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SRS: Scoliosis Research Society

Scoliosis Research Society

Dedicated to the optimal care of patients with spinal deformity

2016-17 Award Host Sites

University of Arkansas - Department of Orthopaedics and Neurosurgery: Richard E. McCarthy, MD

Site Location:
1 Children's Way
Slot 839
Little Rock, Arkansas 72202 USA

Phone: 501-364-1421 and 501-526-7219

Hospital Universitario La Paz: Francisco Sanchez Perez-Grueso, MD

Site Location:
Paseo Castellana 233
Madrid, Spain

Contact: perezgrueso@gmail.com

Site Description:
Spine deformity. Both adult and paediatric. Research available with local research coordinator and statistician support. 4 staff members two of them SRS members (Active and Candidate) Paediatric and adult clinics 3 times a week. 3 days in OR.

Preferred Fellowship:

• GOP
• Luque

The University of Hong Kong: Kenneth M.C. Cheung, MD

Site Location:
5/F, Professional Block, Department of Orthopaedics and Traumatology
Queen Mary Hospital, Pokfulam, Hong Kong
Hong Kong

Contact: Jason Cheung cheung@hku.hk or by phone 852-22554341

Site Description:
The team includes 7 spine specialists, 2 residents and 1 training fellow. Both adult and pediatric spine conditions are managed in this tertiary referral center. These conditions range from early onset and adolescent idiopathic scoliosis; degenerative scoliosis; both cervical and lumbar degenerative disorders; TB spine; and tumor surgery. A typical week includes 4 days of surgery, 4 clinic sessions and 2 grand rounds.

Preferred Fellowship:

• Luque
• GOP
• Winter (with followup)
• OrthoPediatrics
• Medtronic Research

Research Opportunities for Medtronic Research Fellow:
• Early onset scoliosis specifically use of the magnetically controlled growing rods.
• Adolescent idiopathic scoliosis: epidemiology, outcome assessments based on fulcrum-bending radiographs and alternate level screw fixation, 3D assessments of flexibility, in brace and postoperative radiographs.
• Growth assessments: maturity parameters and assessment of child growth
• Genetics of scoliosis
Email: cheungjp@hku.hk; cheungmc@hku.hk with proposals

Cairo University: Youssry Elhawary, MD and Hossam Salah, MD, FRCS

Site Location:
Manial
Cairo, Egypt

Contact: yhawary@hotmail.com

Site Description:
We have a load of different pathologies than US and Europe. TB, severe rigid deformities, post traumatic deformities and early onset scoliosis.

Preferred Fellowship:

• Luque
• GOP
• OrthoPediatrics
• Medtronic Research

Research Opportunities for Medtronic Research Fellow:
• Severe rigid scoliosis
• Early onset scoliosis
• Spinal infections
Email: yhawary@hotmail.com with proposals

Hospital Universitario Y Politecnico La Fe: Teresa Bas, MD, PhD

Site Location:
Avda Fernando Abril Martorell 106
Valencia, Spain 46026

Contact: teresabas@gmail.com or by phone 961244000

Site Description:
• The hospital takes care in spinal pathology in adults and children: traumatic, tumor and deformity (early-onset congenital deformities, neuromuscular diseases and other pathologies).
• We have relationship with the Medical University of Valencia: Our research is based on epigenetic factors in scoliosis.
• We have a research foundation in scientific activity and service statistics. We have a training unit for training in animals.
• In the Spine Unit  we are four members, two residents and sometimes one fellow from other parts of Spain
• In one week we have 4 days of operating theater and one outpatient Clinic . We alternate the days of research work.

Preferred Fellowship:

• Luque
• GOP
• OrthoPediatrics

New Orleans Children's Hospital/Louisiana State University Health Science Center: Andrew G. King, MB, ChB, FRACS, FACS.

