ambulatory cerebral palsy patients

PURPOSE

Accelerated postoperative discharge (AD) pathways have demonstrated numerous benefits for patients with adolescent idiopathic scoliosis undergoing PSF. Although early evidence supports the application of AD pathways over more traditional discharge (TD) approaches for patients with neuromuscular scoliosis, the economic impact of these pathways has not been investigated.

METHODS

A decision-analysis model was constructed using a hypothetical 15-year-old male with non-ambulatory CP with a 65-degree thoracolumbar scoliosis and pelvic obliquity undergoing operative treatment with PSF from T2-pelvis with pedicle screw fixation. The literature was reviewed to estimate costs, probabilities, and quality-adjusted life years (QALYs)) for identified complication profiles for discharge pathways. QALYs were constructed using age-matched values for US population average, applying a CP diagnosis corrective value. A probabilistic sensitivity analysis was performed using a second-order Monte Carlo simulations. Incremental cost-utility ratio and incremental net monetary benefit (NMB) were calculated. One-way sensitivity analyses were performed by selective variable variation.

RESULTS

AD pathway resulted in an average cost and effectiveness of $67,069 and 15.4 QALYs compared with $81,312 and 15.4 QALYs for TD. AD resulted in a 2.1% greater NMB with a cost-effectiveness ratio of $4361/QALY compared with $5290/QALY in the TD. The cost-effectiveness of TD was inversely sensitive to implant cost variation while the AD maintained effectiveness despite cost variations.

CONCLUSION

This cost-utility analysis demonstrated that the implementation of an AD pathway following PSF for non-ambulatory CP scoliosis is economically more effective, providing a 17.5% cost reduction with enhanced value of care evidenced by a 2.1% greater NMB over a TD pathway. The cost-effectiveness of the AD was maintained despite implant cost variations.

Power versus manual pedicle tract preparation: a multi-center study of early adopters

STUDY DESIGN

Retrospective cohort, multicenter. A single surgeon study demonstrated that pedicle tract preparation with power tools was associated with lower fluoroscopy times and revision rates compared to manual tools, while maintaining patient safety.

OBJECTIVE

Our purpose was to determine the safety of power-assisted pedicle tract preparation by early adopters of this technology.

METHODS

Retrospective review comparing patients that underwent posterior spinal fusion by seven pediatric spine surgeons at six institutions between January 1, 2008 and August 31, 2019. The manual pedicle tract preparation used a pedicle awl. Power tract preparation used a flexible 2.0-2.4 mm drill bit, followed by a larger drill bit or a reamer. All screws were inserted with power technique.

RESULTS

In the manual tract preparation group, 9424 screws were placed in 585 cases. In the power tract preparation group, 22,209 screws were placed in 1367 cases. Seven patients (7/1952; 0.36%; 95% CI: 0.14-0.74%) had 11 mal-positioned screws (11/31,633; 0.03%; 95% CI: 0.017-0.062%). Seven screws (7/9424; 0.07%; 95% CI: 0.030-0.15%) were in the manual cohort and four (4/22,209; 0.02%; 95% CI: 0.0049-0.046%) were in the power cohort. There were significantly more revisions per screw in the manual cohort (p = 0.02). However, there were not significantly more revisions per patient in the manual cohort (manual: 0.5%, 3/585 vs. power: 0.3%, 4/1,367; p = 0.43). Of these seven, three patients (3/585; 0.5%; 95% CI: 0.1-1.5%) experienced neurologic injury or neuro-monitoring changes requiring screw removal in the manual cohort, and 1 patient (1/1,367, 0.07%; 95% CI: 0.002-0.4%) in the power cohort (p = 0.08). Three additional patients underwent revision in the power cohort: 1 for an asymptomatic lateral breech, 1 for a spinal headache/medial breech that developed after an MVA, and 1 for an iliac vein injury during pedicle tract preparation.

CONCLUSION

This is the first multi-center study examining power pedicle preparation. Overall, 99.9% of pedicle screws placed with power pedicle preparation did not have complications or revision. Equivalent patient safety was demonstrated compared to manual technique.

LEVEL OF EVIDENCE

III.

Short term outcomes of an enhanced recovery after surgery (ERAS) pathway versus a traditional discharge pathway after posterior spinal fusion for adolescent idiopathic scoliosis

PURPOSE

Enhanced Recovery after Surgery (ERAS) pathways have been shown to decrease length of stay (LOS) after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). The aim of this study was to compare immediate post-operative outcomes following an ERAS pathway with a traditional pathway for AIS.

METHODS

A prospective dual-center study of patients treated using an ERAS pathway (203 patients) or a traditional discharge (TD) pathway (73 patients) was performed with focus on pain at discharge, quality of life at one month, and return to school/work.

RESULTS

LOS was 55% less in the ERAS group (4.8 days TD vs. 2.2 days ERAS, p < 0.001). Length of surgery (4.8 h TD vs. 2.8 h, p < 0.001) and EBL (500 cc vs. 240 cc, p < 0.001) were greater in the TD group, likely related to larger curve magnitudes ((62.0° TD vs. 54.0° ERAS, p < 0.001), a higher percentage of patients undergoing osteotomies (94% vs. 46%, p < 0.001) and more levels fused (11.4 ± 1.6 vs. 10.1 ± 2.6, p < 0.001) in the TD group. Regression analysis showed no difference in Visual Analog Score (VAS) score at discharge or quality of recovery using the QOR9 instrument between groups at follow up. There was no difference in return to school (p = 0.43) and parents' return to work (p = 0.61) between the groups.

CONCLUSION

Patients managed with an ERAS pathway had similar pain scores at discharge than those managed with a TD pathway. Both groups showed evidence of rapid return to normalcy by the first follow up visit.

In-hospital opioid usage following posterior spinal fusion for adolescent idiopathic scoliosis: Does methadone offer an advantage when used with an ERAS pathway?

PURPOSE

Intraoperative methadone has been shown to decrease opioid medication requirement following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). No study to date has investigated the effect of methadone on opioid medication requirement when used in conjunction with an enhanced recovery after surgery (ERAS) protocol following PSF.

METHODS

A retrospective cohort study was performed at a single, tertiary care pediatric hospital. Patients with AIS undergoing PSF were consecutively given a single intra-operative methadone dose and matched 1:2 to a AIS control group without methadone. Patients were matched for age, curve magnitude, levels fused, blood loss, and operating time. All children followed a standard ERAS protocol with methadone being the only change in the post-operative regimen. In-hospital data for opioid and non-opioid medication use, surgical, and patient variables were recorded and compared between cohorts.

