Quality & Safety Resource Library

INTRAOPERATIVE EXECUTION

Intraoperative Checklists

• Vitale MG, Skaggs DL, Pace GI, et al. Best Practices in Intraoperative Neuromonitoring in Spine Deformity Surgery: Development of an Intraoperative Checklist to Optimize Response. Spine Deform. 2014;2(5):333-339. doi:10.1016/j.jspd.2014.05.003
  • Implementation of checklists has been associated with improved safety and management of operating room crises, neuromonitoring events, and significant decreases in rate of complication.
     

Team based approaches in the operating room

• Scheer JK, Sethi RK, Hey LA, et al. Results of the 2015 Scoliosis Research Society Survey on Single Versus Dual Attending Surgeon Approach for Adult Spinal Deformity Surgery. Spine (Phila Pa 1976). 2017;42(12):932-942.
  • A survey of surgeons demonstrate that most believe the involvement of 2 attending surgeons in the operating room for a spinal deformity surgery overall improve patient care and have better outcomes: however, few attending surgeons current do cases with another one present, usually due to reimbursement purposes.
     
• Mallory MA, Losk K, Camuso K, Caterson S, Nimbkar S, Golshan M. Does “Two is Better Than One” Apply to Surgeons? Comparing Single-Surgeon Versus Co-surgeon Bilateral Mastectomies. Ann Surg Oncol. 2016;23(4):1111-1116. doi:10.1245/s10434-015-4956
  • Several studies have demonstrated a dual attending approach to spine surgery improved outcomes, including operative time, blood loss, and length of stay, but there are some in contention with this.
     
• Ames CP, Barry JJ, Keshavarzi S, Dede O, Weber MH, Deviren V. Perioperative Outcomes and Complications of Pedicle Subtraction Osteotomy in Cases With Single Versus Two Attending Surgeons. Spine Deform. 2013;1(1):51-58. doi:10.1016/j.jspd.2012.10.004
  • Dual Surgeon approach when performing a pedicle subtraction osteotomy (PSO) has shown to be decrease operative time, blood loss, and overall complications.
     

Intraoperative Neuromonitoring

• Pelosi L, Lamb J, Grevitt M, Mehdian SMH, Webb JK, Blumhardt LD. Combined monitoring of motor and somatosensory evoked potentials in orthopaedic spinal surgery. Clin Neurophysiol. 2002;113(7):1082-1091. doi:10.1016/s1388-2457(02)00027-5
  • Combined SEPs and multi-pulse TES-MEPs is highly recommended because it provides a safe, reliable and sensitive method of monitoring spinal cord function in spine surgery and has been shown to be superior to single modality techniques.
     

Minimally Invasive versus Open Procedures

• Uribe JS, Deukmedjian AR, Mummaneni P V, et al. Complications in adult spinal deformity surgery: an analysis of minimally invasive, hybrid, and open surgical techniques. Neurosurg Focus. 2014;36(5):E15. doi:10.3171/2014.3.FOCUS13534
  • Minimally invasive approaches to the spine have been shown to have significantly reduced intraoperative blood loss, intraoperative complications, and improved functional scores when compared to open procedures.
  • If the goals of ASD surgery can be achieved, consideration should be given to less invasive techniques.
     

Pedicle Subtraction Osteotomy (PSO)

• Daubs MD, Brodke DS, Annis P, Lawrence BD. Perioperative Complications of Pedicle Subtraction Osteotomy. Glob spine J. 2016;6(7):630-635. doi:10.1055/s-0035-1570088
  • The overall rate of pseudarthrosis after a lumbar PSO spans 10-45%  
  • Optimizing patients to reduce the risk of pseudoarthrosis is highly suggested.
  • Other complications of PSO include: neurologic deficit, severe blood loss, infection, dural tears, and death.
     
• Baldus CR, Bridwell KH, Lenke LG, Okubadejo GO. Can we safely reduce blood loss during lumbar pedicle subtraction osteotomy procedures using tranexamic acid or aprotinin? A comparative study with controls. Spine (Phila Pa 1976). 2010;35(2):235-239. doi:10.1097/BRS.0b013e3181c86cb9
  • Use of antifibrinolytics such as tranexamic acid can reduce likelihood of developing severe blood loss during PSO.
     

Intraoperative Complications

• Rampersaud YR, Moro ERP, Neary MA, et al. Intraoperative adverse events and related postoperative complications in spine surgery: implications for enhancing patient safety founded on evidence-based protocols. Spine (Phila Pa 1976). 2006;31(13):1503-1510. doi:10.1097/01.brs.0000220652.39970.c2
  • Adverse events can frequently occur (14%) during spinal surgery, however, the majority (76.5%) are not associated with complications
     

Dural Tears

• Iyer S, Klineberg EO, Zebala LP, et al. Dural Tears in Adult Deformity Surgery: Incidence, Risk Factors, and Outcomes. Glob spine J. 2018;8(1):25-31. doi:10.1177/2192568217717973
  • Adult spinal deformity surgery has a 3-10% rate of dural tears in with decompressive techniques being the largest risk factor.
  • Patients who suffer an intraoperative durotomy are more likely to have a post-operative complication, but 6-week and 2-year functional health scores are similar to those that don’t suffer an incidental dural tear.
     

Hemorrhagic Blood Loss

• Yu X, Xiao H, Wang R, Huang Y. Prediction of massive blood loss in scoliosis surgery from preoperative variables. Spine (Phila Pa 1976). 2013;38(4):350-355. doi:10.1097/BRS.0b013e31826c63cb
  • Adult spinal deformity surgery is associated with severe intraoperative blood loss. Risk factors for massive blood loss include preoperative Cobb angle larger than 50º,  planned osteotomy, or fusion of more than 6 levels.
     
• Elgafy H, Bransford RJ, McGuire RA, Dettori JR, Fischer D. Blood loss in major spine surgery: are there effective measures to decrease massive hemorrhage in major spine fusion surgery? Spine (Phila Pa 1976). 2010;35(9 Suppl):S47-56.
  • Based on the current literature, there is little support for routine use of CS during elective spinal surgery.
  • With respect to the antifibrinolytics of the lysine analog class (tranexamic acid and aminocaproic acid), based on the available efficacy and safety data, we recommend that they be considered as possible agents to help reduce major hemorrhage in adult spine surgery. Concerns related to the use of aprotinin were such that we recommended against its use in spine surgery on the basis of the reports of increased complications. ^51,57

POST-OPERATIVE RECOVERY

Rapid Recovery Protocol

• Development of an Enhanced Recovery After Surgery (ERAS) approach for lumbar spinal fusion. J Neurosurg Spine. 2017;26(4):411-418. doi:10.3171/2016.9.SPINE16375
  • Development of a post-operative spine recovery protocol reduces postoperative recovery times, complications, and acute care cost
  • Protocol focuses on these major components: pre-operative education, multimodal pain management, surgical approach, blood loss, nutrition, and physiotherapy.
     

Pain control

• Turan A, Karamanlioğlu B, Memiş D, et al. Analgesic effects of gabapentin after spinal surgery. Anesthesiology. 2004;100(4):935-938. doi:10.1097/00000542-200404000-00025
   
• Nielsen R V, Siegel H, Fomsgaard JS, et al. Preoperative dexamethasone reduces acute but not sustained pain after lumbar disk surgery: a randomized, blinded, placebo-controlled trial. Pain. 2015;156(12):2538-2544. doi:10.1097/j.pain.0000000000000326
   
• Khurana G, Jindal P, Sharma JP, Bansal KK. Postoperative pain and long-term functional outcome after administration of gabapentin and pregabalin in patients undergoing spinal surgery. Spine (Phila Pa 1976). 2014;39(6):E363-8. doi:10.1097/BRS.0000000000000185
  • Surgery as a whole has recently been shifting away from opioid pain monument due to the risk of addiction, nausea, and other side effects.
  • Preoperative oral gabapentin, pregabalin, dexamethazone have been shown to decrease pain scores in the early postoperative period and reduce post-operative morphine consumption after spine surgery.
  • they have been shown to improve patient function within the 90 day post operative period
     
• De Oliveira GS, Castro-Alves LJ, McCarthy RJ. Single-dose systemic acetaminophen to prevent postoperative pain: a meta-analysis of randomized controlled trials. Clin J Pain. 2015;31(1):86-93. doi:10.1097/AJP.0000000000000081
  • Systemic acetaminophen, when used as a single-dose preventive regimen, is an effective intervention to reduce postoperative pain. It also reduces postoperative nausea and/or vomiting.
     
• Loftus RW, Yeager MP, Clark JA, et al. Intraoperative ketamine reduces perioperative opiate consumption in opiate-dependent patients with chronic back pain undergoing back surgery. Anesthesiology. 2010;113(3):639-646. doi:10.1097/ALN.0b013e3181e90914
  • Intraoperative ketamine has also been shown to reduce overall patient opioid consumption in the post-operative period.
     
• Mathiesen O, Dahl B, Thomsen BA, et al. A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery. Eur Spine J. 2013;22(9):2089-2096. doi:10.1007/s00586-013-2826-1
  • A comprehensive and standardized multimodal pain and post-operative nausea and vomiting protocol can reduced opioid consumption, improved postoperative mobilization, and present with concomitant low levels of nausea, sedation and dizziness
     

Post-operative Complications

• Glassman SD, Hamill CL, Bridwell KH, Schwab FJ, Dimar JR, Lowe TG. The impact of perioperative complications on clinical outcome in adult deformity surgery. Spine (Phila Pa 1976). 2007;32(24):2764-2770. doi:10.1097/BRS.0b013e31815a7644
  • Minor complications have a small effect on patient quality of life
  • Major complications, with a rate of 10%, have significant effects on a patients 1-year disposition.
     
• Howe CR, Agel J, Lee MJ, et al. The morbidity and mortality of fusions from the thoracic spine to the pelvis in the adult population. Spine (Phila Pa 1976). 2011;36(17):1397-1401. doi:10.1097/BRS.0b013e3181f453e2
  • Major Medical complications after long fusion from thoracic spine to pelvis have been shown to be associated with ASA and CCI and estimated blood loss, but not age.
     
• Lee MJ, Hacquebord J, Varshney A, et al. Risk factors for medical complication after lumbar spine surgery: a multivariate analysis of 767 patients. Spine (Phila Pa 1976). 2011;36(21):1801-1806. doi:10.1097/brs.0b013e318219d28d
  • The cumulative incidences of complication after lumbar spine surgery per organ system are as follows: cardiac - 13%, pulmonary – 7%, gastrointestinal – 6.7%, neurological – 8.2%, hematological – 17.5% and urologic complications – 10.3%.
  •  occurrence of cardiac or respiratory complication after lumbar spine surgery was significantly associated with death within 2 years (RR 6.09, 10.9 respectively).
  • Elevated surgical invasiveness is a significant risk factor for cardiac, pulmonary, neurological and hematological complication.
     
• Schwab FJ, Hawkinson N, Lafage V, et al. Risk factors for major peri-operative complications in adult spinal deformity surgery: a multi-center review of 953 consecutive patients. Eur Spine J. 2012;21(12):2603-2610. doi:10.1007/s00586-012-2370-4
  • The major peri-operative complication rate was 8.4 % for 953 surgically treated ASD patients.
  • Higher rates of complications were associated with staged and combined anterior-posterior surgeries.
     