Site Location:
New Orleans Children's Hospital
200 Henry Clay Avenue
New Orleans, Louisiana, 70118 USA

Contact: aking@lsuhsc.edu or by phone 504-896-9569

Site Description:
• The large majority of pediatric spinal deformity cases from Louisiana and the southern gulf region are carried out at New orleans Childrens Hospital. • The large majority of pediatric spinal deformity cases from Louisiana and the southern gulf region are carried out at New orleans Childrens Hospital.
• Over 300 cases /year with three busy surgeons, 6 residents and a fellow from 5 teaching institutions.
• Senior surgeons caseload and clinics confined to pediatric deformity.
• Hospital has a spinal unit, and a spinal nurse coordinator all cases reviewed and discussed at a monthly spine conference open to visiting surgeons
• A large early onset population, with Mehta casting, MAGEC, VEPTR, and spine based growth rods.
• Active research including evaluating Surgimap and UNID patient specific rods, reduction and fixation of high grade spondylolisthesis, craniocervical fixation, neuromuscular scoliosis.
• Basic science research through the LSU consortium for musculoskeletal research.
 

Preferred Fellowship:

• Dawson
• Luque
• GOP
• Winter (with followup)
• OrthoPediatrics
• Medtronic Research

Research Opportunities for Medtronic Research Fellow:
Patient specific rods derived from preoperative mapping of the sagittal plane radiographs will result in improved postoperative sagittal contours and in turn, improved measurable patient outcomes.
Reduction and fixation of high grade spondylolisthesis by anterior and posterior fusion and instrumentation at L5/S1 alone, sparing L4/5, and with no posterior decompression
Email: aking@lsuhsc.edu with proposals

SpineUnit at Rigshospitalet & University of Copenhagen: Benny T. Dahl, MD, PhD, DMSci

Site Location:
9 Blegdamsvej
Copenhagen, Osterbro 2900 Denmark

Contact: bennydahl@gmail.com or by phone 4540465555

Site Description:
At the SpineUnit at Rigshospitalet, approximately 700 complex spinal procedures are performed every year. The department is a tertiary referral unit for the Capital Region of Denmark, serving 1.5 million people. Ten full time spine surgeons, eight orthopaedic and two neurosurgeons, cover all areas of modern spine surgery, both adult and pediatric. Having the only full time professor in spine surgery the department publishes 10 to 15 scientific papers yearly, and have two full time ph.d.-fellows. The professor of spine surgery is an active SRS-member and has hosted the IMAST meeting. He is the chair-elect of the SRS Worldwide Conferences. The typical week's activities consists of three days in the operation room, one day in clinic and one day doing research. 

Preferred Fellowship:

• Luque
• GOP
• Winter
• OrthoPediatrics
• Medtronic Research

Research Opportunities for Medtronic Research Fellow:
1. Radiographic risk factors in the development of adult spinal deformities.
2. Risk stratification in surgical treatment of adult spinal deformities.
Email: bennydahl@gmail.com with proposals

Spine Unit Bordeaux University Hospital: Ibrahim Obeid, MD and Jean-Marc Vital, MD, PhD

Site Location:
Spine Unit1 Pellegrin Hospital
Place Amelie Raba Leon
Bordeaux 33000 France

Contact: ibrahim.obeid@gmail.com

Site Description:
4 deformity, 20 degenerative, 3 tumor and 2 to 10 traumatic spinal surgeries per week.
4 permanent surgeon, 3 clinical fellows and 5 residents.

Preferred Fellowship:

• Luque
• GOP
• Winter
• OrthoPediatrics
• Medtronic Research

Research Opportunities for Medtronic Research Fellow:
Many projects are now in progress especially in adult deformity and spinal alignment.
Email: ibrahim.obeid@gmail.com with proposals

UMC Utrecht: Rene M. Castelein, MD, PhD and M.C. Kruyt, MD, PhD

Site Location:
Heidelberglaan 100
Utrecht, Utrecht Netherlands

Contact: mkruyt@umcutrecht.nl or by phone 088 7556971

Site Description:
The orthopedic department incorporates a large spinal unit that serves both adult and pediatric spine. The spine unit is a tertiary referral center for about 5 million patients, about 500 cases are treated annually (350 adult and 150 pediatric) The spine unit has 5 orthopedic staff members, 2 neurosurgeons and 2-3 fellows. The vast majority of cases are complex multilevel deformity cases. Both clinical and fundamental research programs are ongoing with 2 postdocs, 6 PhD students and research support. For foreign fellows the typical week activities are 2-4 days OR and 1-2 days interactive and research meetings The spine unit also serves as a AO spine fellowship center, see https://aospine.aofoundation.org/Structure/education/spine-centers/Pages/europe-and-southern-africa/university-medical-center-utrecht.aspx

