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Adolescent idiopathic scoliosis (AIS) is the most prevalent pediatric spine disorder, developing in the absence of obvious physiological defects. Genome sequencing and functional studies have demonstrated association of musculoskeletal collagen variants and cartilaginous extracellular matrix (ECM) defects in a subset of patients. However, the underlying biological causes of AIS remain poorly understood, limiting treatment options. Using multiple zebrafish AIS models, we demonstrate that reduction-oxidation (redox) imbalances induce cell stress and collagen remodelling within intervertebral segments of the developing spine. Mutant spines are consequently stiffer, as measured by shear wave elastography, and exhibit deformations of intervertebral structures. Remarkably, elevated stiffness and intervertebral ECM phenotypes are detectable prior to scoliosis onset, suggesting a causal relationship, and can be suppressed by antioxidant treatment. Together, our preclinical studies implicate oxidative stress-induced intervertebral deformations in the pathogenesis of AIS and identify elevated spine stiffness and redox imbalance as plausible first-in-kind prognostic biomarkers and therapeutic targets. Scoliosis is a common yet poorly understood pediatric disorder. Using zebrafish disease models, Pumputis et al. identify pervasive cell stress responses as causing spine deformity and present possibilities for new therapies and diagnostic tools.

PurposeThe objective of this meta-analysis and systematic review is to compare the methodology and evaluate the efficacy of Enhanced recovery after Spine Surgery (ERAS) for adolescent idiopathic scoliosis (AIS) and to compare the outcomes with traditional discharge (TD) pathways.MethodsUsing major databases, a systematic search was performed. Studies comparing the implementation of ERAS or ERAS-like and TD pathways in patients with AIS were identified. Data regarding methodology and outcomes were collected and analyzed.ResultsFourteen studies (n = 2456) were included, comprising 1081 TD and 1375 ERAS or ERAS-like patients. Average age of patients was 14.6 ± 0.4 years. Surgical duration was on average 35.6 min shorter for the ERAS group compared to TD cohort ([2.8, 68.3], p = 0.03), and blood loss was 112.3 milliliters less ([102.4, 122.2], p < 0.00001). ERAS group reached first ambulation 29.6 h earlier ([11.2, 48.0], p-0.002), patient-controlled-analgesia (PCA) discontinuation 0.53 day earlier ([0.4, 0.6], p < 0.00001), urinary catheter discontinuation 0.5 day earlier ([0.4, 0.6], p < 0.00001), and length-of-stay (LOS) was 1.6 days shorter ([1.4, 1.8], p < 0.00001). Rates of complications and 30-day-readmission-to-hospital were similar between both groups. Pain scores were significantly lower for ERAS group on days 0 through 2 post-operatively.ConclusionsUse of ERAS after AIS is safe and effective, decreasing surgical duration and blood loss. ERAS methodology effectively focused on reducing time to first ambulation, PCA discontinuation, and urinary catheter removal. Outcomes showed significantly decreased LOS without a significant increase in complications. There should be efforts to incorporate ERAS in AIS surgery. Further studies are necessary to assess patient satisfaction.Level of Evidence IIIMeta-analysis of Level 3 studies.

PurposeThere is currently no consensus on the management of high-grade spondylolisthesis (HGS) in paediatric populations. The objective of this analysis is to compare the outcomes of reduction followed by fusion (RFF) or in situ fusion (ISF) in paediatric patients.MethodsUsing major databases, a systematic literature search was performed. Primary studies comparing ISF with RFF in paediatric and adolescent patients were identified. Study data including patient-reported outcomes, complications, and spinopelvic parameters were collected and analysed.ResultsSeven studies were included, comprising 97 ISF and 131 RFF. Average patient age was 14.4 ± 2.1 years and follow up was 8.2 ± 5.1 years. Patients undergoing RFF compared to patients undergoing ISF alone were less likely to develop pseudarthrosis (RR 0.51, 95% CI, [0.26, 0.99], p = 0.05). On average, RFF led to 11.97º more reduction in slip angle and 34.8% more reduction in sagittal translation (p < 0.00001) compared to ISF. There was no significant difference between patient satisfaction and pain at follow up. Neurologic complications and reoperation rates were not significantly different.ConclusionsBoth RFF and ISF are effective techniques for managing HGS. Performing a reduction followed by fusion reduces the likelihood of pseudarthrosis in paediatric patients. The difference between risk of neurologic complications, need for reoperation, patient satisfaction, and pain outcomes did not reach statistical significance. Correlation with patient-reported outcomes still needs to be further explored.Level 3 evidenceMeta-analysis of Level 3 studies.

PurposeThe purpose of this study is to present the outcomes all patients with osteogenesis imperfecta (OI) who underwent cementless posterior spinal fusion for the treatment of severe spine deformity in our institution.MethodsAll patients with OI who underwent surgical correction of their spine deformity in our institution between 2003 and 2020 were enrolled. The collected data included demographics, operative and follow-up findings, medical history, bisphosphonate therapy, HGT protocol, pre- and post-HGT and postoperative scoliosis and kyphosis curve measurements, hospitalization length, complications, and revision surgeries. General treatment strategies included cessation of bisphosphonate therapy around the surgery, 30-day HGT protocol, titanium rods, cementless screw technique, and a high implant density policy.ResultsEleven consecutive patients with OI who underwent surgery for spine deformity in our institution were identified. The mean age at surgery was 15.6 ± 2.3. Mean follow-up period was 6.6 ± 5.8 years. The mean pre- and postoperative scoliosis curves were 85.4 ± 19.3° and 43.1 ± 12.5°, respectively, representing a 49.5% correction rate. Five patients underwent HGT and achieved a mean correction of 27.6 ± 7.1° (31.6%) preoperatively. Implant density ratio was 1.5 (screw or hook/level). Mean postoperative hospitalization length was 5.9 ± 1.6 days. One patient had deep wound infection which resolved following treatment according to our protocol for surgical site infection, and one patient had skull penetration by one of the halo pins.ConclusionSurgical treatment of severe spine deformity in OI patients with cementless posterior spinal fusion is safe and effective after applying a specific preoperative strategy.

Purpose The study aims to establish the diagnostic accuracy of community spine x-rays for brace candidates. Methods A review of adolescent idiopathic scoliosis patients seen for initial visit at a tertiary care pediatric hospital was conducted ( n  = 170). The index test was the pre-referral community spine x-ray interpreted by a community radiologist. Measures of diagnostic accuracy for the index test were determined against the reference standard if images were obtained within 90 days ( n  = 111). The reference standard was the 3-foot standing EOS spine x-ray evaluated by spine specialists. Diagnostic criterion for a brace candidate was dichotomized by Cobb angle range (25–40°) according to Scoliosis Research Society criteria. Risser stage was not included given significant missing data in index reports. To mitigate the uncertainty around true progression, sensitivity analyses were conducted on a sub-sample of data when index test was within 60 days of the reference standard ( n  = 67). Results Accuracy of the community spine x-ray to detect a brace candidate was 65.8% (95% CI 56.2–74.5). Sensitivity of the index test was 65.4% with a false negative rate of 34.6%. Specificity was 66.1% with a false positive rate of 33.9%. Positive and negative predictive values were 63.0% and 68.4%, respectively. Of the total number of brace candidates ( n  = 52), 32.7% were missed because of underestimation in Cobb angle (95% CI 21.5–46.2). The proportion of missed brace candidates because of underestimation was unchanged with 60-day data ( p  = 0.37). Conclusions Inaccuracies in community spine radiology may lead to missed opportunities for non-operative treatment.