• Sciubba DM, Yurter A, Smith JS, Kelly MP, et al. A Comprehensive Review of Complication Rates After Surgery for Adult Deformity: A Reference for Informed Consent. Spine Deform. 2015 Nov;3(6):575-594. doi: 10.1016/j.jspd.2015.04.005.
  • Review of the literature
  • Overall mean complication rate for adult spinal surgery was 55%
  • Major perioperative complications occurred at a mean rate of 18.5%
  • Minor perioperative complications occurred at a mean rate of 15.7%
  • Long-term complications occurred at a mean rate of 20.5%
     
• Tormenti MJ, Maserati MB, Bonfield CM, et al. Perioperative surgical complications of transforaminal lumbar interbody fusion: a single-center experience. J Neurosurg Spine2012;16:44–50. 11
  • Complications with TLIF occurred more often in patients undergoing revision surgery or multilevel interbody fusion
  • Durotomy and infections were the most common complications
     
• Street JT, Lenehan BJ, DiPaola CP, et al. Morbidity and mortality of major adult spinal surgery. A prospective cohort analysis of 942 consecutive patients. Spine J 2012;12:22–34. 12
  • The rate of intraoperative surgical complication was 10.5%
  • The incidence of postoperative complication was 73.5% (wound complications, 13.5%; delerium, 8%; pneumonia, 7%; neuropathic pain, 5%; dysphagia, 4.5%; and neurological deterioration, 3%).
     
• Sansur CA, Smith JS, Coe JD, et al. Scoliosis research society morbidity and mortality of adult scoliosis surgery. Spine (Phila Pa 1976) 2011;36:E593–7. 15
  • The overall complication rate for ASD treatment is 13.4%
  • Complication rate is significantly higher when osteotomies, revision procedures, and combined anterior/posterior approaches are used.
     
• Charosky S, Guigui P, Blamoutier A, et al. Complications and risk factors of primary adult scoliosis surgery: a multicenter study of 306 patients. Spine (Phila Pa 1976)2012;37:693–700. 16
  • Overall complication rate was 39% with a re-operative rate of 26% (mean follow-up 54-months)
  • Risk factors include number of instrumented vertebra, fusion to the sacrum, PSO, and preoperative pelvic tilt of 26° or more
  • There is a 44% risk of a new operation in the 6-year-period after the primary procedure.
     
• Cho SK, Bridwell KH, Lenke LG, et al. Major complications in revision adult deformity surgery: risk factors and clinical outcomes with 2-to 7-year follow-up. Spine (Phila Pa 1976) 2012;37:489–500. 17
  • Overall, 34.4% of patients experienced major complications after long revision fusion surgery.
  • Performance of a 3-column osteotomy and postoperative radiographic changes that suggested progressive loss of sagittal correction were recognized as risk factors for follow-up complications
• Zuckerman SL, Berven S, Streiff MB, Kerolus M, Buchanan IA, Ha A, Bonfield CM, Buchholz AL, Buchowski JM, Burch S, Devin CJ, Dimar JR, Gum JL, Good C, Kim HJ, Kim JS, Lombardi JM, Mandigo CE, Bydon M, Oppenlander ME, Polly Jr DW, Poulter G, Shah SA, Singh K, Than KD, Spyropoulos AC, Kaatz S, Jain A, Schutzer RW, Wang TZ, Mazique DC, Lenke LG, Lehman RA. Management of Anticoagulation/Antiplatelet Medication and Venous Thromboembolism Prophylaxis in Elective Spine Surgery: Concise Clinical Recommendations Based on a Modified Delphi Process. Spine (Phila Pa 1976). 2023 Mar 1;48(5):301-309. doi: 10.1097/BRS.0000000000004540. Epub 2022 Nov 14.
  • This study used a Delphi method involving 20 spine surgeons to achieve consensus regarding the peri-operative use of anticoagulation (AC) and antiplatelet (AP) and venous thromboembolism (VTE) prophylaxis.  In this study consensus was achieved on 26/27 items, with the objectives being 1) When should AC/AP medication be stopped before surgery; 2) When should AC/AP medication be restarted after surgery; 3) When, how, and in whom should VTE chemoprophylaxis be started after elective spinal surgery?

Neurologic Complications

• Lenke LG, Fehlings MG, Shaffrey CI, et al. Neurologic Outcomes of Complex Adult Spinal Deformity Surgery: Results of the Prospective, Multicenter Scoli-RISK-1 Study. Spine (Phila Pa 1976). 2016;41(3):204-212. doi:10.1097/BRS.0000000000001338
  • Complex ASD surgery can restore neurologic function in patients with a preoperative neurologic deficit.
  • There is yet a significant portion of patients with ASD experienced postoperative decline in lower extremity motor function.
  • Many of those who had a neurologic deficit were found to have significant improvement at 6 months
     
• Kim HJ, Iyer S, Zebala LP, Kelly MP, et al. Perioperative Neurologic Complications in Adult Spinal Deformity Surgery: Incidence and Risk Factors in 564 Patients. Spine (Phila Pa 1976). 2017 Mar 15;42(6):420-427. doi: 10.1097/BRS.0000000000001774
  • The overall incidence of neurologic complications in ASD surgery was 17.6%
  • Incidence of surgical neurologic complications was 13.7%
  • higher risk of neurologic complications in revision cases and in cases in which interbody fusion was required
     

Infection

• Simchen E, Stein H, Sacks TG, Shapiro M, Michel J. Multivariate analysis of determinants of postoperative wound infection in orthopaedic patients. J Hosp Infect. 1984;5(2):137-146. doi:10.1016/0195-6701(84)90117-8
  • Diabetes, prolonged operative times (>3 hours), body mass index more than 35, posterior approach, smoking, and number of intervertebral levels (≥7) are associated with an increased risk of SSI after spinal surgery.
     
• Anderson PA, Savage JW, Vaccaro AR, et al. Prevention of Surgical Site Infection in Spine Surgery. Neurosurgery. 2017;80(3S):S114-S123. doi:10.1093/neuros/nyw066
  • Screening for nasal carriage of methicillin-sensitive S. aureus (MSSA) and MRSA 5-days prior to surgery with subsequent eradication treatment has been shown to reduce rate of infection in several surgical procedures.
     

Mechanical failure and Pseudarthrosis

• Berjano P, Bassani R, Casero G, Sinigaglia A, Cecchinato R, Lamartina C. Failures and revisions in surgery for sagittal imbalance: analysis of factors influencing failure. Eur Spine J. 2013;22 Suppl 6:S853-8. doi:10.1007/s00586-013-3024-x
  • Etiology of Mechanical failure and pseudoarthrosis include insufficient correction, junctional kyphosis, screw loosening and pseudoarthrosis with rod breakage.
     
• Marques MF, Fiere V, Obeid I, et al. Pseudarthrosis in adult spine deformity surgery: risk factors and treatment options. Eur Spine J. 2021;30(11):3225-3232. doi:10.1007/s00586-021-06861-w
  • Risk factors for reoperation of pseudoarthrosis include age, long fusion constructs, osteotomies, and fusion to the sacrum.
  • Patients who are at high likelihood of developing pseudarthrosis following surgery should be closely monitored for their development to prevent catastrophic failure of the fusion construct.
     

Vision Loss

• Baig MN, Lubow M, Immesoete P, Bergese SD, Hamdy E-A, Mendel E. Vision loss after spine surgery: review of the literature and recommendations. Neurosurg Focus. 2007;23(5):E15. doi:10.3171/FOC-07/11/15
  • Estimates for the incidence of post-operative vision loss after spinal surgery between 0.028 and 0.2%.
  • The most common diagnosis in patients in whom perioperative visual deficits develop after spine surgery is Ischemic Optic Neuropathy.
  • Perioperative factors that have been implicated in the development of ischemic optic neuropathy include intraoperative hypotension, duration of surgery, intraoperative blood loss, use of replacement fluids, and anemia.
  • Post-operative flat positioning should be avoided except in cases of hypotension.

Neuromuscular ERAS

• Tøndevold N, Bari TJ, Andersen TB, Gehrchen M. The Collateral Effect of Enhanced Recovery After Surgery Protocols on Spine Patients With Neuromuscular Scoliosis. J Pediatr Orthop. 2023; 43(6): e476-e480.  
  • This study assessed the indirect impact of implementing ERAS protocols designed for adolescent idiopathic scoliosis (AIS) patients on those with neuromuscular scoliosis (NMS). While the ERAS protocol was specific to AIS patients, a 41% reduction in length of stay (LOS) was observed in neuromuscular scoliosis patients treated in the same ward, indicating a collateral benefit. The study involved 46 patients, 20 pre-ERAS and 26 post-ERAS, with no significant differences in postoperative care in the intensive care unit or 90 day readmission rates between the groups. The results suggest that the holistic training of caregiving staff can have a positive effect even on complex cases like NMS.
• Shaw KA, Harris H, Sachwani N, et al. 
  Avoiding PICU Admission Following PSF for Neuromuscular Scoliosis in Non-ambulatory Cerebral Palsy Managed with ERAS Protocol. 
  Spine Deform. 2023; 11: 671–676. 
  • This study aimed to identify predictors of PICU (Pediatric Intensive Care) admission for children with non-ambulatory cerebral palsy (GMFCS 4/5) undergoing posterior spinal fusion (PSF) for neuromuscular scoliosis (NMS) within the context of an ERAS protocol. The authors retrospectively reviewed 103 patients managed at two institutions. They found that 38.8% of patients required PICU admission, with pre-existing feeding tubes and surgery lasting more than 5 hours being independent predictors of PICU admission. The study concluded that the majority of these patients could be successfully managed on the hospital floor, highlighting the potential for cost reduction and improved recovery outcomes with ERAS implementation.
• Fletcher ND, Bellaire LL, Dilbone ES, Ward LA, Bruce RW Jr. 
  Variability in Length of Stay Following Neuromuscular Spinal Fusion. 
  Spine Deform. 2020 Aug; 8(4): 725-732.
  • This study evaluated 197 patients with neuromuscular scoliosis who underwent posterior spinal fusion (PSF) with a focus on factors influencing extended LOS. Early mobilization and rapid transition to enteral feeding were emphasized in the care pathway. Key predictors of prolonged hospitalization included severe cerebral palsy (GMFCS 4/5), major coronal Cobb angles, pelvic obliquity, and the need for postoperative ICU admission or blood transfusion. Radiographic and intraoperative predictors significantly influenced the variability in recovery.
• Nakamura N, Kawabe Y, Momose T, et al. 
  Adoption of an Enhanced Recovery After Surgery Protocol for Neuromuscular Scoliosis Shortens Length of Hospital Stay. 
  Spine Surg Relat Res. 2024; 8(4): 427-432. 
  • In this retrospective cohort study, 54 pediatric patients with neuromuscular scoliosis (NMS) were compared before and after the implementation of the ERAS protocol. ERAS led to a significant reduction in LOS, from 11.6 to 8.2 days. The study highlights the impact of ERAS in managing intraoperative factors such as blood loss and postoperative care, concluding that ERAS protocols are more influential than intraoperative variables in reducing recovery time. No significant differences were observed in complication rates between the two groups.
• Simpson BE, Kara S, Wilson A, et al. 
  Reducing Patient Length of Stay After Surgical Correction for Neuromuscular Scoliosis. 
  Hosp Pediatr. 2022; e2021006196. 
  • This study implemented a standardized postoperative clinical pathway for neuromuscular scoliosis (NMS) patients, aiming to reduce the length of stay (LOS) after surgery. Through quality improvement (QI) methodology, LOS was reduced from 8.0 to 5.3 days. The use of enhanced recovery after surgery (ERAS) protocols, including early mobilization and standardized pain management, was central to this reduction, demonstrating improved adherence to postoperative care protocols and decreased variability in recovery times. 