Preferred Fellowship:

• GOP
• Winter (with followup)
• OrthoPediatrics
• Medtronic Research

Research Opportunities for Medtronic Research Fellow:
Fundamental research on etiology of scoliosis (Prof. RM Castelein)
Development of a new scoliosis reduction implant (Dr. M Kruyt)
Spinal trauma, clinical and fundamental (Prof. FC Oner)
Oncology research (Dr. JJ Verlaan)
Email: mkruyt@umcutrecht.nl with proposals

University of Texas Health Science Center at San Antonio - Department of Orthopaedics: Albert Sanders, MD; James Walter Simmons III, DO, PhD; Zachary Childs; Anton Jorgensen, MD; Robert Quinn

Site Location:
7703 Floyd Curl Dr.
San Antonio, Texas 78239 USA

Contact: Zachary Childs childz@uthscsa.edu or by phone 210 567 5125

Site Description:
UTHSCSA Ortho Pediatrics & Adult Zack Child childz@yahoo.com
San Antonio Military Medical Center Adult (largest military hospital in the USA) Contact Anton Jorgensen ayj75@yahoo.com
Children's Hospital of San Antonio Pediatrics James Walter Simmons III docsim3@yahoo.com

Preferred Fellowship:

• Dawson
• Luque
• GOP
• Winter (with followup)
• OrthoPediatrics
• Medtronic Research

Research Opportunities for Medtronic Research Fellow:
to be decided by applicant
Email: childz@uthscsa.edu with proposals

Washington University Orthopedics: Munish C. Gupta, MD

Site Location:
660 S. Euclid Ave
Campus Box 8233
Saint Louis, Missouri 63110 USA

Contact: Tricia Nester nestert@wudosis.wustl.edu or by phone 314-362-7140

Site Description:
• The spine specialists with Washington University Orthopaedics are nationally and internationally renowned and cover all spinal diseases/conditions of the cervical (40% of cases), thoracic & lumbar spine (60%): degenerative (35%), deformity (50%), trauma/tumor (15%); pediatric (30%), adult (70%).  Among the five attending physicians (Drs. Munish Gupta, Keith Bridwell, Jacob Buchowski, Michael Kelly and Lukas Zebala), approximately 1000 cases are performed annually.
• Each spine attending has his own research coordinator to help with research projects.  The five coordinators (and one research manager), three of whom have master's degrees and one with a PhD, also assist our fellows, residents and visiting researchers with their projects.  Statistical analysis is provided by Washington University's biostatistics department, as well as by some of our research coordinators who use SPSS.  The spine research group is housed together in a state-of-the-art facility at the medical center, with room for several visiting researchers as well.
• The Spine Service is supported clinically by two residents (PGY-1 and -4 levels) and four spine fellows, as well as clinical staff comprised of six nurse practitioners, a nurse manager, five registered nurses, and six medical assistants.
• In general, activities in a typical week are spent approximately 60% in the operating room and 40% spent in clinic.  Operations are performed at Barnes-Jewish Hospital, St. Louis Children's Hospital and Shriners Hospital for Children, as well as the Orthopedic Center/Chesterfield (same-day cases).  Clinics are at these locations as well.  Each attending has a half-day to a whole day dedicated weekly to research and administration. For more information about our spine specialists at Washington University Orthopedics, visit: http://www.ortho.wustl.edu/content/Patient-Care/2389/SERVICES/Spine/Overview/Meet-Our-Physicians.aspx.