RESULTS

Twenty-six patients received methadone (average 15.1 ± 1.9 years) and were matched with 52 control patients without methadone (average 14.7 ± 2.2 years). There were no significant differences in total opioid usage at any time-interval prior to hospital discharge or in cumulative opioid usage. Additionally, patients had a similar VAS pain level at discharge (methadone: 4.0 ± 2.3 vs control: 3.8 ± 1.9; P = 0.572). Total opioid usage was correlated with LOS. There were no opioid-related medication complications in either cohort.

CONCLUSION

There was no decrease of in-hospital opioid usage when methadone was used with an ERAS protocol. Total opioid usage is correlated with hospital LOS following PSF.

Risk factors for gastrointestinal complications after spinal fusion in children with cerebral palsy

DESIGN

Prospective cerebral palsy (CP) registry review.

OBJECTIVES

(1) Evaluate the incidence/risk factors of gastrointestinal (GI) complications in CP patients after spinal fusion (SF); and (2) investigate the validity of the modified Clavien-Dindo-Sink classification.

BACKGROUND

Perioperative GI complications result in increased length of stay (LOS) and patient morbidity/mortality. However, none have analyzed the outcomes of GI complications using an objective classification system.

METHODS

A prospective/multicenter CP database identified 425 children (mean, 14.4 ± 2.9 years; range, 7.9-21 years) who underwent SF. GI complications were categorized using the modified Clavien-Dindo-Sink classification. Grades I-II were minor complications and grades III-V major. Patients with and without GI complications were compared.

RESULTS

87 GI complications developed in 69 patients (16.2%): 39 minor (57%) and 30 major (43%). Most common were pancreatitis (n = 45) and ileus (n = 22). Patients with preoperative G-tubes had 2.2 × odds of developing a GI complication compared to oral-only feeders (OR 2.2; 95% CI 0.98-4.78; p = 0.006). Similarly, combined G-tube/oral feeders had 6.7 × odds compared to oral-only (OR 6.7; 95% CI 3.10-14.66; p < 0.001). The likelihood of developing a GI complication was 3.4 × with normalized estimated blood loss (nEBL) ≥ 3 ml/kg/level fused (OR 3.41; 95% CI 1.95-5.95; p < 0.001). Patients with GI complications had more fundoplications (29% vs. 17%; p = 0.03) and longer G-tube fasting periods (3 days vs. 2 days; p < 0.001), oral fasting periods (5 days vs. 2 days; p < 0.001), ICU admissions (6 days vs. 3 days; p = 0.002), and LOS (15 days vs. 8 days; p < 0.001). LOS correlated with the Clavien-Dino-Sink classification.

CONCLUSION

Gastrointestinal complications such as pancreatitis and ileus are not uncommon after SF in children with CP. This is the first study to investigate the validity of the modified Clavien-Dindo-Sink classification in GI complications after SF. Our results suggest a correlation between complication severity grade and LOS. The complexity of perioperative enteral nutritional supplementation requires prospective studies dedicated to enteral feeding protocols.

LEVEL OF EVIDENCE

Therapeutic-level III.

Application of a Halo Fixator for the Treatment of Pediatric Spinal Deformity

Background

In spine surgery, the halo fixator was initially utilized to stabilize cervical fusions in patients with poliomyelitis. More recently, the indications for halo fixation have evolved to include stabilization and definitive treatment for upper cervical spine injuries (Jefferson fractures, atlanto-occipital dissociations, odontoid fractures, etc.), treatment of atlantoaxial rotatory subluxation, stabilization of long cervical fusions, and preoperative traction. In the realm of pediatric spinal deformity, halo fixation has proved to be a valuable resource for severe or neglected spinal deformities. In this video article, we demonstrate the application of a halo fixator in a pediatric patient with severe scoliosis.

Description

The procedure includes appropriate pin placement in the safe zones of the skull performed under either general anesthesia or local anesthesia. Pins are secured to a halo frame that is sized to be 2 cm larger than the circumference of the skull and are tightened according to age-specific torque guidelines.

Alternatives

Alternative treatments vary from cervical spine immobilization to definitive surgical treatment in the spine, or even spinal osteotomies, depending on the underlying spinal pathology.

Rationale

The halo fixator works by limiting motion of the cervical spine in flexion, extension, and axial rotation. The halo is also able to control and correct translational injuries of the cervical spine. In the setting of spinal deformity, the halo fixator can also be utilized to overcome the effects of gravity and lengthen the spine.

Expected Outcomes

For spinal deformities, the halo fixator can be expected to lengthen the spine and increase deformity flexibility prior to definitive surgical treatment in the spine or growth-friendly spinal instrumentation.

Important Tips

Correct identification of safe zones for pin placement is vital to correct pin placement.For pediatric patients, it is important to obtain fixation with a minimum of 6 to 8 pins.Pins should be tightened with use of a torque-limiting wrench, up to no more than 1 in/lb (55.9 mm/kg) per year of age, up to a maximum of 8 in/lb (447.9 mm/kg).Applied traction should be a maximum of 50% of the body weight of the patient.Neurovascular examination is vital following application of weight.

Effects of race on blood loss in spinal fusions for adolescent idiopathic scoliosis

OBJECTIVE

Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) can be associated with significant blood loss. It has been suggested that blood loss is greater in different racial groups. The purpose of this study was to evaluate differences in blood loss between African American and Caucasian patients undergoing PSF for AIS.

METHODS

A retrospective review was performed of patients aged 10-18 years with AIS who were treated with PSF from 2014 to 2017 at a single children's healthcare system. Patient demographic, radiographic, and operative data were obtained from medical records. Intraoperative blood loss was calculated using the formula described by Waters et al. Patients who declined reporting their race or had prior spinal surgery, neuromuscular or syndromic diagnoses, a history of cardiac or thoracic surgery, or a bleeding disorder were excluded. Blood loss variables were log-transformed for normality and modeled using multivariable linear regression.

RESULTS

A total of 433 PSFs for AIS qualified for the analysis. The average age was 14.1 years, and 73.7% of the patients were female. With respect to race, 44.6% identified themselves as African American. There was no significant difference in blood loss (p = 0.31) or blood loss per level fused (p = 0.36) in African American patients. African American patients, however, did have significantly lower preoperative hemoglobin and hematocrit levels and greater operating room time than Caucasian patients (p < 0.001). There was no difference between race and transfusion rate.