Adolescent Idiopathic Scoliosis (AIS) Enhanced Recovery After Surgery (ERAS)

• Ding H, Hai Y, Guan L, Liu Y, Pan A, Han B.
  The outcome of enhanced recovery after surgery vs. a traditional pathway in adolescent idiopathic scoliosis surgery: A retrospective comparative study.
  Front Surg. 2022 Oct 5; 9: 989119. doi: 10.3389/fsurg.2022.989119. eCollection 2022. PMID: 36277279
  • This is a retrospective study (n=90) from China comparing traditional versus enhanced recovery after surgery (ERAS) pathways in adolescent idiopathic scoliosis patients who underwent posterior spinal fusion.  The ERAS protocol was inclusive of 3 phases of care:  Preoperative preparation, intraoperative procedures, and postoperative care.  Their results showed no differences in demographic characteristics.  For surgical characteristics, EBL and length of surgery were less in the ERAS group.  Postoperative outcomes noted higher postoperative hemoglobin.  There were lower pain scores on POD 1 and 3 in the ERAS group.  There was lower analgesic duration as well as lower transfusion rates in the ERAS group.  Drain volume and duration was lower in the ERAS group.  The ERAS group was also earlier to mobilize.  Postoperative LOS was lower in the ERAS group (4.64 versus 6.22 days).  There were no differences in early postoperative complications. 
• Miegoń J, Zacha S, Skonieczna-Żydecka K, Wiczk-Bratkowska A, Andrzejewska A, Jarosz K, Deptuła-Jarosz M, Biernawska J. 
  Optimising Intraoperative Fluid Management in Patients Treated with Adolescent Idiopathic Scoliosis-A Novel Strategy for Improving Outcomes.
  Children (Basel). 2023 Aug 10;10(8):1371. doi: 10.3390/children10081371. PMID: 37628370 
  • This is a prospective, single center, non-randomized study of 70 adolescent idiopathic scoliosis patients who had posterior spinal fusion.  The purpose of the study was to evaluate patient outcome with protocolized intraoperative hemodynamic monitoring, goal-directed therapy, and components of an enhanced recovery after surgery (ERAS) pathway.  Goal-directed therapy (GDT) refers to hemodynamic treatment where fluids and inotropic agents are titrated based on physiologic flow related endpoints.  The control group did not have any specific anesthesia protocol, and this was left to the discretion of the individual anesthesiologist.  The intervention group had a standardized treatment algorithm to manage hemodynamics during surgery.  Results showed similar baseline data with only preoperative hemoglobin being higher in the control group.  The intervention group had statistically significant decreased hospital length of stay (7 versus 10 days), hypotension time, fresh frozen plasma transfusion rates, time to extubation, and change in hemoglobin/hematocrit levels after surgery.  There were 3 hemodynamic complications and 1 neurologic complication in the control group and none in the intervention group although this did not reach statistical significance.
• Tøndevold N, Dybdal B, Bari TJ, Andersen TB, Gehrchen M.
  Rapid Discharge Protocol Reduces Length of Stay and Eliminates Postoperative Nausea and Vomiting After Surgery for Adolescent Idiopathic Scoliosis.
  World Neurosurg. 2022 Feb;158: e566-e576. doi: 10.1016/j.wneu.2021.11.024. Epub 2021 Nov 11. PMID: 34775082
  • This prospective study from Denmark (n=154) assessed outcomes of an enhanced recovery after surgery protocol in patients with adolescent idiopathic scoliosis who underwent posterior spinal fusion. The goal of the study was to reduce length of hospital stay and post-operative morphine usage. Length of stay, daily morphine consumption, and gastrointestinal (GI) adverse events/side effects related to morphine were monitored and compared between groups.  Baseline characteristics were similar between groups.  The ERAS cohort had shorter time in post-operative recovery and lower rates of nausea and vomiting at all time points throughout the hospitalization. There were no differences in rehospitalization for GI issues.  Pain scores were higher in the first two days for the ERAS group but lower on POD 3 and 4.  Morphine consumption was significantly higher on POD 1 and 2.  Opioid induced pruritus was less frequent in the ERAS group and mobility milestones were met earlier with the ERAS group.  Length of stay was reduced 43% in ERAS group (3.6 versus 6.3 days).  In this study, the authors were not able to show decreased morphine consumption but were able to reduce LOS and side effects of morphine use with their ERAS protocol.
• Boylan MR, Riesgo AM, Chu A, Paulino CB, Feldman DS.
  Costs and complications of increased length of stay following adolescent idiopathic scoliosis surgery.
  J Pediatr Orthop B. 2019 Jan;28(1):27-31. doi: 10.1097/BPB.0000000000000543. PMID: 30256316
  • The authors analyzed the New York comprehensive data reporting system over a 5-year period (2007-2012) to determine the costs associated with longer hospital for patients with adolescent idiopathic scoliosis who had posterior spinal fusion.  They assessed length of stay (LOS) along with insurance charges, hospital costs, and 90-day complications associated with longer LOS.  There were 1286 patients who met the inclusion and exclusion criteria.  The average LOS was 4.9 days.  For 1 additional day in the hospital, insurance charges averaged $11,033 and hospital costs averaged $5198.  Longer hospitalization correlated with an increased risk of 90-day post-operative complications including readmission and return to surgery.  The authors could only identify the association between longer hospitalizations with these complications and not a causal relationship.  However, they showed that shorter hospitalization was not associated with increased complications and advocated for pursing accelerated discharge pathways to reduce hospital LOS.
• Chidambaran V, Subramanyam R, Ding L, Sadhasivam S, Geisler K, Stubbeman B, Sturm P, Jain V, Eckman MH.
  Cost-effectiveness of intravenous acetaminophen and ketorolac in adolescents undergoing idiopathic scoliosis surgery.
  Paediatr Anaesth. 2018 Mar;28(3):237-248. doi: 10.1111/pan.13329. Epub 2018 Jan 29. PMID: 29377376 
  • Prospective, non-randomized cohort study (n=106) comparing opioid use, side effects, and cost-effectiveness of adding IV acetaminophen with or without ketorolac in the post-operative management of adolescent scoliosis patients undergoing spine fusion surgery.  Patients received either opioid only (n=36), opioids + IV acetaminophen (n=26), or opioid + IV acetaminophen + IV ketorolac (n=44).  The addition of IV acetaminophen showed decreased opioid consumption.  With acetaminophen and ketorolac, there was less constipation and earlier tolerance of meals.  Opioids with IV acetaminophen and ketorolac was found to be the most cost effective of the three cohorts with IV acetaminophen alone having intermediate cost effectiveness. 
• Dass D, Dhawan R, Maybin J, Kiely NT, Davidson NT, Trivedi JM.
  Minimizing the need for high dependency unit support in adolescent idiopathic scoliosis surgery. Is enhanced recovery and the multidisciplinary team key?
  J Pediatr Orthop B. 2021 May 1;30(3):218-224. doi: 10.1097/BPB.0000000000000764. PMID: 32694433
  • This comparative study performed in the United Kingdom on patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis to determine whether outcomes of patients using an enhanced recovery pathway that includes bypassing care in a high dependency unit (HDU).  Patients in the non-HDU enhanced recovery pathway were prospectively enrolled (n=33) and compared against a historical control HDU group (n=22) with the same inclusion criteria.  Patients in the traditional HDU group were treated without any formally agreed upon clinical pathway.  Baseline characteristics were similar between cohorts.  There were no differences in post-operative complications. The non-HDU enhanced recovery group had lower length of hospital stay (7.4 versus 5.8 days).  There was also less variation in the length of stay in the non-HDU group.  The use of the non-HDU enhanced recovery pathway saved an average £2038.80 per case.
• DeVries Z, Barrowman N, Smit K, Mervitz D, Moroz P, Tice A, Jarvis JG.
  Is it feasible to implement a rapid recovery pathway for adolescent idiopathic scoliosis patients undergoing posterior spinal instrumentation and fusion in a single-payer universal health care system?
  Spine Deform. 2020 Dec;8(6):1223-1229. doi: 10.1007/s43390-020-00146-w. Epub 2020 Jun 2. PMID: 32488767
  • This is a retrospective study of 244 AIS patients undergoing posterior spinal fusion to compare postoperative outcomes between conventional (n=113) versus rapid recovery (n=131) pathways.  This was conducted at a single center in Canada where this is a single-payer universal health care system.  The premise of the study was to determine if rapid recovery pathways can be effective within this health care system.  Pre-operative and operative variables were similar between group with only differences being larger pre-operative curve magnitudes, better percent correction, and lower estimated blood loss in the rapid recovery pathway.  Results of the study showed a shorter length of stay in the rapid recovery pathway versus the convention pathway (5.2 versus 3.1 days).  There were no differences in early post-operative complications (first 20 days) between groups.  This includes return to the OR, readmission to hospital, or visit to the ED.
• Fletcher ND, Andras LM, Lazarus DE, Owen RJ, Geddes BJ, Cao J, Skaggs DL, Oswald TS, Bruce RW Jr.
  Use of a Novel Pathway for Early Discharge Was Associated With a 48% Shorter Length of Stay After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.
  J Pediatr Orthop. 2017 Mar;37(2):92-97. doi: 10.1097/BPO.0000000000000601. PMID: 26214327
  • This study is a retrospective comparison (n=150) between a hospital using an accelerated discharge pathway (n=105) to a similar hospital with a traditional post-operative protocol n=45) in patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis.  Length of hospital stay and post-operative complications within 180 days of surgery were assessed between groups.  Baseline characteristics between groups should larger curves, numbers of levels fused, implant density, and surgical times in the traditional pathway.  Length of stay was 48% shorter in the accelerated discharge cohort (2.17 versus 4.21 days).  There were no differences in readmission or post-operative wound complications between cohorts.  Authors concluded that the accelerated pathway can reduce length of stay without increasing wound complications or readmission to the hospital.
• Fletcher ND, Marks MC, Asghar JK, Hwang SW, Sponseller PD; Harms Study Group; Newton PO.
  Development of Consensus Based Best Practice Guidelines for Perioperative Management of Blood Loss in Patients Undergoing Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.
  Spine Deform. 2018 Jul-Aug;6(4):424-429.  doi: 10.1016/j.jspd.2018.01.001. PMID: 29886914
  • This study used expert opinion and the Delphi process to develop clinical practice guidelines for the perioperative blood loss management in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion.  Twenty-one pediatric or spinal deformity trained orthopedic surgeons who were deemed “expert” in management of AIS patients participated in this process.  Twenty-one of the 35 questions reached consensus.  Six questions did not reach consensus for inclusion in the guidelines. 
• Fletcher ND, Shourbaji N, Mitchell PM, Oswald TS, Devito DP, Bruce RW.
  Clinical and economic implications of early discharge following posterior spinal fusion for adolescent idiopathic scoliosis
  • This retrospective cohort study evaluated the impact of an accelerated discharge (AD) pathway on 279 patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis. The findings indicated that implementing such protocols led to faster mobilization and earlier discharge without compromising patient safety. Additionally, the quality of pain management improved, and there were significant reductions in hospital length of stay and associated costs.
• Gornitzky AL, Flynn JM, Muhly WT, Sankar WN.
  A Rapid Recovery Pathway for Adolescent Idiopathic Scoliosis That Improves Pain Control and Reduces Time to Inpatient Recovery After Posterior Spinal Fusion
  • This retrospective comparative cohort study introduced a rapid recovery pathway for 66 patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion. The pathway, developed by a multidisciplinary team, focused on enhanced pain control and early mobilization. Results demonstrated improved pain management and a significant reduction in inpatient recovery time, highlighting the benefits of standardized care protocols in surgical recovery.
• Lambrechts MJ, Boeyer ME, Tweedy NM, Gupta SK, Kimchi ET, Hoernschemeyer DG.
  Team Integrated Enhanced Recovery (TIGER) Protocol after Adolescent Idiopathic Scoliosis Correction Lowers Direct Cost and Length of Stay While Increasing Daily Contribution Margins
  • This retrospective cohort study evaluated the effectiveness of the Team Integrated Enhanced Recovery (TIGER) protocol in 66 adolescent idiopathic scoliosis patients undergoing posterior spinal fusion between 2015 and 2019. Implementing the TIGER protocol resulted in a 26% reduction in hospital length of stay and a 7.9% decrease in total hospital costs. Daily contribution margins increased by 7.9%, and daily net income rose by 10.6%, indicating improved financial efficiency alongside enhanced patient outcomes.
• Muhly WT, Sankar WN, Ryan K, Norton A, Maxwell LG, DiMaggio T, Farrell S, Hughes R, Gornitzky A, Keren R, McCloskey JJ, Flynn JM.
  Rapid Recovery Pathway After Spinal Fusion for Idiopathic Scoliosis
  • This quality improvement initiative assessed the implementation of a standardized rapid recovery pathway (RRP) for 322 patients aged 10 to 21 years undergoing posterior spinal fusion for adolescent idiopathic scoliosis. The RRP emphasized multimodal analgesia, early mobilization, and standardized postoperative care. Findings revealed that patients experienced improved pain control, earlier ambulation, and reduced average hospital length of stay from 5.7 days to 4 days, underscoring the efficacy of structured recovery protocols in surgical care.
• Matthew E Oetgen, Benjamin D Martin, Heather Gordish-Dressman, Jessica Cronin, Sophie R Pestieau