Preferred Fellowship:

• Luque
• GOP
• Winter (with followup)
• OrthoPediatrics

Toronto Western Hospital, Hospital for Sick Children (SickKids Hospital), University of Toronto Department of Surgery Spine Program: Michael G. Fehlings, MD, PhD, FRCSC FACS and Stephen J. Lewis, MD, MSc, FRCSC

Site Location:
Department of Surgery, 5th Floor Stewart Building
149 College Street
Toronto, Ontario M5T 1P5 Canada

Contact: Nadia Jaber uoft.spine@utoronto.ca or by phone (416) 978 8468

Site Description:
The University of Toronto (U of T) is ranked among the top institutions of higher learning in the world for its unique clinical, research, educational and multicultural experience. The University of Toronto Spine Program is recognized worldwide as a leading program with the goal to enhance clinical care, research, and education. The Program is integrated across several citywide hospitals that form the Toronto Academic Health Science Network (TAHSN) affiliated with the University of Toronto. This dynamic network is one of the largest, most productive academic health centres in the world as evidenced on a number of dimensions including academic standing, research activity/output, visionary collaboration and contribution to healthcare innovation. The host academic hospitals, SickKids Hospital and Toronto Western Hospital each hold national and international standing as leaders in their particular fields of paediatric and adult spine surgery.

Each year, the U of T Spine Program has 12 neurosurgical and orthopedic spine fellows and a number of  residents and visitors who are attracted locally and from around the world.  These individuals are trained in the affiliated hospitals in the full breadth of spine surgery including  Adult Spine Deformity, Paediatric Spine, Spinal Oncology, Spine Trauma and Spinal Cord Injury, Degenerative Spine, Complex Cervical Surgery and MIS (Minimal Invasive Spine Surgery).

The Program has a unique surgeon scientist training program, also staffed with active SRS members, driven by world renowned spine surgeons scientists, who are passionate about training the young spine surgeons on their technical and evidence-based clinical decision making with consumer engagement to improve outcomes and quality of life. The program acts as a hub for one of  the largest spinal care and research communities in the world.

The visiting fellows will be exposed to a mix of  clinical and academic  and administrative moments in the life of a Spine Surgeon (i.e. OR cases and Spine Rounds: Paediatric and Adult Scoliosis, Paediatric and Adult deformity).  The fellows will also be provided with a varied and stimulating academic schedule which will include, a tour of the University complex, clinic and OR observerships to Toronto's three leading academic health science centres/hospitals and learn about state of the art Scoliosis care at these centers. Participate in Regional Spine Rounds and discuss advances in Scoliosis care.  The visiting surgeon will also enjoy the opportunity to learn about techniques to minimize perioperative neurological risk in high risk spinal deformity. There are several Paediatric and Adult Scoliosis clinical trials and research projects in progress. The visiting surgeons will learn and discuss the current advances in scoliosis surgery and will have the opportunity to meet and hear s  ome of the current fellows' presentations on clinical and research projects at the University of Toronto Spine Program. The visiting fellows will also have the opportunity to develop and build on future collaborations for various research projects and participation in the trials.

Finally, the U of T Spine Program is known for excellence in hosting traveling fellows and ranked the top host site in providing a rich academic, clinical and outstanding fun-packed social program for the young visitors. The social events provide the visiting fellow with the opportunity to network in a relaxing atmosphere with the Scoliosis surgeon scientists, spine faculty, fellows and trainees including research fellows on surgeon scientist programs.

U of T Spine Program Co-Directors:
Michael G. Fehlings MD PhD FRCSC FACS, Toronto Western Hospital- University Health Network, and Albert Yee MD MSc FRCSC DABOS, Sunnybrook Health Sciences Centre

University Citywide Affiliated Hospitals:
Toronto Western Hospital-University Health Network,  Hospital for Sick Children (SickKids Hospital) , Sunnybrook Health Sciences Centre,  St. Michael's Hospital, and Mount Sinai Hospital.

Co- Principal Investigators:
- Michael G. Fehlings MD PhD FRCSC FACS, Toronto Western Hospital- University Health Network (SRS Fellow)
- Stephen Lewis MD MSc FRCSC, SickKids Hospital, and Toronto Western Hospital- University Health Network (SRS Fellow)

Preferred Fellowship:

• Dawson
• Luque
• GOP
• Winter (with followup)
• OrthoPediatrics
• Medtronic Research

Research Opportunities for Medtronic Research Fellow:
A) Studies Based on Prospective Data

     1. ScoliRisk Study
This database is available for a wide variety of analyses on predictors of neurological decline and other complications in high risk deformity case. This large multicentre study, representing a collaboration between the SRS and AOSpine, has defined the rate and severity of neurological complications following high risk adult spine deformity surgery. The study has been jointly led by Larry Lenke and Michael Fehlings. The dataset is now available for analysis by prospective fellows. A large, prospective RCT is being planned to examine the role of the neuroprotective drug Riluzole in reducing neurological complications in high risk deformity surgery. The fellows will be able to participate in patient enrolment and learn about the conduct of a complex, multicentre prospective RCT.