CONCLUSIONS

There appears to be no relationship between race and blood loss during PSF for AIS. Standardized protocols for minimizing perioperative blood loss can be applied to both Caucasian and African American patients.

Postoperative Dexamethasone Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

BACKGROUND

Surgeons have hesitated to use steroids in patients undergoing posterior spinal fusion because of the risk of wound complications. The literature has supported the use of postoperative steroids in other areas of orthopaedics on the basis of more rapid recovery and improved postoperative pain control. We hypothesized that a short course of postoperative dexamethasone following posterior spinal fusion for the treatment of adolescent idiopathic scoliosis (AIS) would decrease opioid usage without increasing wound-healing problems.

METHODS

Consecutive patients undergoing posterior spinal fusion for the treatment of AIS from 2015 to 2018 at a single hospital were included. A review of demographic characteristics, curve characteristics, surgical data, and postoperative clinic notes was performed. Opioid usage was determined by converting all postoperative opioids given into morphine milligram equivalents (MME).

RESULTS

Sixty-five patients underwent posterior spinal fusion for the treatment of AIS without postoperative steroids (the NS group), and 48 patients were managed with 3 doses of postoperative steroids (the WS group) (median, 8.0 mg/dose). There was no difference between the groups in terms of curve magnitude, number of vertebrae fused, or estimated blood loss. There was a 39.6% decrease in total MME used and a 29.5% decrease in weight-based MME used in the group receiving postoperative steroids (82.0 mg [1.29 mg/kg] in the NS group versus 49.5 mg [0.91 mg/kg] in the WS group]; p < 0.001). This difference persisted after accounting for gabapentin, ketorolac, and diazepam usage; surgical time; curve size; levels fused; and number of osteotomies (median decrease, 0.756 mg/kg [95% CI, 0.307 to 1.205 mg/kg]; p = 0.001). Three patients in the NS group (4.6%) and 4 patients in the WS group (8.3%) developed wound dehiscence requiring wound care (p = 0.53). One patient in the NS group required surgical debridement for the treatment of an infection. Patients in the WS group were more likely to walk at the time of the initial physical therapy evaluation (60.4% versus 35.4%; p = 0.013).

CONCLUSIONS

A short course of postoperative steroids after posterior spinal fusion was associated with a 40% decrease in the use of opioids, with no increase in wound complications. Surgeons may consider the use of perioperative steroids in an effort to decrease the use of postoperative opioids following posterior spinal fusion for the treatment of AIS.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Fusions ending above the sagittal stable vertebrae in adolescent idiopathic scoliosis: does it matter?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To validate whether fusions that end proximal to the sagittal stable vertebrae are at risk for developing distal junctional kyphosis in adolescent idiopathic scoliosis.

BACKGROUND

Posterior spinal fusion is routinely used for the treatment of patients with adolescent idiopathic scoliosis. Fusions that end in either the lower thoracic or upper lumbar spine have the advantage of preserving motion segments. However, fusions ending proximal to the sagittal stable vertebrae has been shown to be at higher risk for developing distal junctional kyphosis.

METHODS

A multi-center database of prospectively enrolled subjects was queried for patients with adolescent idiopathic scoliosis that had Lenke type 1, 2 and 3 curves treated with posterior pedicle screw instrumentation. PA (posterior-anterior) and lateral full-length scoliosis films were obtained on each patient. PA radiographs were viewed to determine the coronal deformity and lateral radiographs to determine the sagittal deformity. Distal junctional kyphosis was defined as a greater than 10° increase in segmental kyphosis between the LIV and the LIV + 1 vertebra.

RESULTS

346 patients were included with 85% being female and mean age of cohort 14.2 [Formula: see text] 2.08 years. At 5 years postoperatively, there was significant difference occurrence of distal junctional kyphosis dependent on whether the LIV relative to SSV with only 2.2% of fusions below the SSV developing DJK compared to 6.5% for fusions ending at the SSV and 15% for fusions with LIV above the SSV (p < 0.001). There was no statistical difference in revision rates based on the relationship of LIV to SSV.

CONCLUSION

There is an increased risk for development of DJK in patients with AIS treated with posterior fusion where the LIV was chosen proximal to the SSV.

LEVEL EVIDENCE

Level III.

Variability in length of stay following neuromuscular spinal fusion

BACKGROUND

Patients with neuromuscular scoliosis (NMS) who undergo posterior spinal fusion (PSF) often have long, protracted hospital stays because of numerous comorbidities. Coordinated perioperative pathways can reduce length of hospitalization (LOH) without increasing complications; however, a subset of patients may not be suited to rapid mobilization and early discharge.

METHODS

197 patients with NMS underwent PSF at a single hospital by two surgeons with a post-operative care pathway emphasizing early mobilization, rapid transition to enteral feeds, and discharge prior to first bowel movement. Average LOH was 4.9 days for all patients. Patients were divided into quartiles (< 3 days, 3-5 days, 5-7 days, > 7 days) based on their LOH, and their charts were retrospectively reviewed for preoperative, intraoperative, and postoperative factors associated with their LOH.

RESULTS

Age at surgery, gender, the need for tube feeds, and specific underlying neuromuscular disorder were not significant predictors of LOH; however, severely involved cerebral palsy (CP) patients (GMFCS 4/5) were more likely to have extended stays than GMFCS 1-3 patients (p = 0.02). Radiographic predictors of LOH included major coronal Cobb angle (p = 0.002) and pelvic obliquity (p = 0.02). Intraoperative predictors included longer surgical times, greater numbers of levels fused and need for intraoperative or postoperative blood transfusion (p < 0.05). The need for ICU admission and development of a pulmonary complication were significantly more likely to fall into the extended LOH group (p < 0.05).

CONCLUSIONS

Several variables have been identified as significant predictors of LOH after PSF for NMS in the setting of a standardized discharge pathway. Patients with smaller curves and less complex surgeries were more amenable to accelerated discharge. Conversely, patients with severe CP with large curves and pelvic obliquity requiring longer surgeries with more blood loss may not be ideal candidates. These data can be used to inform providers' and families' post-operative expectations.

LEVEL OF EVIDENCE

Therapeutic Level III.

Doing Our Part to Conserve Resources: Determining Whether All Personal Protective Equipment Is Mandatory for Closed Reduction and Percutaneous Pinning of Supracondylar Humeral Fractures

BACKGROUND

Closed reduction and percutaneous pinning (CRPP) of supracondylar humeral fractures is one of the most common procedures performed in pediatric orthopaedics. The use of full, standard preparation and draping with standard personal protective equipment (PPE) may not be necessary during this procedure. This is of particular interest in the current climate as we face unprecedented PPE shortages due to the current COVID-19 pandemic.