  Effectiveness and Sustainability of a Standardized Care Pathway with Use of Lean Process Mapping for the Treatment of Patients Undergoing Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis
  • This retrospective comparison study evaluated the impact of implementing a standardized care pathway, developed using Lean process mapping, for patients undergoing posterior spinal fusion to treat adolescent idiopathic scoliosis. The pathway aimed to reduce care variability, improve outcomes, and decrease costs. Forty-four patients managed before implementation (pre-pathway group) were
    compared to 169 patients managed after implementation (post-pathway group). Results demonstrated that patients in the post-pathway group sustained improvements in postoperative pain management,
    reduced opioid usage, decreased transfusion requirements, and shorter hospital stays over the years compared to the pre-pathway group, indicating the pathway’s effectiveness and sustainability.
• Raudenbush BL, Gurd DP, Goodwin RC, Kuivila TE, Ballock RT.
  Cost analysis of Adolescent Idiopathic Scoliosis surgery: early discharge decreases hospital costs much less than intraoperative variables under the control of the surgeon
  • This retrospective cost analysis and chart review study analyzed the factors influencing hospital costs for 80 patients undergoing adolescent idiopathic scoliosis surgery, focusing on early discharge and intraoperative variables. Findings revealed that while early discharge contributes to cost reduction, intraoperative factors under the surgeon’s control – such as operative time, blood loss, and implant selection – substantially impact hospital expenses. The study suggests that optimizing intraoperative practices may be more effective in reducing costs than solely focusing on early discharge protocols.
• Sanders AE, Andras LM, Sousa T, Kissinger C, Cucchiaro G, Skaggs DL
  Accelerated Discharge Protocol for Posterior Spinal Fusion Patients with Adolescent Idiopathic Scoliosis Decreases Hospital Postoperative Charges
  • This retrospective review study assessed the effects of an accelerated discharge protocol on hospital postoperative charges for patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis. There were 90 patients included in the accelerated pathway and 104 in the traditional path. The accelerated protocol emphasized early mobilization, multimodal pain management, and standardized
    postoperative care. Results indicated that implementing the accelerated discharge protocol significantly reduced hospital postoperative charges ($18,360 vs $23,640, p<0.0001), demonstrating the financial benefits of such protocols in surgical care.
• Shaw KA, Ange B, George V, Murphy JS, Fletcher ND
  Continued Increase in Cost of Care Decrease in Stay After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis
  • This study examined hospital costs and length of stay trends for patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis. Despite a decrease in hospital length of stay (pre-ERAS: 5.4 ±4 vs 4.3 ± 3.2 days) over the study period days, findings revealed a continued increase in the cost of care (pre-ERAS: $193,544.4 ± $108,116.1 vs $200,469.1 ± $110,112.6). The authors suggest that factors such
    rising implant costs, increased use of advanced technologies, and higher perioperative care expenses may contribute to the escalating costs, highlighting the need for strategies to control expenses without compromising patient outcomes.
• Sarah E. Temby, Greta M. Palmer, Sueann P. Penrose, Donna M. Peachey & Michael B. Johnson
  Implementation of an enhanced recovery pathway in Australia after posterior spinal fusion for adolescent idiopathic scoliosis delivers improved outcomes
  • The primary goal of this pre-post intervention study was to assess how postoperative enhanced recovery pathways affect length of stay, complication rates, and hospital costs. The study concluded that enhanced recovery pathways reduced length of stay and postoperative inpatient costs—a larger-scale audit needed to be produced for the impact on complications to be assessed.
• Amy L. McIntosh, MD, and Christopher McLeod, MD
  Accuracy of Non-Invasive Hemoglobin (nHgb) Monitoring in an AIS Population
  • The study's primary goal is to compare the accuracy and reliability of non-invasive and invasive hemoglobin monitoring in an adolescent idiopathic scoliosis
    population. They wanted to develop a noninvasive hemoglobin threshold to examine when a patient no longer required blood to be drawn to minimize anxiety, resource utilization, and pain. The study concluded that there was a positive correlation between noninvasive and invasive Hgb monitoring in pediatric AIS patients undergoing posterior spinal fusion/instrumentation.
• Amy L. McIntosh, MD and Christopher McLeod, MD
  Local Infiltration Anesthesia with Liposomal Bupivacaine Decreases Postoperative Narcotic Consumption in AIS
  • The goal of the initiative was to enhance standardized postoperative care for Adolescent Idiopathic Scoliosis patients undergoing posterior spinal fusion by minimizing narcotic usage and allowing for earlier mobilization using liposomal bupivacaine. The initiative concluded that liposomal bupivacaine is associated with less narcotic consumption and earlier ambulation.
• Julien PICO, Chrystelle SOLA, Anne Charlotte SAOUR, Kevin CHAPRON, Lucie CORUBLE, Sophie BRINGUIER, Christophe DADURE
  Enhanced recovery after surgery (ERAS) for adolescent idiopathic scoliosis: Standardisation of Care Improves Patient Outcomes
  • The main objective of this study was to evaluate the impact of implementing an ERAS program for AIS on length of stay (LOS) and postoperative recovery. The study concluded that implementing the ERAS program resulted in faster mobilization and earlier discharge. The quality of pain management also appeared to improve.
• David E. Lebel, Masayoshi Machida, Robert Kouchek, Fiona Campbell, Natasha Bath, Martin Koyle, Danielle Ruskin, David Levin, Sarah Brennenstuhl, Jennifer Stinson
  Utilization of individual components of enhanced recovery after surgery (ERAS) protocol improves postoperative outcomes in adolescent idiopathic scoliosis: a blueprint for progressive adoption of ERAS
  • A retrospective comparative review of patients treated with PSF for AIS at the same institution during the same time with different degrees of adherence to the ERAS protocols compared to non-ERAS patients (81 patients). The study's primary objective was to determine if there were differences in LOS according to protocol type. In the ERAS group (59 patients), 12 received two elements, 13 received three, and 34 received four. 
    A modified ERAS intervention for AIS patients results in significantly shorter LOS after surgery, reduced pain, and lower opioid consumption. The use of intrathecal morphine, NSAIDs, early removal of a urinary catheter, and early ambulation, when combined, contributed to shorter LOS. Implementation of ERAS principles and better adherence to the suggested protocol might promote further change in the LOS, pain control, and opioid
    consumption.
• Lindsey L. Locke, Leslie N. Rhodes, Benjamin W. Sheffer
  Accelerated Protocols in Adolescent Idiopathic Scoliosis Surgery
  • This article reviews preoperative, intraoperative, and postoperative pain control with an accelerated protocol in patients with AIS undergoing PSF. Each phase was developed with a multidisciplinary team, including pediatric orthopedic surgeons, advanced practice providers, pharmacists, physical therapists, and physician analysts. Pain control and patient outcomes can be improved without increasing the risk of postoperative complications following an accelerated protocol.
• Akshay D. Gadiya, Jonathan E. J. Koch, Mohammed Shakil Patel, Masood Shafafy, Michael P. Grevitt, Nasir A. Quraishi
  Enhanced recovery after surgery (ERAS) in adolescent idiopathic scoliosis (AIS): a meta‑analysis and systematic review
  • This is a systematic review and meta-analysis evaluating studies implementing ERAS protocols for the length of stay, complication rates, and readmission rates in patients undergoing posterior corrective surgery for AIS. Ten studies met the inclusion criteria (9 were Level III and 1 of Level IV evidence) and were analyzed. Overall, 1040 patients underwent an ERAS-type protocol compared to 959 traditional protocol patients.
    ERAS protocols significantly reduced the length of stay without increasing the complications or readmission rates compared to conventional protocols. However, current literature on ERAS in AIS is restricted mainly to retrospective studies with non-randomized data and initial cohort studies lacking formal control groups.
• Yu-Jie Yang, Xin Huang, Xiao-Ning Gao, Bing Xia, Jian-Bo Gao, Chen Wang, Xiao-Ling Zhu, Xiao-Juan Shi, Hui-Ren Tao, Zhuo-Jing Luo, Jing-Hui Huang
  An Optimized Enhanced Recovery After Surgery (ERAS) Pathway Improved Patient Care in Adolescent Idiopathic Scoliosis Surgery: A Retrospective Cohort Study
  • The study explored the potential benefits of a comprehensive ERAS pathway optimized for patients with AIS who underwent posterior spinal fusion (PSF) without 3-column osteotomy. The study population consisted of 79 patients with AIS who underwent PSF without 3-column osteotomy, with 35 patients in the ERAS group and 44 patients in the traditional group. The ERAS protocol included 17 preoperative, intraoperative, and postoperative components. The ERAS pathway improves the perioperative status of patients with AIS, by offering more potent analgesia, faster ambulation, and earlier discharge.
• Florence Julien-Marsollier, Daphné Michelet, Rita Assaker, Antoine Doval, Simon Louisy, Chrystèle Madre, Anne-Laure Simon, Brice Ilharreborde, Christopher Brasher, Souhayl Dahmani
  Enhanced recovery after surgical correction of adolescent idiopathic scoliosis
  • A retrospective, observational, monocentric study. 81 ERAS group patients and 82 controls were recruited. The main goal of the present study was to evaluate the effect of an ERAS protocol on the hospital length of stay after adolescent idiopathic scoliosis (AIS) surgery. 81 ERAS group patients and 82 controls were recruited. The implementation of a specific ERAS program for surgical management of AIS resulted in reduced hospital length of stay, along with reductions in opioid use and constipation.
• K. Aaron Shaw, Nicholas D. Fletcher, Dennis P. Devito, Michael L. Schmitz, Jorge Fabregas, Simran Gidwani, Pankaj Chhatbar, Joshua S. Murphy
  In‑hospital opioid usage following posterior spinal fusion for adolescent idiopathic scoliosis: Does methadone offer an advantage when used with an ERAS pathway?
  • This study retrospectively compared 26 consecutive AIS patients undergoing PSF and ERAS protocol who received intraoperative single-dose methadone to 52 matched patients who did not receive it.  This study found that the use of a single, intra-operative dose of methadone during PSF for AIS did not influence the total usage of opioid medication following PACU discharge when used in conjunction with an ERAS protocol. 
• Nicholas D. Fletcher, Joshua S. Murphy, Thomas M. Austin, Robert W. Bruce Jr., Hilary Harris, Patricia Bush, Austin Yu, Hirofumi Kusumoto, Michael L. Schmitz, Dennis P. Devito, Jorge A. Fabregas, Firoz Miyanji
  Short term outcomes of an enhanced recovery after surgery (ERAS) pathway versus a traditional discharge pathway after posterior spinal fusion for adolescent idiopathic scoliosis
  • This study compared outcomes in the immediate post-operative period between an ERAS pathway and a more traditional discharge (TD) pathway. Patients (203 ERAS group, 73 TD group) with a PSF for AIS were included between the ages of 10 and 21.
    They concluded that patients managed with an enhanced recovery pathway that combines multimodal pain management, rapid mobilization, and early discharge showed no difference in pain scores at discharge or overall recovery at first follow-up. Patients and parents rapidly returned to normal activities after surgery, including school and work, regardless of the pathway used.
• Robert Koucheki, Martin Koyle, George M. Ibrahim, Jeremie Nallet, David E. Lebel
  Comparison of interventions and outcomes of enhanced recovery after surgery: a systematic review and meta‑analysis of 2456 adolescent idiopathic scoliosis cases
  • This “Medline” and “Embase” systematic review and meta-analysis aimed to compare ERAS and ERAS-like protocols' clinical and patient-reported outcomes to TD pathways. Comparative studies assessing ERAS protocols with TD pathways for the surgical management of AIS patients were included. 14 articles met the inclusion criteria and were included.
    Studies implementing ERAS or ERAS-like strategies led to shorter hospital stays, reduced pain scores, decreased opioid use, and decreased healthcare costs without any increase in postoperative complications. Better documentation of pain scores, opioid utilization, time to removal of urinary catheters, and ambulation is recommended for future comparison and a deeper understanding of the cause-effect relationship.
• Kristen Spisak, Matthew D. Thomas, Zachary J. Sirois, Alvin Jones, Lucinda Brown, Andrew W. Froehle, Michael Albert
  Novel Enhanced Recovery After Surgery Pathway Reduces Length of Stay and Postoperative Opioid Usage in Adolescent Idiopathic Scoliosis Patients Undergoing Posterior Spinal Fusion
  • The goal of this study was to compare a recently implemented ERAS protocol to previous post-operative management for AIS patients undergoing PSF, specifically assessing length of stay, opioid consumption, and pain scores. The study examined 22 patients in the TPP (Traditional Pain Pathway) cohort and 20 in the ERAS cohort. The ERAS pathway significantly reduced LOS and opioid consumption in AIS patients undergoing PSF in the hospital care setting.
• Hongtao Ding, Yong Hai, Li Guan, Yuzeng Liu, Aixing Pan and Bo Han
  The outcome of enhanced recovery after surgery vs. a traditional pathway in adolescent idiopathic scoliosis surgery: A retrospective comparative study
  • The study compares the ERAS pathway outcomes and the traditional AIS postoperative care method. 90 AIS patients who underwent PSF without three-column osteotomies were reviewed, with 45 in the ERAS group and 45 in the traditional group. Implementing a standard ERAS protocol in AIS correction surgery could result in less EBL, lower pain intensity, early ambulation, shorter LOS, and rapid rehabilitation. 