     2. AOSpine North America CSM-NA and CSM-I:
A Degenerative cervical myelopathy (DCM) is all-encompassing and includes myelopathy secondary to chronic disc herniation, spondylosis, ossification of the posterior longitudinal ligament, hypertrophy of the ligamentum flavum, subluxation or a combination of these degenerative changes. The CSM-North American study was conducted between 2005 and 2007 to prospectively evaluate the efficacy and safety of surgical decompression in these patients and to examine outcomes following anterior versus posterior surgery. The conclusions of this study demonstrated that surgery is safe and results in significant improvements in clinical, disability and quality of life outcomes in patients with mild, moderate and severe disease. Furthermore, outcomes were similar following anterior versus posterior surgery after controlling for important confounders including age, disease severity and number of levels decompressed. The CSM-International study was primarily undertaken to ascertain regional differenc  es in disease causation, management strategies and surgical outcomes and to validate the findings from the North American study. CSM-International was conducted across 16 global sites in Asia Pacific, Europe, Latin America and North America. Other goals of these two studies were to
1) evaluate important predictors of outcome and complications
2) to validate the modified Japanese Orthopaedic Association (mJOA) scale and to determine its minimum clinically important difference
3) to assess the relative efficacy and safety of laminectomy with fusion versus laminoplasty
4) to establish standardized imaging criteria for diagnosis.  We have the combined CSM-NA and CSM-I databases.  We are doing interesting work on cervical deformity and myelopathy development.

     3. NACTN and STASCIS Registry:
The North American Clinical Trials Network (NACTN) is a large clinical registry of with biostatistical infrastructure for testing new promising therapies, evaluating their efficacy, bringing them through the regulatory process, and if shown to improve outcome, incorporating them as standards of care. It has been supported by the Department of Defense since 2006 and AO Spine is providing continued support.

NACTN has established an SCI database characterizing spinal cord injuries. This database is being used to establish trajectories of recovery for defined injuries and to develop models to predict outcomes of recovery.

NACTN has also organized a Neurological Outcome Assessment initiative (NOA), an international task force of scientists and clinicians to develop, test, and validate outcome measures to detect incremental improvements (Motor, Autonomic, Sensory and Pain) for use in clinical trials.
Most importantly NACTN is running the Riluzole trial which is approved for treating patients with amyotrophic lateral sclerosis (ALS). We have examined its safety, pharmacokinetics and preliminary efficacy in patients with traumatic spinal cord injury. The promising results have allowed us to embark on a larger, Phase 2/3 efficacy trial on Riluzole and improved recovery.

     4. Surgical Timing in Acute Spinal Cord Injury Study (STASCIS):
Given the preclinical evidence that early decompression in the setting of spinal cord injury (SCI) improves neurologic outcomes. Dr. Fehlings led the STASCIS trial. Our objective was to evaluate the relative effectiveness of early (<24 hours after injury) versus late (≥24 hours after injury) decompressive surgery after traumatic cervical SCI. It was one of the first lengthy clinical study examining the potential benefits of early surgical decompression of the spinal cord after injury were released in the open source journal: PlosONE.  We have combined the NACTN and  STASCIS databases available for further analysis, it has a large number of patients treated for spinal cord injury and spine trauma, preliminary results appear to show a beneficial effect to the rapid decompression protocol developed by the Fehlings group and collaborators.