METHODS

This is a retrospective chart review of 1,270 patients treated with CRPP of a supracondylar humeral fracture at 2 metropolitan pediatric centers by 10 fellowship-trained pediatric orthopaedic surgeons. One surgeon in the group did not wear a mask when performing CRPP of supracondylar humeral fractures, and multiple surgeons in the group utilized a semisterile preparation technique (no sterile gown or drapes). Infectious outcomes were compared between 2 groups: full sterile preparation and semisterile preparation. We additionally analyzed a subgroup of patients who had semisterile preparation without surgeon mask use. Hospital cost data were used to estimate annual cost savings with the adoption of the semisterile technique.

RESULTS

In this study, 1,270 patients who underwent CRPP of a supracondylar humeral fracture and met inclusion criteria were identified. There were 3 deep infections (0.24%). These infections all occurred in the group using full sterile preparation and surgical masks. No clinically relevant pin-track infections were noted. There were no known surgeon occupational exposures to bodily fluid. It is estimated that national adoption of this technique in the United States could save between 18,612 and 22,162 gowns and masks with costs savings of $3.7 million to $4.4 million annually.

CONCLUSIONS

We currently face critical shortages of PPE due to the COVID-19 pandemic. Data from this large series suggest that a semisterile technique during CRPP of supracondylar humeral fractures is a safe practice. We anticipate that this could preserve approximately 20,000 gowns and masks in the United States over the next year. Physicians are encouraged to reevaluate their daily practice to identify safe opportunities for resource preservation.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Managing Resident Workforce and Education During the COVID-19 Pandemic: Evolving Strategies and Lessons Learned

Background:

The novel coronavirus and associated Coronavirus Disease 2019 (COVID-19) is rapidly spreading throughout the world, with robust growth in the United States. Its drastic impact on the global population and international health care is swift, evolving, and unpredictable. The effects on orthopaedic surgery departments are predominantly indirect, with widespread cessation of all nonessential orthopaedic care. Although this is vital to the system-sustaining measures of isolation and resource reallocation, there is profound detriment to orthopaedic training programs.

Methods:

In the face of new pressures on the finite timeline on an orthopaedic residency, the Emory University School of Medicine Department of Orthopaedics has devised a 5-pronged strategy based on the following: (1) patient and provider safety, (2) uninterrupted necessary care, (3) system sustainability, (4) adaptability, and (5) preservation of vital leadership structures.

Results:

Our 5 tenants support a 2-team system, whereby the residents are divided into cycling “active-duty” and “working remotely” factions. In observation of the potential incubation period of viral symptoms, phase transitions occur every 2 weeks with strict adherence to team assignments. Intrateam redundancy can accommodate potential illness to ensure a stable unit of able residents. Active duty residents participate in in-person surgical encounters and virtual ambulatory encounters, whereas remotely working residents participate in daily video-conferenced faculty-lead, case-based didactics and pursue academic investigation, grant writing, and quality improvement projects. To sustain this, faculty and administrative 2-team systems are also in place to protect the leadership and decision-making components of the department.

Conclusions:

The novel coronavirus has decimated the United States healthcare system, with an unpredictable duration, magnitude, and variability. As collateral damage, orthopaedic residencies are faced with new challenges to provide care and educate residents in the face of safety, resource redistribution, and erosion of classic learning opportunities. Our adaptive approach aims to be a generalizable tactic to optimize our current landscape.

Fusions ending at the thoracolumbar junction in adolescent idiopathic scoliosis: comparison of lower instrumented vertebrae

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To compare clinical outcomes and radiographic parameters between patients treated with a posterior spinal fusion that had a lower instrumented vertebra at T11, T12, and L1.

BACKGROUND

Posterior instrumented fusions are well established for treating patients with adolescent idiopathic scoliosis (AIS). Fusions limited to the thoracic spine can adequately correct a spinal deformity while preserving lumbar segmental mobility. However, fusions that end at the thoracolumbar junction have been proposed to cause adjacent segment complications. Studies comparing outcomes between patients who were treated with fusions that end at the thoracolumbar junction with varying LIVs are limited.

METHODS

A multicenter database was queried for patients with AIS that had Lenke Type 1 and 2 curves treated with a fusion that had an LIV at T11, T12, or L1. Coronal curve magnitude, degree of junctional kyphosis, C7-central sacral line, thoracic apical translation, and sagittal stable vertebrae were measured. Clinical and functional outcomes were assessed using the Scoliosis Research Society-22 (SRS-22) questionnaire and lumbar flexibility testing.

RESULTS

The lower instrumented level was below the sagittal stable vertebrae in 22.7%, 40%, and 66.2% of patients in the LIV-T11, T12, and L1 groups, respectively (p < 0.001). The 5-year postoperative lumbar curve magnitudes were 20.3°, 16.3°, and 14.0° for T11, T12, and L1-LIV, respectively (p < 0.001). No patients in the T11 group (0%), two patients in the T12 group (2.5%), and one patient in the L1 (0.8%) group developed distal junctional kyphosis (p = 0.5). The 5-year postoperative total SRS-22 scores were 4.21, 4.50, and 4.38 (p = 0.029). Lumbar flexion decreased by 0.78 cm in the T11-LIV group, increased by 0.01 cm in the T12-LIV group, and decreased by 0.15 cm in the L1-LIV group (p = 0.434).

CONCLUSION

There was no significant difference in SRS-22 scores, development of distal junctional kyphosis or loss of lumbar mobility between patients treated with a spinal fusion that had an LIV at T11, T12, or L1.

LEVEL OF EVIDENCE

Level III.

Resource Utilization for Patients With Distal Radius Fractures in a Pediatric Emergency Department

IMPORTANCE

Improvement of clinician understanding of acceptable deformity in pediatric distal radius fractures is needed.

OBJECTIVE

To assess how often children younger than 10 years undergo a potentially unnecessary closed reduction using procedural sedation in the emergency department for distal radial metaphyseal fracture and the associated cost implications for these reduction procedures.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study included 258 consecutive children younger than 10 years who presented to a single, level I, pediatric emergency department and who had a distal radius fracture with or without ulna involvement between January 1, 2016, and December 31, 2017. Reductions were deemed to be potentially unnecessary if the coronal and sagittal plane angulation of the radius bone measured less than 20° and shortening measured less than 1 cm on initial injury radiographs. Use of procedural sedation or transfer status to another facility was noted if present. Statistical analysis was performed from April 2019 to June 2019.