INTRAOPERATIVE

Neurologic Injury Prevention

• Halsey M, Myung K, Ghag A, Vitale M, Newton P, de Kleuver M. Neurophysiological monitoring of spinal cord function during spinal deformity surgery: 2020 SRS neuromonitoring information statement. Spine Deformity.2020; 8:591-596.
  • The Scoliosis Research Society developed an updated information statement on intraoperative neurophysiological monitoring of spinal cord function during spinal deformity surgery, expressing the opinion that its utilization in spinal deformity surgery is the standard of care when the spinal cord is at risk.
     
• Iyer R, Vitale M, Fano A, Matsumoto H, Sucato D, Samdani A, Smith J, Gupta M, Kelly M, Kim H, Sciubba D, Cho S, Polly D, Boachie-Adjel O, Angevine P, Lewis S, Lenke L. Establishing consensus: determinants of high-risk and preventative strategies for neurological events in complex spinal deformity surgery. Spine Deformity. 2022; 10:733-744.
  • A resource highlighting several clinical factors found in complex, high-risk spinal deformity patients as well as strategies to prevent neurological events was created through expert consensus.
     
• Lenke L, Fano A, Iyer R, Matsumoto H, Sucato D, Samdani A, Smith J, Gupta M, Kelly M, Kim H, Sciubba D, Cho S, Polly D, Boachie-Adjei O, Lewis S, Angevine P, Vitale M. Development of consensus-based best practice guidelines for response to intraoperative neuromonitoring events in high-risk spinal deformity surgery. Spine Deformity. 2022; 10:745-761.
  • The authors provide consensus guidelines to help organize and direct surgical teams in exploring common diagnostic patterns of intraoperative neuromonitoring events and to serve as a source of potentially useful avenues for investigation and intervention.
     
• Strike S, Hassanzadeh H, Jain A, Kebaish K, Njoku D, Becker D, Ain M, Sponseller P. Intraoperative Neuromonitoring in Pediatric and Adult Spine Deformity Surgery. Clin Spine Surg. 2017; 30:E1174-E1181.
  • This review of intraoperative neuromonitoring modalities provides a framework from which spine surgeons can select appropriate monitoring for their patients
     
• Vitale MG, Skaggs DL, Pace GI, et al. Best practices in intraoperative neuromonitoring in spine deformity surgery: development of an intraoperative checklist to optimize response. Spine Deformity. 2014; 2(5):333-339.
  • The authors developed a checklist which includes the most important items to consider when responding to intraoperative neuromonitoring (IONM) changes in patients with a stable spine. 
     
• Bjerke B, Zuchelli D, Nemani V, Emerson R, Kim H, Boachie-adjei O. Prognosis of significant intraoperative neurophysiologic monitoring events in severe spinal deformity surgery. Spine Deformity. 2017; 5:117-123.
  • In this study of 88 patients with severe deformities, intraoperative signal changes were most frequently from traction or positioning. The incidence of postoperative neurologic deficit is very low when the inciting cause is reversed; however, osteotomy-related events are irreversible, with a high incidence of associated lasting neurologic injury.
     
• Dikmen P, Halsey M, Yucekul A, de Kleuver M, Hey L, Newton P, Havlucu I, Zulemyan T, Yilgor C, Alanay A. Intraoperative neuromonitoring practice patterns in spinal deformity surgery: a global survey of the Scoliosis Research Society. Spine Deformity. 2021; 9:315-325.
  • The responses of 205 experienced SRS members from different regions of the world showed that surgeons had different approaches in their routine IONM practices and in the handling of alerts, highlighting the need for consensus guidelines.
     
• Sielatycki J, Cerpa M, Baum G, Pham M, Thuet E, Lehman R, Lenke L. A novel MRI-based classification of spinal cord shape and CSF presence at the curve apex to assess risk of intraoperative neuromonitoring data loss with thoracic spinal deformity correction. Spine Deformity. 2020; 8:655-661.
  • The authors present a new spinal cord risk classification scheme to identify patients with increased odds of losing spinal cord monitoring data during thoracic deformity correction. The odds of losing intraoperative MEPs/SSEPs are greater in type 3 spinal cords, where the cord is deformed against the concave pedicle in the axial plane.
     

Perioperative Blood Management

• Bible JE, Mirza M, Knaub MA. Blood-loss Management in Spine Surgery. J Am Acad Orthop Surg. 2018;26(2):35–44. PMID: 29303921                   
  • Advocate antifibrinolytic agents and anesthesia techniques over cell saver.
     
• Dong Y, Tang N, Wang S, Zhang J, Zhao H. Risk factors for blood transfusion in adolescent patients with scoliosis undergoing scoliosis surgery: a study of 722 cases in a single center. BMC Musculoskeletal disorders 2021; 22:131-8.  PMID:  33402158.                                               
  • Diagnosis, osteotomies, number of segments fused, intra-operative blood loss were risk factors for allogenic blood transfusion.
     
• Fletcher ND, Marks MC, Asghar JK, Hwang SW, Sponseller PD; Harms Study Group, Newton PO. Development of Consensus Based Best Practice Guidelines for Perioperative Management of Blood Loss in Patients Undergoing Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis. Spine Deform. 2018 Jul-Aug;6(4):424-429. doi: 10.1016/j.jspd.2018.01.001.PMID: 29886914
   
• Goobie SM, Zurakowski D, Glotzbecker MP, McCann ME, Hedequist D, Brustowicz RM, Sethna NF, Karlin LI, Emans JB, Hresko MT. Tranexamic acid is efficacious at decreasing the rate of blood loss in adolescent scoliosis surgery: a randomized placebo-controlled trial. J Bone Joint Surg Am. 2018; 100(23):2024 –32. https://doi.org/10.2106/JBJS.18.00314. PMID: 30516625
  • 50 mg/kg loading dose and 10 mg/kg/h infusion.  For AIS risk for clinically relevant blood loss of 20ml/kg was more than 2x higher in the placebo group compared to the TXA group and the TXA group had 27% less blood loss than the placebo group.  Duration of surgery, TXA, and number of levels fused were the main determinants of requiring a allogenic transfusion.
     
• Liang J, Shen J, Chua S, Fan Y, Zhai J, Feng B, Cai S, Li Z, Xue X. Does intraoperative cell salvage system effectively decrease the need for allogeneic transfusions in scoliotic patients undergoing posterior spinal fusion? A prospective randomized study. Eur Spine J 2015 Feb;24(2):270-5.  PMID: 24682378                                                                                      
  • Cell saver use significantly reduces the need for allogeneic blood in spine deformity surgery, particularly in patients with low preoperative hemoglobin or longer operation time. This study confirms the utility of routine cell saver use during PSF with segmental spinal instrumentation for scoliosis patients
     
• Mange TR, Sucato DJ, Poppino KF, Jo CH, Ramo BR. The incidence and risk factors for perioperative allogeneic blood transfusion in primary idiopathic scoliosis surgery. Spine Deform. 2020. Case Series Published 09 March 2020.   PMID: 32152964                                                                                   
  • Knowing risk factors for allogeneic blood transfusion can help the surgeon avoid transfusion.
     
• McVey MJ, Lau W, Nariaine N, Zaarour C, Zeller R. Perioperative blood conservation strategies for pediatric scoliosis surgery. Spine Deformity 2021 Sep:9(5):1289-1302.  PMID: 33900586        
  • Recommends interdisciplinary communication and multimodal blood conservation techniques.  This is an up-to-date review of many of the modalities available for effective PBC.  Autologous donation is no longer encouraged. Eventually evidence based individualized PBC interventions will become available.
     
• Mihas A, Ramchandran S, Rivera S, Mansour A, Asghar J, Shufflebarger H, George S. Safe and effective performance of pediatric spinal deformity surgery in patients unwilling to accept blood transfusion: a clinical study and review of the literature. BMC Musculoskeletal Disord 2021 Feb 19;22(1):204 PMID: 33607982           
  • Protocols developed for patients such as Jehovah witness can be applied to all patients to assure much less risk of needing an allogenic blood transfusion.  Technique included potentially staging a procedure, hypotensive (< 75 mm Hg) anesthesia, intraoperative blood salvage, tranexamic acid (50 mg/kg load, 5 mg/kg/hr), skin injection with 1% lidocaine and 1:100,000 epinephrine, bipolar tissue searler, topical TXA, surgifoam, bone scalpel.
     
