Georgina E. Sellyn, Andrew T. Hale, Alan R. Tang, Alaina Waters, Chevis N. Shannon, and Christopher M. Bonfield
Spinal conditions and injuries in the pediatric population can necessitate surgical treatment. For many pediatric patients, a return to athletic activity after spinal surgery is a significant postoperative focus. However, there is a lack of standardized guidelines to determine criteria for safe return to play (RTP). To understand clinical criteria for patients to safely RTP, the authors conducted a systematic review of outcomes and the period of time before physicians recommend an RTP for pediatric patients undergoing spinal surgery.
English-language publications were searched systematically in the PubMed electronic database, and a review was conducted in accordance with the PRISMA guidelines. Additional relevant studies found via a supplementary literature search were also included. Studies assessing return to athletic activity in a pediatric population after spinal surgery were included. Studies without an RTP, postsurgical activity outcomes, or surgical intervention were excluded.
A PubMed search identified 295 articles, with 29 included for the systematic review. In addition, 4 studies were included from a supplementary literature search. The majority of these studies were retrospective case series and cohort studies, and the remaining studies included questionnaire-based studies, prospective cohorts, and case-control studies. The most common spinal conditions or injuries included spondylolysis, and this was followed by adolescent idiopathic scoliosis. Overall, the most frequent recommendation for RTP for noncontact and contact sports was 6 months after surgery (range 1–12 months), and for collision sports it was 12 months after surgery. However, some physicians recommended never returning to collision sports after spinal intervention.
Most pediatric patients are able to return to some level of sports after spinal surgery. However, no standardized criteria have been proposed, and RTP recommendations vary according to the treating surgeon. In addition, limited data are published on the variation in timelines for RTP with regard to classifications of sports (noncontact, contact, and collision). Further analysis of specific spinal conditions and injuries with postoperative athletic recovery is needed.
Georgina E. Sellyn, Alan R. Tang, Shilin Zhao, Madeleine Sherburn, Rachel Pellegrino, Stephen R. Gannon, Bradley S. Guidry, Travis R. Ladner, John C. Wellons III, and Chevis N. Shannon
The authors’ previously published work validated the Chiari Health Index for Pediatrics (CHIP), a new instrument for measuring health-related quality of life (HRQOL) for pediatric Chiari malformation type I (CM-I) patients. In this study, the authors further evaluated the CHIP to assess HRQOL changes over time and correlate changes in HRQOL to changes in symptomatology and radiological factors in CM-I patients who undergo surgical intervention. Strong HRQOL evaluation instruments are currently lacking for pediatric CM-I patients, creating the need for a standardized HRQOL instrument for this patient population. This study serves as the first analysis of the CHIP instrument’s effectiveness in measuring short-term HRQOL changes in pediatric CM-I patients and can be a useful tool in future CM-I HRQOL studies.
The authors evaluated prospectively collected CHIP scores and clinical factors of surgical intervention in patients younger than 18 years. To be included, patients completed a baseline CHIP captured during the preoperative visit, and at least 1 follow-up CHIP administered postoperatively. CHIP has 2 domains (physical and psychosocial) comprising 4 components, the 3 physical components of pain frequency, pain severity, and nonpain symptoms, and a single psychosocial component. Each CHIP category is scored on a scale, with 0 indicating absent and 1 indicating present, with higher scores indicating better HRQOL. Wilcoxon paired tests, Spearman correlations, and linear regression models were used to evaluate and correlate HRQOL, symptomatology, and radiographic factors.
Sixty-three patients made up the analysis cohort (92% Caucasian, 52% female, mean age 11.8 years, average follow-up time 15.4 months). Dural augmentation was performed in 92% of patients. Of the 63 patients, 48 reported preoperative symptoms and 42 had a preoperative syrinx. From baseline, overall CHIP scores significantly improved over time (from 0.71 to 0.78, p < 0.001). Significant improvement in CHIP scores was seen in patients presenting at baseline with neck/back pain (p = 0.015) and headaches (p < 0.001) and in patients with extremity numbness trending at p = 0.064. Patients with syringomyelia were found to have improvement in CHIP scores over time (0.75 to 0.82, p < 0.001), as well as significant improvement in all 4 components. Additionally, improved CHIP scores were found to be significantly associated with age in patients with cervical (p = 0.009) or thoracic (p = 0.011) syrinxes.
The study data show that the CHIP is an effective instrument for measuring HRQOL over time. Additionally, the CHIP was found to be significantly correlated to changes in symptomatology, a finding indicating that this instrument is a clinically valuable tool for the management of CM-I.
Jaims Lim, Alan R. Tang, Campbell Liles, Alexander A. Hysong, Andrew T. Hale, Christopher M. Bonfield, Robert P. Naftel, John C. Wellons III, and Chevis N. Shannon
Many studies have aimed to determine the most clinically effective surgical intervention for hydrocephalus. However, the costs associated with each treatment option are poorly understood. In this study, the authors conducted a cost-effectiveness analysis, calculating the incremental cost-effectiveness ratio (ICER) of ventriculoperitoneal shunting (VPS), endoscopic third ventriculostomy (ETV), and ETV with choroid plexus cauterization (ETV/CPC) in an effort to better understand the clinical effectiveness and costs associated with treating hydrocephalus.
The study cohort includes patients under the age of 18 who were initially treated for hydrocephalus between January 2012 and January 2015 at the authors’ institution. Overall treatment costs were calculated using patient-level hospitalization costs and professional fees reimbursable to the hospital and directly related to the initial and follow-up (postoperative day 1 to 12 months) treatment of hydrocephalus. TreeAge Pro was used to conduct the cost-effectiveness analyses.
A total of 147 patients were identified. Based on the initial intervention for hydrocephalus, their cases were classified as follows: 113 VPS, 14 ETV, and 20 ETV/CPC. During the initial intervention, VPS patients required a longer length of stay at 5.6 days, compared to ETV/CPC (3.35 days) and ETV (2.36 days) patients. Failure rates for all treatment options ranged from 29% to 45%, leading to recurrent hydrocephalus and additional surgical intervention between postoperative day 1 and 12 months. Cost-effectiveness analyses found ETV to be less costly and more clinically effective, with an ICER of $94,797 compared to VPS ($130,839) and ETV/CPC ($126,394). However, when stratified by etiology, VPS was found to be more clinically effective and cost-effective in both the myelomeningocele and posthemorrhagic hydrocephalus patient groups with an incremental cost per clinical unit of effectiveness (success or failure of intervention) of $76,620 compared to ETV and ETV/CPC. However, when assessing cases categorized as “other etiologies,” ETV was found to be more cost-effective per clinical unit, with an ICER of $60,061 compared to ETV/CPC ($93,350) and VPS ($142,135).
This study is one of the first attempts at quantifying the patient-level hospitalization costs associated with surgical management of hydrocephalus in pediatric patients treated in the United States. The results indicate that the conversation regarding CSF diversion techniques must be patient-specific and consider etiology as well as any previous surgical intervention. Again, these findings are short-run observations, and a long-term follow-up study should be conducted to assess the cost of treating hydrocephalus over the lifetime of a patient.