MAIN OUTCOMES AND MEASURES

Potentially unnecessary reduction was the primary outcome. Radiographic findings were measured to determine reduction necessity. Additional variables measured were age, sex, time in the emergency department, transfer status, required reduction procedure, use of sedation, and cost associated with care.

RESULTS

Of the 258 participants studied, 156 (60%) were male, with a mean (SD) age of 6.7 (2.3) years. Among 142 patients (55%) who underwent closed reduction with procedural sedation in the emergency department, 38 (27%) procedures were determined to be potentially unnecessary. Review of Common Procedural Terminology charges revealed an approximately $7000 difference between the stated cost of a reduction procedure in the emergency department vs a cast application in an outpatient orthopedic clinic for distal radial metaphyseal fractures. The mean (SD) maximal angulation in either plane for fractures that underwent appropriate reduction was 30.6° (10.3°) compared with 13.9° (4.5°) for those unnecessarily reduced (P < .001). Patients who were transfers from other facilities were more than twice as likely to undergo a potentially unnecessary reduction (odds ratio, 2.3; 95% CI, 1.1-5.0; P = .03).

CONCLUSIONS AND RELEVANCE

The findings suggest that improved awareness of these acceptable deformities in young children may be associated with limiting the number of children requiring reduction with sedation, improving emergency department efficiency, and substantially reducing health care costs.

Improving Complex Pediatric and Adult Spine Care While Embracing the Value Equation

INTRODUCTION

Value in health care is defined as the quotient of outcomes to cost. Both pediatric and adult spinal deformity surgeries are among the most expensive procedures offered today. With high variability in both outcomes and costs in spine surgery today, surgeons will be expected to consider long-term cost effectiveness when comparing treatment options.

METHODS

We summarize various methods by which value can be increased in complex spine surgery, both through the improvement of outcomes and the reduction of cost. These methods center around standardization, team-based and collaborative approaches, rigorous outcomes tracking through dashboards and registries, and continuous process improvement.

RESULTS

This manuscript reviews the expert opinion of leading spine specialists on the improvement of safety, quality and improvement of value of pediatric and adult spinal surgery.

CONCLUSION

Without surgeon leadership in this arena, suboptimal solutions may result from the isolated intervention of regulatory bodies or payer groups. The cooperative development of standardized, team-based approaches in complex spine surgery will lead to the high-quality, high-value care for patients.

Development of Consensus Based Best Practice Guidelines for Perioperative Management of Blood Loss in Patients Undergoing Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

STUDY DESIGN

Delphi process with multiple iterative rounds using a nominal group technique.

OBJECTIVE

The aim of this study was to use expert opinion to achieve consensus on various methods for minimizing blood loss in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

BACKGROUND DATA

Perioperative blood loss management represents a critical component of safely performing PSF in children with AIS. Little consensus exists on ways to mitigate excessive blood loss after PSF.

METHODS

An expert panel composed of 21 pediatric spine surgeons was selected. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were presented with a detailed literature review and asked to voice opinion collectively during three rounds of voting. Agreement >80% was considered consensus. Interventions without consensus were discussed and revised, if feasible.

RESULTS

Consensus was reached to support 21 best practice guideline measures for perioperative management of blood loss in patients undergoing PSF for AIS. Areas included preoperative assessment and preparation, intraoperative strategies to decrease blood loss, and postoperative transfusion indications.

CONCLUSION

We present a consensus-based best practice guideline consisting of 21 recommendations for strategies to minimize and manage blood loss during PSF. This can serve to reduce variability in practice in this area, help develop hospital specific protocols, and guide future research.

Complications following lengthening of spinal growing implants: is postoperative admission necessary?

OBJECTIVE The aim of this study was to evaluate the effect of postoperative admission status on 30-day perioperative complications in patients with growing spinal instrumentation undergoing surgical lengthening. METHODS This retrospective case-control study of records from the 2014-2015 National Surgical Quality Improvement Program-Pediatric database was performed to identify surgical lengthening procedures of spinal implants in patients with growing instrumentation by Current Procedural Terminology code. The 30-day postoperative complications were classified according to the Clavien-Dindo system. Patients were subdivided according to their postsurgical admission status. Admission status, American Society of Anesthesiologists (ASA) Physical Status classification, tracheostomy, neuromuscular diagnosis, ventilator dependence, and nutritional support were considered as possible risk factors in univariate and multivariate logistic regression analyses. RESULTS A total of 796 patients were identified (mean age 9.09 ± 3.44 years; 54% of patients were female), of whom 73% underwent lengthening on an inpatient basis. Patients with a tracheostomy or ventilator dependence were more likely to be admitted postoperatively. The overall rate of major complications was 3.5% and did not differ based on admission status (2.8% inpatient vs 3.8% outpatient, p = 0.517). On univariate analysis, ventilator dependence (9.5% vs 2.7%, p = 0.002), need for nutritional support (7.1% vs 2.5%, p = 0.006), and ASA class > II (4.8% vs 1.3%, p = 0.04) placed patients at a higher risk for any postoperative complications. Multivariate analysis identified only ventilator dependence as an independent risk factor for any perioperative complication. CONCLUSIONS Postoperative admission status did not affect the rate of 30-day perioperative complications, readmission, or rate of unplanned operations following lengthening of growing spinal instrumentation. Outpatient lengthening appears to be safe; however, consideration for postoperative admission should be given for those who are ventilator dependent.

The Use of a Transolecranon Pin in the Treatment of Pediatric Flexion-type Supracondylar Humerus Fractures

BACKGROUND

Flexion-type supracondylar humerus fractures are much more uncommon than their extension-type counterparts. Instability in elbow flexion renders traditional closed techniques inadequate and often results in the need for open reduction. We present a simple technique for closed reduction using a transolecranon pin for temporary stability.

METHODS

A retrospective review of 9 patients treated with a transolecranon pin technique for a flexion-type supracondylar humerus fracture was performed. Operative time, need for open reduction, postoperative range of motion, final radiographic alignment using Baumann angle, and the intersection of the anterior humeral line with the capitellum was evaluated.

RESULTS

All 9 patients were treated with closed reduction using a temporary transolecranon pin technique. Total surgical time averaged 38±15 minutes and was longer for type III than type II flexion-type fractures. All fractures healed by first follow-up at 1 month. There was 1 preoperative ulnar nerve deficit that resolved by the first postoperative visit. Average Baumann angle at radiographic healing was 71.2±3.3 degrees and all cases showed restoration of the normal anterior humeral line:capitellar relationship. Average postoperative flexion at final follow-up was 125 degrees and extension was 5 degrees. One patient had a flexion contracture of 10 degrees.