• Oetgen, ME, Litenta J. Perioperative blood management in pediatric spine surgery. J Am Acad Orthop Surg 2017 July;25(7):480-488  PMID: 28644187
   
• Stone N, Sardana V, Missiuna P. Indications and outcomes of cell saver in adolescent scoliosis correction surgery: a systematic review. Spine (Phila Pa 1976). 2017;42(6):E363–70. PMID: 27398896. https://doi.org/10.1097/BRS.0000000000001780   
  • Cell saver reduces the demand for allogenic transfusion.  This review supports the use of cell saver if the associated monetary costs are expected to be less than the cost of transfusing one unit of allogenic blood.
     
• Verma K, Errico T, Diefenbach C, Hoelscher C, Peters A, Dryer J, Huncke T, Boenigk K, Lonner BS. The relative efficacy of antibibrinolytics in adolescent idiopathic scoliosis. A prospective randomized trial. J Bone Joint Surg Am 2014;96:e80 (1-10).                                                             
  • Double blind, placebo controlled.  Small study.  TXA loading dose was 10 mg/kg and maintained at 1 mg/kg/hr.  Tranexamic acid and epsilon-aminocaproic acid reduced operative blood loss but not transfusion rate. Tranexamic acid is more effective at reducing postoperative drainage and total blood losses compared with epsilonaminocaproic acid. Maintenance of the mean arterial pressure at < 75 m Hg during surgical exposure appears to be critical for maximizing antibibrinolytic benefit. 
     

Infection Prevention

• Michael G Vitale, Matthew D Riedel, Michael P Glotzbecker, Hiroko Matsumoto, David P Roye, Behrooz A Akbarnia, Richard C E Anderson, Douglas L Brockmeyer, John B Emans, Mark Erickson, John M Flynn, Lawrence G Lenke, Stephen J Lewis, Scott J Luhmann, Lisa M McLeod, Peter O Newton, Ann-Christine Nyquist, B Stephens Richards 3rd, Suken A Shah, David L Skaggs, John T Smith, Paul D Sponseller, Daniel J Sucato, Reinhard D Zeller, Lisa Saiman. Building consensus: development of a Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high-risk pediatric spine surgery. J Pediatr Orthop. 2013 Jul-Aug;33(5):471-8. doi: 10.1097/BPO.0b013e3182840de2.
  • A 14-statement consensus reached through a Delphi method regarding best practices for prevention of SSI in high-risk pediatric patients. It addresses pre-op, intraop and post-operative practices.
     
• Michael P Glotzbecker, Tricia A St Hilaire, Jeff B Pawelek, George H Thompson, Michael G Vitale, Children’s Spine Study Group; Growing Spine Study Group. Best Practice Guidelines for Surgical Site Infection Prevention With Surgical Treatment of Early Onset Scoliosis. J Pediatr Orthop. 2019 Sep;39(8):e602-e607. doi: 10.1097/BPO.0000000000001079.
  • A 22-statement consensus reached through a Delphi method regarding best practices for prevention of SSI in EOS. It addresses pre-op, intraop and post-operative practices.
     
• Matsumoto H, Campbell M, Minkara A, Roye DP, Garg S, Johnston C, Samdani A, Smith J, Sponseller P, Sturm PF, Vitale M; Children’s Spine Study Group; Growing Spine Study Group. Paper #45: Development of a Risk Severity Score (RSS) Predicting Surgical Site Infection in Early Onset Scoliosis: Identifying High-Risk Patients. Spine Deform. 2017 Nov;5(6):464-465. Spine Deform. 2017 Nov;5(6):464-465. doi: 10.1016/j.jspd.2017.09.048.PMID: 31997165
  • Retrospective study assessing Risk Severity score that allows to predict SSI risk in patients with EOS. The presence of myelomeningocele, GI, endocrine, and pulmonary comorbidities, developmental delay, urinary incontinence, and ventriculoperitoneal shunt increase the risk of infection to 68.4% while the absence of these comorbidities lowers the risk to 3.3%.
     
• Luhmann SJ, Smith JC. Preoperative MRSA Screening in Pediatric Spine Surgery: A Helpful Tool or a Waste of Time and Money? Spine Deform. 2016 Jul;4(4):272-276. doi: 10.1016/j.jspd.2015.12.006. Epub 2016 Jun 16.
  • In 6.5% of the cases, the use of nasal swab as a method for screening the presence of MRSA changed the preoperative antibyotic regime due to the presnece of resistance (4.7% MRSA and 1.8% MSSA).
     
• Mistovich RJ, Jacobs LJ, Campbell RM, Spiegel DA, Flynn JM, Baldwin KD. Infection Control in Pediatric Spinal Deformity Surgery: A Systematic and Critical Analysis Review. KD. JBJS Rev. 2017 May;5(5):e3. doi: 10.2106/JBJS.RVW.16.00071.
  • Systematic review on the risk of SSI in pediatric population: There is insufficient evidence to recommend either topical gentamycin or vancomycin, the use of irrigation (and other surgical preparation solutions), a specific type of dressing (including incisional vacuum and the participation of two attendings. There is grade B recommendation for any type of closure methods, in favor of titanium (instead of stainless steel), against the use of drains, the increased risk with the use of pelvic fixation (no difference with S2A1 screws), intraop hypothermia does not increase the risk of SSI and that length of surgery doesn’t impact SSI rates. There is grade C recommendation in favor of the use of iv atb, mixed evidence regarding allografts, mixed reviews regarding obesity, incontinence and malnutrition as modifiable factors.
     

Navigation and Enabling Technology

• Safety in Spine Surgery site
  https://safetyinspinesurgery.com/surgical-navigation-in-2017-why-and-how-i-do-it/
  https://safetyinspinesurgery.com/2nd-annual-safety-in-spine-surgery-month-videos/
  (21 April 2022)
  Program: PDF available
   
• Baky FJ, Milbrandt T, Echternacht S, et al. Intraoperative computed tomography-guided navigation for pediatric spine patients reduced return to operating room for screw malposition compared with freehand/fluoroscopic techniques. Spine Deform 2019; 7: 577-81.
  • Single center retrospective review of patients younger than 18 undergoing pedicle screw instrumentation were included. 112 patients had screws inserted using fluoroscopic guidance, whereas, 105 had screws inserted using intraoperative CT-guided navigation. Blood loss and number of levels fused were similar. There was a higher rate of screw malposition by >4mm in the fluoroscopic group (3.3% vs. 1%), higher rate of unplanned return to OR for screw malposition in the fluoroscopic group (3.6% vs. 0%). Use of intraop CT navigation eliminated unplanned return to OR for screw malposition
     
• Baldwin KD, Kadiyala M, Talwar D, et al. Does intraoperative CT navigation increase the accuracy of pedicle screw placement in pediatric spinal deformity surgery? A systematic review and meta-analysis. Spine Deform 2022; 10: 19-29.
  • Systematic review of 13 articles comparing pedicle screws placed with freehand or 2D fluoroscopy assistance with screws placed using CT navigation. EBL was similar between groups but operative time was longer by about 30 minutes in the Navigation group. Intraop navigation resulted in more accurate screws and less unsafe screws. Effective radiation dose trended higher in navigated cases compared to non-navigated cases but did not reach statistical significance.
     
• Chan A, Parent E, Narvacan K, et al. Intraoperative image guidance compared with free-hand methods in adolescent idiopathic scoliosis posterior spinal fusion surgery: a systematic review on screw-related complications and breach rates. Spine J 2017; 17: 1215-29.
  • Systematic review of 79 studies. CT guidance has lower breach rates than free-hand methods. Screw related complications were 0% in CT guidance and up to 1.7% in free-hand.
     
• Chan A, Parent E, Wong J, et al. Does image guidance decrease pedicle screw-related complications in surgical treatment of adolescent idiopathic scoliosis: a systematic review update and meta-analysis. Eur Spine J 2020; 29: 694-71
  • Systematic review of 94 studies. Image/CT guidance had lower breach rate than free hand but with a surgical time longer by about 30 minutes.
     
• Kaur J, Koltsov JCB, Kwong JW, et al. Does navigation make spinal fusion for adolescent idiopathic scoliosis safer? Insights from a national database. Spine 2021;46: E1049-57.
  • Retrospective review of 12,046 patients from a national database undergoing spinal fusion for AIS. 90 day complication rate was lower with navigation. Nav did not have an impact on neurologic complications or return to OR. Nav was associated with increased total reimbursement and a 0.32-day decrease in length of stay
     
• Kudo H, Wada K, Kumagai G, et al. Accuracy of pedicle screw placement by fluoroscopy, a three-dimensional printed model, local electrical conductivity measurement device, and intra-operative computed tomography navigation in scoliosis patients. Eur J Orthop Surg Traumatolo 2021; 31: 563-9.
  • Retrospective, single center study that analyzed 553 pedicle screws in 31 patients. No significant difference in clinical results with different techniques except for longer operative time with Navigation. Accuracy of screw placement ranged from 91.3% to 93.7%
     
• Moore HG, Samuel AM, Burroughs PJ, et al. Use of intraoperative navigation for posterior spinal fusion in adolescent idiopathic scoliosis surgfery is safe to consider. Spine Deform 2021; 9: 403-10.
  • Retrospective review of 12,739 non-navigated and 340 navigated patients from NSQIP-Pediatric database. Use of navigation increased from 0.5% of cases in 2012 to 5.2% of cases in 2018. No difference in demographics, comorbidities, and number of levels fused. Navigated cases were longer by about 41 minutes but had a 0.4-day decrease in length of stay. Perioperative adverse outcomes were not significantly different between groups
     
• Tian W, Zeng C, An Y, et al. Accuracy and postoperative assessment of pedicle screw placement during scoliosis surgery with computer-assisted navigation: a meta-analysis. Int J Med Robot 2017; 13. Doi:10.1002/rcs.1732.
  • Meta-analysis. Pedicle screw accuracy was higher with navigation but operative time and curve correction was not different from non navigated cases.
     
• Urbanski W, Jurasz W, Wolanczyk M, et al. Increased radiation but no benefits in pedicle screw accuracy with navigation versus a freehand technique in scoliosis surgery. Clin Orthop Relat Res 2018; 476: 1020-7.
  • Retrospective review of 49 patients undergoing posterior spinal fusion with all pedicle screw constructs for idiopathic scoliosis. 27 patients with navigation and 22 patients with freehand screw placement. Pedicle breach assessed on intraop O-Arm scan. There was no difference in screw accuracy, while navigated patients received a greater mean radiation dose.
     
• Wong HK. CORR Insights^®: Increased radiation but no benefits in pedicle screw accuracy with navigation versus a freehand technique in scoliosis surgery. Clin Orthop Relat Res 2018; 476: 1028-30.
  • This article is a commentary on the previous article.

POSTOPERATIVE

Optimizing Length of Stay in Adolescent Idiopathic Scoliosis Surgery

• Fletcher ND, Glotzbecker MP, Marks M, Newton PO,Harms Study Group. Development of Consensus-Based Best Practice Guidelines for Postoperative Care Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.  Spine (Phila Pa 1976). 2017 May 1;42(9): E547-E554. doi: 10.1097/BRS.0000000000001865.PMID: 28441684 
  • An expert panel of 26 pediatric spine surgeons opined upon a detailed literature review and consensus was sought using the Delphi process. Consensus (agreement > 80%) was reached to support 19 best practice guideline (BPG) measures for postoperative care supporting non-ICU admission, perioperative pain control (supporting PCA pump, gabapentin, antispasmodics and ketorolac use; limiting epidural, early transition to oral narcotics), dietary management (supporting early clear liquids, chewing gum, bowel regimen and antiemetics), physical therapy (sitting, standing and twice daily PT POD#1), limiting postoperative radiographs, and indications for discharge (pain tolerated with oral analgesic, tolerating regular diet, bowel movement unnecessary, meeting PT goals).
     
