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Christopher I. Shaffrey and Justin S. Smith

to be symptom free. 8 Many patients who have undergone surgical management of ASD subsequently require outpatient interventions such as physical therapy and pain medications, costs that were not captured in this study. These treatments could substantially increase the cost for the surgical cohort over a 10-year time frame. This study also does not capture costs related to lost productivity, costs of rehabilitation, or family burden during the prolonged recovery period following ASD surgery. Results of this study were projected through a 10-year follow-up period

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Gregory C. Wiggins, Christopher I. Shaffrey, Mark F. Abel and Arnold H. Menezes

Pediatric spinal deformity results from multiple conditions including congenital anomalies, neuromuscular disorders, skeletal dysplasia, and developmental disorders (idiopathic). Pediatric spinal deformities can be progressive and cause pulmonary compromise, neurological deficits, and cardiovascular compromise. The classification and treatment of these disorders have evolved since surgical treatment was popularized when Harrington distraction instrumentation was introduced.

The advent of anterior-spine instrumentation systems has challenged the concepts of length of fusion needed to arrest curvature progression. Segmental fixation revolutionized the surgical treatment of these deformities. More recently, pedicle screw–augmented segmental fixation has been introduced and promises once again to shift the standard of surgical therapy. Recent advances in thoracoscopic surgery have made this technique applicable to scoliosis surgery.

Not only has surgical treatment progressed but also the classification of different forms of pediatric deformity continues to evolve. Recently, Lenke and associates proposed a new classification for adolescent idiopathic scoliosis. This classification attempts to address some of the shortcomings of the King classification system.

In this article the authors review the literature on pediatric spinal deformities and highlight recent insights into classification, treatment, and surgery-related complications.

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Christopher I. Shaffrey and Justin S. Smith

effective as and far less expensive than surgical intervention for most spinal disorders. Several recent studies have called these beliefs into question. 3 , 14–17 Nonoperative management can be costly, particular if there are not demonstrable improvements in pain and function. 8 Glassman and associates evaluated 55 scoliosis patients who received only nonoperative care and collected utilization data for 8 specific treatment methods: medication, physical therapy, exercise, injections/blocks, chiropractic care, pain management, bracing, and bed rest. 6 The authors found

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Justin S. Smith, Kai-Ming Fu, Peter Urban and Christopher I. Shaffrey

neurological deficits typically involves nonoperative treatment in an effort to avoid the potential complications of an extensive surgical intervention, especially in elderly patients. The frequent use of nonoperative resources in adults with scoliosis has been well-documented by Glassman et al. 10 These resources, including physical therapy, steroid injections, nonsteroidal antiinflammatory drugs, and narcotics, may temporize, but a subset of patients will ultimately reach a point at which the risks of surgical intervention are offset by the impact of the deformity. The

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Christopher I. Shaffrey and Justin S. Smith

sacroiliitis or SI joint disruption. The authors found that the mean cumulative 5-year direct medical costs attributable to management of the SI joint pathology were $18,527, with the 5-year Medicare reimbursement being $270 million for 14,552 Medicare beneficiaries. 1 Their conclusions are valid, that the economic burden of SI joint disruption and degenerative sacroiliitis among Medicare beneficiaries in the US is substantial and that more cost-effective therapies to treat this condition and reduce health care expenditures are needed. 1 The limitations of this article

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Andrei F. Joaquim, Catherine C. Shaffrey, Charles A. Sansur and Christopher I. Shaffrey

discuss the workup in this case, the terminology of this syndrome, and review other causes of this unusual neurological finding. Case Report History and Examination This 70-year-old woman with a history of lumbar stenosis and scoliosis had undergone multiple previous surgeries before presenting to the treating surgeon (C.I.S.). The patient initially underwent placement of T11–S1 posterior instrumentation and fusion and the postoperative course was complicated by infection requiring debridement and a prolonged period of antibiotic therapy. A nonunion at L5

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Sean M. Jones-Quaidoo, Travis Hunt, Christopher I. Shaffrey and Vincent Arlet

was able to ambulate short distances with physical therapy, she was discharged to a rehabilitation facility on postoperative Day 10, and she was followed up in the clinic 5 days later. At the 6-month follow-up evaluation, she reported faring quite well. Her strength had returned to normal and she had walked extensively. She no longer needed to self-catheterize for bladder dysfunction and was able to void spontaneously. She no longer had pain in her back or legs. Urodynamic studies were not done as the patient had improved remarkably. At the 18-month follow up, her

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Devon Hoover, Aruna Ganju, Christopher I. Shaffrey, Henry Bartkowski and Michael J. Rauzzino

At birth this 12-year-old boy had undergone an L-3 myelomeningocele and placement of a ventriculoperitoneal shunt for hydrocephalus. The shunt remained functional throughout childhood. By the time he presented to our institution at age 12 years, he had developed progressive neuromuscular scoliosis that was refractory to brace therapy. Preoperatively, his lateral curvature measured 103° with severe pelvic obliquity ( Fig. 1 left ). He underwent placement of posterior instrumentation as well as arthrodesis in which a Luque—Galveston technique was performed by

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Christopher I. Shaffrey, Gregory C. Wiggins, Cynthia B. Piccirilli, Jacob N. Young and LaVerne R. Lovell

C ervical spondylotic myelopathy results from the degenerative process of vertebral columns and related soft-tissue structures. This results in stenosis and cervical cord compression with myeloradiculopathy. Nonsurgical (conservative) treatment results in a 64% nonimprovement rate, with 26% of those patients displaying neurological deterioration. 5 Anterior and posterior surgical approaches have been reported for treatment of cervical spondylotic myelopathy. With multisegment cervical disease, wide laminectomy has been a standard therapy. Complications

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Russ P. Nockels, Christopher I. Shaffrey, Adam S. Kanter, Syed Azeem and Julie E. York

in which fusion of the atlantoaxial junction is difficult because of assimilation or disruption of the axis. Therapies involving simple posterior onlay bone grafts and halo immobilization have gradually been replaced by posterior fusion involving instrumentation and bone grafts as the primary procedure. The application of an implant in the posterior craniocervical region has proven challenging because of the unique 3D anatomical aspects of the region. The considerations include the varying thickness of the occipital bone and unusual load requirements of the implant