DISCUSSION

Use of a temporary transolecranon pin allowed for closed reduction of all flexion-type fractures with no radiographic malunion. This technique is technically simple and avoids the need for open reduction or multiple fluoroscopy views.

LEVEL OF EVIDENCE

Level IV-case series.

Impact of insurance status on ability to return for outpatient management of pediatric supracondylar humerus fractures

PURPOSE

Outcomes are excellent following surgical management of displaced supracondylar humerus fractures. Short delays until surgical fixation have been shown to be equivalent to immediate fixation with regards to complications. We hypothesized that insurance coverage may impact access to care and the patient's ability to return to the operating room for outpatient surgery.

METHODS

A retrospective review of supracondylar humerus fractures treated at a large urban pediatric hospital from 2008 to 2012 was performed. Fractures were classified by the modified Gartland classification and baseline demographics were collected. Time from discharge to office visits and subsequent surgical fixation was calculated for all type II fractures discharged from the emergency department. Insurance status and primary carrier were collected for all patients.

RESULTS

2584 supracondylar humerus fractures were reviewed, of which 584 were type II fractures. Of the 577 type II fractures with complete records, 383 patients (61 %) were admitted for surgery and the remaining 194 were discharged with plans for outpatient follow-up. There was no difference in insurance status between patients admitted for immediate surgery. Of the 194 patients who were discharged with type 2 fractures after gentle reduction, 59 patients (30.4 %) ultimately underwent surgical fixation. Of these, 42 patients were privately insured (58.3 % of patients with private insurance), 16 had governmental insurance (15.1 %), and 1 was uninsured (6.3 %). Patients with private insurance were 2.46 times more likely to have surgery than patients with public or no insurance (p = 0.005). Of the 135 patients who did not eventually have surgery, 92 (68.1 %) were seen in the clinic. Patients with private insurance were 2.78 times more likely to be seen back in the clinic when compared to publicly insured or uninsured patients (p = 0.0152).

CONCLUSIONS

Despite an equivalent number of privately insured and publicly insured patients undergoing immediate surgery for type II fractures, those with public or no insurance who were discharged were 2.46 times less likely to obtain outpatient surgery when compared to privately insured patients. Patient insurance status and the ability to follow up in a timely manner should be assessed at the time of initial evaluation in the emergency department. Level of evidence Level 3.

Continuing Delay in the Diagnosis of Slipped Capital Femoral Epiphysis

OBJECTIVE

To evaluate whether the time from symptom onset to diagnosis of slipped capital femoral epiphysis (SCFE) has improved over a recent decade compared with reports of previous decades.

STUDY DESIGN

Retrospective review of 481 patients admitted with a diagnosis of SCFE at three large pediatric hospitals between January 2003 and December 2012.

RESULTS

The average time from symptom onset to diagnosis of SCFE was 17 weeks (range, 0-to 169). There were no significant differences in time from symptom onset to diagnosis across 2-year intervals of the 10-year study period (P = .94). The time from evaluation by first provider to diagnosis was significantly shorter for patients evaluated at an orthopedic clinic (mean, 0 weeks; range, 0-0 weeks) compared with patients evaluated by a primary care provider (mean, 4 weeks; range, 0-52 weeks; r = 0.24; P = .003) or at an emergency department (mean, 6 weeks, range, 0-104 weeks; r = 0.36; P = .008). Fifty-two patients (10.8%) developed a second SCFE after treatment of the first affected side. The time from the onset of symptoms to diagnosis for the second episode of SCFE was significantly shorter (r = 0.19; P < .001), with mean interval of 11 weeks (range, 0-104 weeks) from symptom onset to diagnosis. There were significantly more cases of mildly severe SCFE, as defined by the Wilson classification scheme, in second episodes of SCFE compared with first episodes of SCFE (OR, 4.44; P = .001).

CONCLUSION

Despite reports documenting a lag in time to the diagnosis of SCFE more than a decade ago, there has been no improvement in the speed of diagnosis. Decreases in both the time to diagnosis and the severity of findings for the second episode of SCFE suggest that the education of at-risk children and their families (or providers) may be of benefit in decreasing this delay.

Improving perioperative care for adolescent idiopathic scoliosis patients: the impact of a multidisciplinary care approach

The complex nature of the surgical treatment of adolescent idiopathic scoliosis (AIS) requires a wide variety of health care providers. A well-coordinated, multidisciplinary team approach to the care of these patients is essential for providing high-quality care. This review offers an up-to-date overview of the numerous interventions and safety measures for improving outcomes after AIS surgery throughout the perioperative phases of care. Reducing the risk of potentially devastating and costly complications after AIS surgery is the responsibility of every single member of the health care team. Specifically, this review will focus on the perioperative measures for preventing surgical site infections, reducing the risk of neurologic injury, minimizing surgical blood loss, and preventing postoperative complications. Also, the review will highlight the postoperative protocols that emphasize early mobilization and accelerated discharge.

Medicaid insurance is associated with larger curves in patients who require scoliosis surgery

Children with Medicaid may have difficulty accessing care for adolescent idiopathic scoliosis (AIS), a condition that may worsen with time. We conducted a study to determine whether patients with Medicaid present with a larger curve magnitude. We reviewed the cases of consecutive AIS patients treated with posterior spinal fusion (PSF) between 2008 and 2012. Children seen for second opinions were excluded. Medical records were evaluated to determine time from evaluation to determination for surgery, time from recommendation for surgery to actual procedure, and insurance status. Radiographs were reviewed to determine Cobb angle at initial presentation. Of the 135 patients who underwent PSF for newly diagnosed AIS, 39% had Medicaid insurance. Compared with private insurance patients, Medicaid patients presented with a larger mean (SD) Cobb angle, 57.2° (15.7°) versus 47.5° (14.3°) (P < .001), and had larger curves at time of surgery, 60.6° (13.9°) versus 54.6° (11.7°) (P = .008). There was no difference in wait time from the decision to undergo surgery to the actual surgery or in mean (SD) number of levels fused, 10.3 (2.2) for Medicaid patients versus 9.7 (2.3) for private insurance patients (P = .16). Compared with private insurance patients, Medicaid patients who underwent PSF for AIS had larger presenting Cobb angles and larger Cobb angles at time of surgery.