• Fletcher ND, Murphy JS, Austin TM, Bruce RW Jr, Harris H, Bush P, Yu A, Kusumoto H, Schmitz ML, Devito DP, Fabregas JA, Miyanji F. Short term outcomes of an enhanced recovery after surgery (ERAS) pathway versus a traditional discharge pathway after posterior spinal fusion for adolescent idiopathic scoliosis.  Spine Deform. 2021 Jul; 9(4): 1013-1019. doi: 10.1007/s43390-020-00282-3. Epub 2021 Jan 18.PMID: 33460022
  • 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. LOS was 55% less in the ERAS group (4.8 days TD vs. 2.2 days ERAS, p < 0.001). 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 and parents' return to work between the groups.
     
• Muhly WT, Sankar WN, Ryan K, Norton A, Maxwell LG, DiMaggio T, Farrell S, Hughes R, Gornitzky A, Keren R, McCloskey JJ, Flynn JM. Rapid Recovery Pathway After Spinal Fusion for Idiopathic Scoliosis. Pediatrics. 2016 Apr; 137(4): e20151568. doi: 10.1542/peds.2015-1568. Epub 2016 Mar 23. PMID: 27009035
  • A quality improvement initiative was undertaken to assess a standardized rapid recovery pathway (RRP). Functional recovery was assessed using LOS and average daily pain scores. Process measures were medication adherence and order set utilization, balancing measure was 30-day readmission rate. Baseline average LOS was 5.7 days and decreased to 4 days after RRP implementation. Average daily pain scores remained stable with improvement on postoperative day 0 (3.8 vs 4.9 days) and 1 (3.8 vs 5 days) after RRP implementation. Gabapentin (91%) and ketorolac (95%) use became routine and order set utilization was 100%. Readmission rates did not increase as a result of the RRP.
     
• Yang J, Skaggs DL, Chan P, Villamor GA, Choi PD, Tolo VT, Kissinger C, Lehman A, Andras LM. High Satisfaction in Adolescent Idiopathic Scoliosis Patients on Enhanced Discharge Pathway. J Pediatr Orthop. 2020 Mar;40(3): E166-170. doi: 10.1097/BPO.0000000000001436.PMID: 31403990
  • 46 prospectively enrolled patients were evaluated with a survey at their first postoperative clinic visit for satisfaction with an enhanced discharge pathway for PSF and whether they felt that their length of stay was appropriate. 80% of patients felt that they were discharged at an appropriate time (mean, 3.2 d) and had a trend toward shorter stays, whereas 20% felt they were discharged too early (mean, 3.7 d). Overall patient satisfaction of hospital stay was high with a mean of 9 on a 10-point scale (range, 1 to 10). There was no correlation between length of stay and patient satisfaction.
     

Optimizing Length of Stay in Neuromuscular Scoliosis Surgery

• Bellaire L., Bruce Jr R., Ward L., Bowman C., Fletcher N. Use of an Accelerated Discharge Pathway in Patients With Severe Cerebral Palsy Undergoing Posterior Spinal Fusion for Neuromuscular Scoliosis. Spine Deform. 2019 Sep; 7(5): 804-811. doi: 10.1016/j.jspd.2019.02.002. PMID: 31495482 
  • 74 patients with GMFCS class 4/5 CP undergoing PSF were reviewed. Thirty consecutive patients were cared for using a traditional discharge (TD) pathway, and 44 patients were subsequently treated using an accelerated discharge (AD) pathway. LOS was 19% shorter in patients managed with the AD pathway (AD 4.0 days vs. TD 4.9 days). There was no difference between groups with respect to age at surgery, GMFCS class, preoperative curve magnitude, pelvic obliquity, kyphosis, postoperative curve correction, fusion to the pelvis, or length of fusion between groups. LOS remained significantly shorter in the AD group by 0.9 days when controlling for EBL and length of surgery. There was no significant difference in wound complications, return to the operating room, or medical readmissions between groups.
     
• Fletcher ND, Bellaire LL, Dilbone ES, Ward LA, Bruce RW Jr. Variability in length of stay following neuromuscular spinal fusion. Spine Deform. 2020 Aug; 8(4): 725-732. doi: 10.1007/s43390-020-00081-w. Epub 2020 Feb 14.PMID: 32060807
  • 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. Severely involved cerebral palsy (CP) patients (GMFCS 4/5) were more likely to have extended stays than GMFCS 1-3 patients. Radiographic predictors included major coronal Cobb angle and pelvic obliquity. Intraoperative predictors included longer surgical times, greater numbers of levels fused and need for intraoperative or postoperative blood transfusion. The need for ICU admission and development of a pulmonary complication were significantly more likely to extend hospital stay.
     
• Shaw KA, Heboyan V, Fletcher ND, Murphy JS. Comparative cost-utility analysis of postoperative discharge pathways following posterior spinal fusion for scoliosis in non-ambulatory cerebral palsy patients. Spine Deform. 2021 Nov; 9(6): 1659-1667. doi: 10.1007/s43390-021-00362-y. Epub 2021 May 18.PMID: 34008146
  • An economic decision-analysis model was constructed using a hypothetical 15-year-old male with non-ambulatory CP undergoing PSF. Literature was reviewed to estimate costs, probabilities, and QALYs (age-matched US values, with a CP diagnosis corrective value applied) for identified complication profiles for discharge pathways, and probabilistic sensitivity analysis was performed. Accelerated discharge (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 traditional discharge (TD). AD resulted in a 2.1% greater net monetary benefit with a cost-effectiveness ratio of $4361/QALY compared with $5290/QALY in the TD.
     
• Simpson BE, Kara S, Wilson A, Wolf D, Bailey K, MacBriar J, Mayes T, Russell J, Chundi P, Sturm P. Reducing Patient Length of Stay After Surgical Correction for Neuromuscular Scoliosis. Hosp Pediatr. 2022 Feb 17: e2021006196. doi: 10.1542/hpeds.2021-006196. Online ahead of print.PMID: 35174385
  • Quality improvement methodology was used to implement a standardized clinical care pathway for NMS patients during their primary spinal surgery. The outcome measure was LOS, and the process measure was percentage compliance with the pathway. Mean LOS decreased from 8.0 to 5.3 days; a statistically significant change based on statistical process control chart rules. Percentage compliance with the NMS pathway improved during the testing and sustain phases, compared with the pretesting phase. LOS variability decreased from pretesting to the combined testing and sustain phases.
     

Narcotic/pain management

• Grant DR, Schoenleber SJ, McCarthy AM, Neiss GI, Yorgova PK, Rogers KJ, Gabos PG, Shah SA. Are We Prescribing Our Patients Too Much Pain Medication? Best Predictors of Narcotic Usage After Spinal Surgery for Scoliosis. J Bone Joint Surg Am. 2016 Sep 21; 98(18): 1555-62. doi: 10.2106/JBJS.16.00101.PMID: 27655983
  • The authors asked patients prior to undergoing surgery for AIS to rate their pain level, level of pain expected each week postop, and their pain tolerance.  Post-discharge pain and narcotic usage was assessed and quantitated.  Pain scores returned to their preop baselines by the 4^th postop week.  Older age, male sex, higher BMI, and higher preop pain scores were associated with increased narcotic usage.
     
• Harris AB, Puvanesarajah V, Marrache M, Gottlich CP, Raad M, Skolasky RL, Njoku DB, Sponseller PD, Jain A. Opioid prescribing practices after posterior spinal arthrodesis for adolescent idiopathic scoliosis. Spine Deform. 2020 Oct; 8(5): 965-973. doi: 10.1007/s43390-020-00127-z. Epub 2020 May 6.PMID: 32378042
  • The authors used a commercial prescription drug claims database to identify opioid and muscle relaxer prescribing practices from 2010-2016 in patients who underwent PSF for AIS.  They found an overall decrease in opioid prescribing over time and significant geographic variability in prescribing practices.
     
• Li Y, Swallow J, Robbins C, Caird MS, Leis A, Hong RA. Gabapentin and intrathecal morphine combination therapy results in decreased oral narcotic use and more consistent pain scores after posterior spinal fusion for adolescent idiopathic scoliosis. J Orthop Surg Res. 2021 Nov 15; 16(1): 672. doi: 10.1186/s13018-021-02525-z.PMID: 34781972 
  • This study assessed whether peri-operative gabapentin + intrathecal morphine (ITM) provided more effective pain control than intrathecal morphine alone after posterior spinal fusion for AIS. The group that received gabapentin + ITM had less oral opioid use, more consistent post-op pain scores, and less nausea/vomiting and pruritis.
     
• Lindgren AM, Bennett R, Yaszay B, Newton PO, Upasani VV. Quality improvement in post-operative opioid and benzodiazepine regimen in adolescent patients after posterior spinal fusion. Spine Deform. 2020 Jun; 8(3): 441-445. doi: 10.1007/s43390-019-00002-6. Epub 2020 Jan 8.
  • The authors used pain diaries to document daily narcotic, benzodiazepine, NSAID, Tylenol, and gabapentin use following PSF for AIS or Scheuermann’s kyphosis.  They studied two cohorts, one sent home with their usual post-operative prescription dosages and amounts, and another prescribed markedly less tablets of oxycodone and diazepam.  They found that patients used far less opioids when prescribed less of the medication, with equivalent satisfaction with post-operative pain control.
     
• Ricciardelli RM, Walters NM, Pomerantz M, Metcalfe B, Afroze F, Ehlers M, Leduc L, Feustel P, Silverman E, Carl A. The efficacy of ketamine for postoperative pain control in adolescent patients undergoing spinal fusion surgery for idiopathic scoliosis. Spine Deform. 2020 Jun; 8(3): 433-440. doi: 10.1007/s43390-020-00073-w. Epub 2020 Feb 27.PMID: 32109313 
  • In this prospective double blinded placebo controlled RCT in patients undergoing spinal fusion for AIS, the authors showed that the addition of ketamine to a standard morphine equivalent pain regimen resulted in a significant reduction in opioid consumption, adjusted postop pain scores, and in nausea and vomiting.
     
• Shaw KA, Fletcher ND, Devito DP, Schmitz ML, Fabregas J, Gidwani S, Chhatbar P, Murphy JS. In-hospital opioid usage following posterior spinal fusion for adolescent idiopathic scoliosis: Does methadone offer an advantage when used with an ERAS pathway?  Spine Deform. 2021 Jul; 9(4): 1021-1027. doi: 10.1007/s43390-021-00288-5. Epub 2021 Mar 18.PMID: 33738766
  • This was a retrospective cohort study examining whether a single intra-operative dose of methadone affected post-operative opioid usage following PSF for AIS.  The authors found no decrease in in-hospital opioid usage when methadone was used with an ERAS protocol.
     
• Postoperative Dexamethasone Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis. Fletcher ND, Ruska T, Austin TM, Guisse NF, Murphy JS, Bruce RW Jr. J Bone Joint Surg Am. 2020 Oct 21;102(20):1807-1813. doi: 10.2106/JBJS.20.00259.PMID: 33086348
  • This study assessed whether post-operative steroids decreased opioid usage in patients undergoing posterior correction for AIS.  They found a 40% decrease in the use of opioids in the group that received steroids with no increase in the rate of wound complications.
     
• Adjunctive Pain Control Methods Lower Narcotic Use and Pain Scores for Patients With Adolescent Idiopathic Scoliosis Undergoing Posterior Spinal Fusion. Wade Shrader M, Nabar SJ, Jones JS, Falk M, Cotugno R, White GR, Segal LS. Spine Deform. 2015 Jan;3(1):82-87. doi: 10.1016/j.jspd.2014.06.002. Epub 2014 Dec 18.PMID: 27927456
  • This was a retrospective review of the effect of adjunctive pain modalities (local bupivacaine, ketorolac, dexmedetomidine) in addition to IV and oral opioids on post-op pain control.  It showed that a local bupivacaine pump improved post-op pain control with lower pain scores, lower opioid requirement, and a shorter length of stay.
     
