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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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Ali A. Baaj, Douglas Brockmeyer, Andrew Jea, and Amer F. Samdani

, and Ohrt-Nissen et al. present their technique for optimizing thoracic kyphosis. Intraoperative neuromonitoring (IONM), with somatosensory evoked potentials and transcranial motor evoked potentials, is now routinely utilized in the correction of pediatric spinal deformity, and Zucarro et al. provide a summary of the experience at a single center. Appropriate response to IONM changes can prevent the vast majority of permanent postoperative neurologic sequelae. Unlike AIS, neuromuscular scoliosis carries a significant complication rate, and Cognetti et al. report on

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Joseph Ferguson, Steven W. Hwang, Zachary Tataryn, and Amer F. Samdani

exceptionally high sensitivity and specificity for communicating intraoperative changes in the spinal cord. 4 , 5 , 9 , 11 , 15 Despite the increased use of IONM throughout the field of spinal surgery, there is a paucity of literature related to its use in pediatrics as compared with the spinal surgery in adults. 4 , 5 , 15 We present the experience of a single institution with IONM and pediatric spinal deformity surgery and one of the largest reported series of IONM changes to date. Methods After obtaining IRB approval, a retrospective review was performed on

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Zach Pennington, Ethan Cottrill, Daniel Lubelski, Jeff Ehresman, Kurt Lehner, Mari L. Groves, Paul Sponseller, and Daniel M. Sciubba

. Enhanced recovery after surgery (ERAS) pathways are now being applied to both adult 9 , 10 and pediatric spine surgery populations. 11–17 Despite the growing body of evidence, no quantitative review exists summarizing the existing literature on outcomes of pediatric spinal deformity ERAS protocols. To address this, we report a systematic review of the literature on ERAS for pediatric scoliosis to 1) identify the components of previously described pediatric spine ERAS protocols; 2) determine whether ERAS protocols reduce LOS, complication rates, and costs in pediatric

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Kristopher G. Hooten, Seth F. Oliveria, Shawn D. Larson, and David W. Pincus

Ogilvie's syndrome is a rare and potentially fatal disease that can easily be mistaken for postoperative ileus. Also known as acute colonic pseudo-obstruction, early recognition and diagnosis of the syndrome allows for treatment prior to bowel perforation and requisite abdominal surgery. The authors report a case of Ogilvie's syndrome following spinal deformity correction and tethered cord release in an adolescent who presented with acute abdominal distension, nausea, and vomiting on postoperative Day 0. The patient was initially diagnosed with adynamic ileus and treated conservatively with bowel rest, reduction in narcotic dosage, and a regimen of stool softeners, laxatives, and enemas. Despite this treatment, her clinical course failed to improve, and she demonstrated significant colonic distension radiographically. Intravenous neostigmine was administered as a bolus with a rapid and dramatic response. This case is the first reported instance of neostigmine use for Ogilvie's syndrome treatment following a pediatric neurosurgical operation.

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Justin S. Smith, Christopher I. Shaffrey, Michael Wang, Mohamad Bydon, and Lawrence Lenke

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Justin Kunes, George H. Thompson, Sunil Manjila, Connie Poe-Kochert, and Alan R. Cohen

in cases of IIH has sometimes been reported at 2 or 3 times that number. 38 Permanent severe visual disturbance occurs in cases of undiagnosed IIH in up to 24% of cases that have been monitored for 5–41 years. 43 We present 3 cases of IIH in a previously unreported setting of pediatric spinal deformity correction surgery ( Table 1 ). The aim of the current report is to alert neurological and orthopedic surgeons that visual disturbances and headaches in the early postoperative period can represent a serious, but treatable, condition. In addition, we propose a

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Maria Zuccaro, James Zuccaro, Amer F. Samdani, Joshua M. Pahys, and Steven W. Hwang

surgical team at the time of TceMEP loss. The results of this study indicate that TceMEP monitoring had a sensitivity of 100% and a specificity ranging from 93% to 100% in detecting spinal cord injury. We also demonstrated that TceMEPs were more sensitive than SSEPs (13.21% sensitivity) in detecting spinal cord injury. Therefore, our findings suggest that TceMEP monitoring during pediatric spinal deformity surgery can significantly reduce the risk of postoperative deficits. Furthermore, TceMEPs are often used for high-risk spinal deformity surgery, and this is consistent

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Richard Menger, Paul J. Park, Elise C. Bixby, Gerard Marciano, Meghan Cerpa, David Roye, Benjamin D. Roye, Michael Vitale, and Lawrence Lenke

OBJECTIVE

Significant investigation in the adult population has generated a body of research regarding proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) following long fusions to the sacrum and pelvis. However, much less is known regarding early complications, including PJK and PJF, in the ambulatory pediatric patient. As such, the objective of this study was to address the minimal literature on early complications after ambulatory pediatric patients underwent fusion to the sacrum with instrumentation to the pelvis in the era of sacral-alar-iliac (S2AI) instrumentation.