Reliability of Proximal Junctional Kyphosis Measurements for Young Children With Scoliosis

DESIGN

Retrospective comparison.

OBJECTIVES

To determine whether the choice of proximal junctional kyphosis (PJK) definition affects reported rates and reliability of measurement of PJK for the same group of children treated with growth-friendly surgery.

BACKGROUND

Distraction-based surgery has been associated with the development of PJK, which may lead to premature implant failure and may affect the upper instrumented level. Proximal junctional kyphosis has not been clearly defined in the literature and recent studies have used various definitions, resulting in widely varying rates of PJK. As a first step toward defining risk factors that may lead to clinically significant PJK, an evaluation of definitions of PJK should be performed.

METHODS

The researchers analyzed radiographs of 36 children who were treated with growth-friendly surgery. The rates of PJK were determined using 3 recently described definitions. Five observers each measured the radiographs 2 weeks apart. Reliability was measured using the kappa statistic and intraclass correlation.

RESULTS

At 2-year follow-up, rates of PJK varied between 6% and 42% depending on the definition used. Interobserver agreement for PJK at time 1 yielded fair agreement for definition 1 (κ = 0.31), moderate for definition 2 (κ = 0.40), and fair for definition 3 (κ = 0.38). Interobserver agreement for junctional angle at time 1 was fair (intraclass correlation coefficient [ICC], 0.48) for definition 1, good (ICC, 0.71) for definition 2, and fair (ICC, 0.55) for definition 3. Intra-observer agreement between times 1 and 2 for junctional angle was good (ICC, 0.61) for definition 1, excellent (ICC, 0.82) for Definition 2, and good (ICC, 0.69) for definition 3.

CONCLUSIONS

When assessed with the same group of children, rates of PJK varied depending on the definition used. Interobserver reliability was fair to moderate; however, better interobserver and intra-observer agreement were noted with definition 2.

Clinical and economic implications of early discharge following posterior spinal fusion for adolescent idiopathic scoliosis

OBJECTIVE

To evaluate the clinical and economic impact of a novel postoperative pathway following posterior spinal fusion (PSF) in patients with adolescent idiopathic scoliosis (AIS).

METHODS

Patient charts were reviewed for demographic data and to determine length of surgery, implant density, use of osteotomies, estimated blood loss, American Society of Anesthesiologists (ASA) score, length of hospital stay, and any subsequent complications. Hospital charges were divided by charge code to evaluate potential savings.

RESULTS

Two hundred and seventy-nine of 365 patients (76.4 %) treated with PSF carried a diagnosis of AIS and had completed 6 months of clinical and radiologic follow-up, a period of time deemed adequate to assess early complications. There was no difference between groups in age at surgery, sex, number of levels fused, or length of follow-up. Patients managed under the accelerated discharge (AD) pathway averaged 1.36 (31.7 %) fewer days of inpatient stay. Operative time was associated with a shorter length of stay. There was no difference in complications between groups. Hospital charges for room and board were significantly less in the AD group ($1.885 vs. $2,779, p < 0.001).

CONCLUSIONS

A pathway aimed to expedite discharge following PSF for AIS decreased hospital stay by nearly one-third without any increase in early complication rate. A small but significant decrease in hospital charges was seen following early discharge. Early discharge following PSF for AIS may be achieved without increased risk of complications, while providing a small cost savings.

Management of the pediatric pulseless supracondylar humeral fracture: is vascular exploration necessary?

BACKGROUND

Radically different conclusions exist in the pediatric orthopaedic and vascular literature regarding the management of patients with a pink hand but no palpable radial pulse in association with a supracondylar humeral fracture.

METHODS

One thousand two hundred and ninety-seven consecutive, operatively treated supracondylar humeral fractures in patients presenting to a level-I pediatric trauma center from January 2003 through December 2007 were studied retrospectively. Clinical records were reviewed to determine vascular and neurological examination findings, Gartland classification, timing of surgery, and postoperative complications.

RESULTS

One thousand two hundred and sixty-six patients had a documented radial pulse examination at the time of arrival in the emergency room; fifty-four (4%) of those patients lacked a palpable radial pulse. All fifty-four patients had type-3 fractures. Five (9%) of the fifty-four patients underwent open exploration of vascular structures on the basis of clinical findings of a pale hand, sluggish capillary refill, and/or weak or no pulse detected with use of Doppler ultrasound after closed reduction and percutaneous pinning. All five underwent vascular surgery to restore blood flow (two primary repairs, three saphenous vein grafts). Twenty (37%) of the fifty-four patients had a pulse documented with use of Doppler ultrasound and a pink hand after closed reduction and percutaneous pinning, but the radial pulse remained nonpalpable. These patients were observed in the hospital for signs of ischemia; one of the twenty patients required vascular repair after developing a pale hand nine hours after closed reduction and percutaneous pinning, and the other nineteen patients were also observed while they were in the hospital, and they all regained a palpable pulse either prior to discharge or by the time of the first postoperative visit. When compared with the group of patients with type-3 fractures for whom data regarding nerve examination were available, patients with type-3 fractures who lacked a palpable radial pulse had a higher rate of nerve palsy postoperatively (31% versus 9%, p < 0.0001).

CONCLUSIONS

In this cohort, nearly 10% of patients who presented with a type-3 supracondylar humeral fracture and no palpable radial pulse underwent immediate vascular repair to restore blood flow following closed reduction and percutaneous pinning. However, in our series, the lack of a palpable radial pulse after closed reduction and percutaneous pinning was not an absolute indication to proceed with vascular exploration if clinical findings (i.e., Doppler signal and capillary refill) suggested that the limb was perfused. Careful inpatient monitoring of these patients postoperatively is mandatory to identify late-developing vascular compromise.

LEVEL OF EVIDENCE

Prognostic level III. See Instructions for Authors for a complete description of levels of evidence.

The mechanical stability of extra-articular distal radius fractures with respect to the number of screws securing the distal fragment

PURPOSE

The treatment of distal radius fractures with volar locked plating (VLP) has gained popularity. Many different designs and sizes of plates afford a wide variety of configurations of locking screws that can be placed into the distal fracture fragment. The purpose of this study was to determine whether using half of the distal locking screws decreased stability when compared with using all possible distal locking screws with 4 different VLP systems.

METHODS

Twenty-four identical synthetic distal radius sawbone models were instrumented with 1 of 4 designs of VLP devices over a standardized dorsal wedge osteotomy to simulate a dorsally comminuted, extra-articular distal radius fracture. Distal locking screws were placed in varying configurations. Six radii per plate model with different screw configurations then underwent axial loading, volar bending, and dorsal bending using a servohydraulic machine. Distal fragment displacement was recorded using a differential variable reluctance transducer.