• Zero Patient-controlled Analgesia is an Achievable Target for Postoperative Rapid Recovery Management of Adolescent Idiopathic Scoliosis Patients. Sarwahi V, Hasan S, Liao B, Galina J, Atlas A, Lo Y, Lee A, Lentz J, Amaral T, Kars M. Spine (Phila Pa 1976). 2021 Nov 1;46(21):1448-1454. doi: 10.1097/BRS.0000000000004062.PMID: 34618705
  • This study assessed a rapid recovery protocol utilizing a single bolus microdose of intrathecal morphine compared to historical controls using opioids via PCA.  They found that the intrathecal morphine group had shorter length of stay, earlier ambulation, lower VAS pain scores, and earlier bowel movements.

MAXIMIZING OUTCOMES IN PEDIATRIC SPINE SURGERY

Adding-on Phenomenon in Scoliosis Surgery

• Cho RH, Yaszay B, Bartley CE, Bastrom TP, Newton PO. Which Lenke 1A curves are at the greatest risk for adding-on... and why? Spine (Phila Pa 1976). 2012 Jul 15;37(16):1384-90. doi: 10.1097/BRS.0b013e31824bac7a.
  • 195 patients with Lenke 1A curves. Patients were grouped on the basis of the direction of the L4 verebral body tilt: 1A-L (left) and 1A-R (right).21% of patients met criteria for adding on. n the 1A-R curves, patients who added-on were fused at an average of 1.6 levels proximal to the neut ral vertebra for the patients who did not add-on
     
• Fujii T, Daimon K, Fujita N, et al. Risk factors for postoperative distal adding-on in Lenke type 1B and 1C and its influence on residual lumbar curve. J Pediatr Orthop 2020; 40: E77-83.
  • This review of 46 patients with selective thoracic fusion examines lumbar curve behavior following adding on, specifically Lenke 1B and 1C patients. When comparing the 11 (24%) adding on patients to those without, there was better spontaneous correction of apical translataion of the lumbar curve, and a more horizontalized L4.
     
• Fujii T, Kawabata S, Suzuki S, et al. Can postoperative distal adding-on be predicted in Lenke type 1B and 1C curves with intra-operative radiographs? Spine 2022; 47: E215-21.
  • This review explores risk factors for adding on in 69 AIS patients with either a Lenke 1B or 1C curve who underwent selective thoracic fusion and received intraoperative radiographs. In addition to selection of LIV as cranial to LTV being a risk factor, the authors identified that intraoperative wedging of the disc immediately below the LIV of greater than 3 degrees was a risk factor for adding on.
     
• Liu CW, Lenke LG, Tan LA, et al. Selection of the lowest instrumented vertebra and relative odds ratio of distal adding-on for Lenke type 1A and 2A curves in adolescent idiopathic scoliosis: a systematic review and meta-analysis. Neurospine 2020; 17: 902-9.  Review Article
  • In a systematic review, the authors reported on 6 studies involving 732 patients treated with selective thoracic fusions. They identified five radiographic landmarks for LIV selection, as well as the pooled risk for adding on when LIV selection is cranial to that level: Stable Vertebra-1, End Vertebra+1, Neutral Vertebra, Touched Vertebra, and Substantially Touched Vertebra. They identified selection of the substantially touched vertebra as the absolute lowest risk of adding on. They also reported that LIV selection caudal to the 5 landmarks, did not reduce the risk of adding on.
     
• Yang M, Zhao Y, Yin X, et al. Prevalence, risk factors, and characteristics of the ‘adding-on’ phenomenon in idiopathic scoliosis after correction surgery: a systematic review and meta-analysis. Spine 2018; 43: 780-90.
  • This systematic review identified 35 studies which were included in a meta-analysis examining the adding-on phenomenon. The overall prevalence of adding on was 14%, with slight variance between Lenke 1A (15%), 2 (12%), 5 (9%) and mixed curves (16%). Risk factors for adding on included smaller proximal thoracic and main thoracic curves, as well as smaller radiographic shoulder difference, and T1 tilt. Younger chronologic age and lower skeletal maturity were also identified as risk factors for adding on.
     

Distal Junctional Kyphosis

• Marciano G, Ball J, Matsumoto H, Roye B, Lenke L, Newton P, Vitale M; Harms Study Group. Including the stable sagittal vertebra in the fusion for adolescent idiopathic scoliosis reduces the risk of distal junctional kyphosis in Lenke 1-3 B and C curves. Spine Deform. 2021 May;9(3):733-741. doi: 10.1007/s43390-020-00259-2. Epub 2021 Jan 5. PMID: 33400234.
  • Large cohort of 856 patients: Patients fused short of the SSV (stable sagittal vertebra) are at significant risk for the development of DJK at 2 years post-operatively. However, patients with shorter fusions were more likely to have an improvement in their pain as measured by patient-reported outcomes than patients with longer fusions.
     
• Segal DN, Ball J, Fletcher ND, Yoon E, Bastrom T, Vitale MG; Harms Study Group. Risk factors for the development of DJK in AIS patients undergoing posterior spinal instrumentation and fusion. Spine Deform. 2022 Mar;10(2):377-385. doi: 10.1007/s43390-021-00413-4. Epub 2021 Sep 16. PMID: 34529249.
  • 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. 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.
     
• Segal DN, Orland KJ, Yoon E, Bastrom T, Fletcher ND; Harms Study Group. Fusions ending above the sagittal stable vertebrae in adolescent idiopathic scoliosis: does it matter? Spine Deform. 2020 Oct;8(5):983-989. doi: 10.1007/s43390-020-00118-0. Epub 2020 May 13. PMID: 32405718.
  • Retrospective cohort study with 5 year follow up. 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.
     
• Wang PY, Chen CW, Lee YF, Hu MH, Wang TM, Lai PL, Yang SH. Distal Junctional Kyphosis after Posterior Spinal Fusion in Lenke 1 and 2 Adolescent Idiopathic Scoliosis-Exploring Detailed Features of the Sagittal Stable Vertebra Concept. Global Spine J. 2021 Jun 7:21925682211019692. doi: 10.1177/21925682211019692. Epub ahead of print. PMID: 34096362.
  • Retrospective cohort study with minimum 2 year follow up, 122 patients. The primary outcome measure was the occurrence of postoperative DJK. When the SSV is intended to be spared from PSF to save more motion segments, TK and TLK should be carefully evaluated and attained in a lesser magnitude (TK < 25°, TLK < 10°) after surgery.
     

Proximal Junctional Kyphosis

• Alzakri A, Vergari C, Van den Abbeele M, Gille O, Skalli W, Obeid I. Global Sagittal Alignment and Proximal Junctional Kyphosis in Adolescent Idiopathic Scoliosis. Spine Deform. 2019 Mar;7(2):236-244. doi: 10.1016/j.jspd.2018.06.014. PMID: 30660217.
  • Case control study 85 patients.  Evaluation of global sagittal alignment including the cranial center of mass (CCOM) and proximal junctional kyphosis (PJK) in adolescent idiopathic scoliosis (AIS) patients treated with posterior instrumentation.13% incidence of PJK- thought to be a compensatory mechanism, which allows for CCOM-HA( cranial center of mass  ) and, to a lesser extent, OD-HA ( dentiform apophysis of C2)to be invariant.
     
• Erkilinc M, Baldwin KD, Pasha S, Mistovich RJ. Proximal junctional kyphosis in pediatric spinal deformity surgery: a systematic review and critical analysis. Spine Deform. 2022 Mar;10(2):257-266. doi: 10.1007/s43390-021-00429-w. Epub 2021 Oct 27. PMID: 34704232.
  • 635 papers:
  • There were 4 findings found to contribute to PJK with Grade B evidence in EOS: higher number of distractions, disruption of posterior elements, greater sagittal plane correction.  
  • Five findings with Grade B evidence were found to contribute to PJK in AIS populations: higher pre-operative thoracic kyphosis, higher pre-operative lumbar lordosis, longer fusion constructs, greater sagittal plane correction, and posterior versus anterior fusion constructs.  
     
• Ferrero E, Bocahut N, Lefevre Y, Roussouly P, Pesenti S, Lakhal W, Odent T, Morin C, Clement JL, Compagnon R, de Gauzy JS, Jouve JL, Mazda K, Abelin-Genevois K, Ilharreborde B; Groupe d’Etude sur la Scoliose (GES). Proximal junctional kyphosis in thoracic adolescent idiopathic scoliosis: risk factors and compensatory mechanisms in a multicenter national cohort. Eur Spine J. 2018 Sep;27(9):2241-2250. doi: 10.1007/s00586-018-5640-y. Epub 2018 Jun 29. PMID: 29959554.
  • Cohort of 365 AIS patients – 2 year f/u: Conclusion PJK is a frequent complication in thoracic AIS, occurring 16%, but remains often asymptomatic (less than 3% of revisions in the entire cohort). An interesting finding is that patients with high pelvic incidence and consequently large LL and TK were more at risk of PJK.
     
• Lonner BS, Ren Y, Newton PO, Shah SA, Samdani AF, Shufflebarger HL, Asghar J, Sponseller P, Betz RR, Yaszay B. Risk Factors of Proximal Junctional Kyphosis in Adolescent Idiopathic Scoliosis-The Pelvis and Other Considerations. Spine Deform. 2017 May;5(3):181-188. doi: 10.1016/j.jspd.2016.10.003. PMID: 28449961.
  • Muticenter study, 851 AIS patients:to assess the incidence of PJK. The incidence of PJK in patients after surgery for AIS is 7.05% and varies based on Lenke type. Loss of kyphosis, larger preoperative kyphosis, UIV caudal to the proximal UEV (Lenke 1), UIV at or cephalad to the UEV (Lenke 5), and decreased RCA were the major risk factors for PJK in AIS.
     
• Zhong J, Cao K, Wang B, Li H, Zhou X, Xu X, Lin N, Liu Q, Lu H. Incidence and Risk Factors for Proximal Junctional Kyphosis in Adolescent Idiopathic Scoliosis After Correction Surgery: A Meta-Analysis. World Neurosurg. 2019 May; 125: e326-e335. doi: 10.1016/j.wneu.2019.01.072. Epub 2019 Jan 26. PMID: 30690145.
  • Meta- Analysis, 7 studies : The incidence of PJK in patients with AIS was 14%. Proximal implants with screws and instrumentation types with all screws were significantly associated with increased occurrence of PJK. Larger preoperative TK, larger preoperative LL, larger postoperative LL, greater TK change, and greater LL change were also identified as risk factors for PJK in AIS after correction surgery.

Vertebral Body Tethering

• Alasadi H, Rajjoub R, Alasadi Y, Wilczek A, Lonner BS. Vertebral body tethering for adolescent idiopathic scoliosis: a review. Spine Deform. 2024 May;12(3):561-575. doi: 10.1007/s43390-023-00806-7. Epub 2024 Jan 29. PMID: 38285164.
  • This article provides a review of the literature reporting the radiographic and clinical outcomes as well as complications, and learning curve associated with the use of Vertebral Body Tethering (VBT) in patients with Adolescent Idiopathic Scoliosis (AIS). VBT was considered a success if there was no subsequent need for a fusion and if the cobb angles were less than 30-35 degrees at skeletal maturity. Reported complications included pulmonary complications, tether breakage, and high rates of reoperations. The impact of patient maturity in achieving successful results is also reviewed.