METHODS

The authors performed a retrospective review of pediatric patients with nonidiopathic spinal deformity < 18 years of age with ambulatory capacity who underwent fusion to the pelvis at a multisurgeon pediatric academic spine practice from 2016 to 2018. All surgeries were posterior-only approaches with S2AI screws as the primary technique for sacropelvic fixation. Descriptive, outcome, and radiographic data were obtained. The definition of PJF included symptomatic PJK presenting as fracture, screw pullout, or disruption of the posterior osseoligamentous complex.

RESULTS

Twenty-five patients were included in this study. Nine patients (36.0%) had 15 complications for an overall complication rate of 60.0%. Unplanned return to the operating room occurred 8 times in 6 patients (24.0%). Four patients (16.0%) had wound issues (3 with deep wound infection and 1 with wound breakdown) requiring reoperation. Three patients (12.0%) had PJF, all requiring reoperation. A 16-year-old female patient with syndromic scoliosis underwent extension of fusion due to posterior tension band failure at 6 months. A 17-year-old male patient with neuromuscular scoliosis underwent extension of fusion due to proximal screw pullout at 5 months. A 10-year-old female patient with congenital scoliosis underwent extension for PJF at 5 months following posterior tension band failure. One patient had pseudarthrosis requiring reoperation 20 months postoperatively.

CONCLUSIONS

Fixation to the pelvis enables significant deformity correction, but with rather high rates of complications and unexpected returns to the operating room. Considerations of sagittal plane dynamics for PJK and PJF should be strongly analyzed when performing fixation to the pelvis in ambulatory pediatric patients.

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Kyle M. Fargen, Richard C. E. Anderson, David H. Harter, Peter D. Angevine, Valerie C. Coon, Douglas L. Brockmeyer, and David W. Pincus

Object

Although rarely encountered, pediatric patients with severe cervical spine deformities and instability may occasionally require occipitocervicothoracic instrumentation and fusion. This case series reports the experience of 4 pediatric centers in managing this condition. Occipitocervical fixation is the treatment of choice for craniocervical instability that is symptomatic or threatens neurological function. In children, the most common distal fixation level with modern techniques is C-2. Treated patients maintain a significant amount of neck motion due to the flexibility of the subaxial cervical spine. Distal fixation to the thoracic spine has been reported in adult case series. This procedure is to be avoided due to the morbidity of complete loss of head and neck motion. Unfortunately, in rare cases, the pathological condition or highly aberrant anatomy may require occipitocervical constructs to include the thoracic spine.

Methods

The authors identified 13 patients who underwent occipitocervicothoracic fixation. Demographic, radiological, and clinical data were gathered through retrospective review of patient records from 4 institutions.

Results

Patients ranged from 1 to 14 years of age. There were 7 girls and 6 boys. Diagnoses included Klippel-Feil, Larsen, Morquio, and VATER syndromes as well as postlaminectomy kyphosis and severe skeletal dysplasia. Four patients were neurologically intact and 9 had myelopathy. Five children were treated with preoperative traction prior to instrumentation; 5 underwent both anterior and posterior spinal reconstruction. Two patients underwent instrumentation beyond the thoracic spine. Allograft was used anteriorly, and autologous rib grafts were used in the majority for posterior arthrodesis. Follow-up ranged from 0 to 43 months. Computed tomography confirmed fusion in 9 patients; the remaining patients were lost to follow-up or had not undergone repeat imaging at the time of writing. Patients with myelopathy either improved or stabilized. One child had mild postoperative unilateral upper-extremity weakness, and a second child died due to a tracheostomy infection. All patients had severe movement restriction as expected.

Conclusions

Occipitocervicothoracic stabilization may be employed to stabilize and reconstruct complex pediatric spinal deformities. Neurological function can be maintained or improved. The long-term morbidity of loss of cervical motion remains to be elucidated.