RESULTS

There was no significant difference in fracture fragment displacement when using half of the distal locking screw set compared with using the full screw set. Mean differences in displacement between half and full screws were less than 0.1 mm. All configurations had the greatest magnitude of displacement during axial loading. Mean displacement was less in plates containing 2 rows of distal locking screws (-0.4 mm) compared with plates containing 1 row (-0.6 mm).

CONCLUSIONS

Using half of the distal locking screws in VLP in an extra-articular, nonosteoporotic distal radial fracture model with noncyclical, nondestructive loading does not decrease construct stability compared with using all of the screws. Not filling all holes in VLP is more cost effective and does not sacrifice plate stiffness or construct stability. Plates with 2 rows of distal locking screws create more stable fixation than plates with 1 row of distal locking screws.

Early onset scoliosis: current concepts and controversies

Early Onset Scoliosis (EOS) may be associated with long-term pulmonary morbidity, which is not commonly seen in Adolescent Idiopathic Scoliosis. Initial evaluation is based on determining any underlying etiology related to congenital or syndromic conditions. Assessing the impact of scoliosis on thoracic development may help guide treatment, which is often required at a young age in these children to prevent irreversible pulmonary insufficiency. Treatment is based on multiple factors but may include non-surgical strategies, such as casting or bracing, along with growth-sparing surgical procedures using growing rods or chest wall expansion. Definitive fusion is rarely indicated in young patients. This chapter will cover the diagnosis, evaluation, and treatment of children with EOS.

Trauma: life in the ER--education or entertainment? The patient's perspective

OBJECTIVES

To determine whether patients felt that the show Trauma: Life in the ER has primarily educational or entertainment value. To determine if people felt that this show violated privacy.

METHODS

Survey in an academic emergency department. Subjects were asked to participate in an initial survey, then asked to watch video clips from the show and complete a second survey.

RESULTS

Three hundred ninety two participated in the initial survey. Fifty-six percent surveyed had seen the program, and of those, 55% stated that they watched the show for both educational and entertainment value. Of the initial participants, 267 watched the video and completed the second survey. Sixty-four percent stated that they would feel comfortable being filmed without prior permission. Eighteen percent of patients felt that the show violated patients' privacy.

CONCLUSIONS

Most patients felt that this show was educational and did not invade their privacy. The majority were willing to be filmed for this television show, even without prior permission.

'Sorry, it's my first time!' Will patients consent to medical students learning procedures?

CONTEXT

The clinical teaching of medical students is essential to medicine; however, medical students often may not inform patients of their inexperience. Hence patients do not have the opportunity to consent specifically to the procedures being performed by medical students.

OBJECTIVES

The purpose of this study was to determine whether patients, when informed of the inexperience of a medical student, would still consent to the procedure.

METHODS

Adult emergency department patients (114) were enrolled if they required one of the following procedures: sutures, intravenous (i.v.) access or splinting. Patients were first surveyed about his or her perceptions of medical student performing procedures. The first-year medical student then informed the patient of their inexperience (the number of procedures they had performed successfully). Finally, the patient was asked to consent to the student performing the procedure (i.e. "this is my first/third time suturing, may I suture you?") The main outcome measure was patient consent to the student performing the procedure.

RESULTS

Only 48% of participants knew they could be the first patient on whom a medical student might perform a procedure. A total of 66% thought they should be told if a student was performing his or her first procedure on them. The majority of patients (90%) consented (69/80 i.v., 20/20 splints, 13/14 sutures). For 7 of the 12 refusals, it was the student's first time performing the procedure.

CONCLUSION

Most patients will allow medical students to perform minor procedures, even when informed of the student's inexperience.

Common bile duct papillary adenoma causing obstructive jaundice: case report and review of the literature

Common bile duct (CBD) adenomas are rare tumors that often present in a fashion similar to their malignant counterparts. We report a case of a papillary CBD adenoma causing obstructive jaundice. We also present a review of the CBD adenomas found in the English literature through a Medline search (1970-2003). A 74-year-old female presented with a 10-day history of pruritus, progressive painless jaundice, acholic stools, bilirubinuria, and 10-lb weight loss. Abdominal exam showed no masses. Abdominal ultrasound (U/S) showed cholelithiasis without choledocholithiasis. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic U/S revealed a shelf-like stricture, 1.5 cm long and 0.9 cm in diameter, located in the distal CBD. At the time of biliary stent placement, fine-needle aspiration showed benign ductal epithelial cells in sheets and clusters. Abdominal CT scan showed a low attenuation 15 x 17 mm lesion in the head of the pancreas that abutted the superior mesenteric vein (SMV) but no metastatic lesions. We performed a standard pancreaticoduodenectomy (Whipple procedure). Final pathology showed a papillary adenoma without evidence of dysplasia in the distal common bile duct proximal to the ampulla of Vater. The incidence of these tumors and their potential for malignant degeneration is unknown. Pancreaticoduodenectomy is an effective means of treatment and cure for CBD adenoma.

Common Bile Duct Papillary Adenoma Causing Obstructive Jaundice: Case Report and Review of the Literature

Common bile duct (CBD) adenomas are rare tumors that often present in a fashion similar to their malignant counterparts. We report a case of a papillary CBD adenoma causing obstructive jaundice. We also present a review of the CBD adenomas found in the English literature through a Medline search (1970–2003). A 74-year-old female presented with a 10-day history of pruritus, progressive painless jaundice, acholic stools, bilirubinuria, and 10-lb weight loss. Abdominal exam showed no masses. Abdominal ultrasound (U/S) showed cholelithiasis without choledocholithiasis. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic U/S revealed a shelf-like stricture, 1.5 cm long and 0.9 cm in diameter, located in the distal CBD. At the time of biliary stent placement, fine-needle aspiration showed benign ductal epithelial cells in sheets and clusters. Abdominal CT scan showed a low attenuation 15 x 17 mm lesion in the head of the pancreas that abutted the superior mesenteric vein (SMV) but no metastatic lesions. We performed a standard pancreaticoduodenectomy (Whipple procedure). Final pathology showed a papillary adenoma without evidence of dysplasia in the distal common bile duct proximal to the ampulla of Vater. The incidence of these tumors and their potential for malignant degeneration is unknown. Pancreaticoduodenectomy is an effective means of treatment and cure for CBD adenoma.