     5. Surgical Versus Non-operative Treatment of Metastatic Epidural Spinal Cord Compression. (MESCC) Quality of Life and Cost-Effectiveness Outcomes:
This is a large North American Trial on Metastatic Spine looking at the epidemiology, that will look at and compare effects of surgical and non-surgical treatment for metastac spinal cord compression. This his trial will evaluate efficacy and costs of de novo surgery and radiotherapy for MESCC as opposed to nonoperative treatment (radiotherapy alone). The primary hypotheses are:

1. Change in pain level between the baseline and 12 weeks F/U as measured using the Brief Pain Inventory (BPI) will be higher in de novo surgical group vs.  nonoperative group
2. Quality of life outcomes will be superior in MESCC patients treated with de novo surgery as oppose to patients treated nonoperatively as measured by FACT-GP.
3. Neurological outcomes measured by American Spinal Injury Association (ASIA) Motor Scale structured clinical examination will be superior in MESCC patients treated with de novo surgery compared to patients treated nonoperatively.
4. De novo surgery has better cost-utility than the nonoperative treatment. Process and Outcomes of Spine onciology-this database is available for analysis and includes an opportunity to examine a surgical series of patients treated for metastatic spine cancer.

     6. Advanced MRI for microstructural  imaging of spinal cord
We are also conducting clinical studies using advanced MRI techniques to characterize aspects of microstructure in the human spinal cord, including diffusion tensor imaging (DTI) to measure axonal integrity to improve diagnostic accuracy, quantify tissue injury, and predict outcomes. However, further refinement of these techniques is necessary to provide highly reliable measures of regeneration near the SCI lesion site, which usually requires imaging in the context of metallic hardware implants that are frequently used for spinal reconstruction. We hypothesize that we can: 1) develop an MRI protocol that provides reliable quantitative assessments above/below the level of hardware implants, 2) show that MRI assessment correlates with neurological/functional changes in human SCI subjects following stem-cell therapy (or other intervention), and 3) demonstrate that certain MRI metrics improve prior to neurological/functional recovery (i.e. reflect underlying regenerative mechanisms). Thi  s research includes the development of a quantitative spinal cord MRI protocol using standard clinical hardware, short acquisition times, and automated image analysis techniques to provide unbiased measures of tissue injury.

     7. Prospective Evaluation of Elderly Deformity Surgery (PEEDS)- AOSpine
As the population continues to age, the prevalence of spinal deformity surgery for older patients is increasing. Questions regarding the suitability of these patients to undergo large spinal procedures and whether the outcomes merit the risks involved are not well known. We propose to undertake an international multicenter study to determine the value of spinal deformity surgery in spinal deformity patients at or over the age of 60 years.

The primary objective is to show an improvement in SRS-22r total score between baseline and 24 months after surgery in patients at age 60 or older treated with major spinal reconstruction (spinal fusion of at least 5 levels) for adult spinal deformity.

Our hypothesis is superiority of SRS-22r total score in patients with adult spinal deformity undergoing spinal fusion 24 months after surgery compared to baseline.

Short Description: 225 subjects greater than or equal 60 years of age with moderate and severe adult spinal deformity requiring surgical correction will be enrolled in a prospective multicenter international study. Spinal deformity will be defined as any coronal or sagittal plane spinal deformity in patients who have not undergone any previous spinal surgery (with the exception of prior decompression of a maximum of 2 levels) necessitating at a minimum a 5-level spinal fusion procedure. Standard radiographs and cross sectional imaging will be performed preoperatively, postoperatively, and at 24 months after surgery. Preoperative disease specific and general health questionnaires will be completed by all patients (EQ-5D, ODI, SRS-22r, NRS for back and leg pain). Follow up visits with questionnaires will be performed at 10 weeks (± 6 weeks), 12 months (± 2 months), and 24 months (± 2 months) post-operatively. All treatment-related AEs will be documented.

Regression analyses will be used to evaluate the association between patient demographics, comorbidities, treatment history, spinal deformity characteristics, surgical characteristics, treatment-related AEs and pre-surgical status to self-reported and radiographic outcomes after surgery.

     8. A Multicenter Prospective Study of Quality of Life in Adult Scoliosis: NIH
This is a Phase III Clinical Trial.  Our overall goals are to evaluate the effectiveness of nonoperative and operative interventions in patients with adult symptomatic lumbar scoliosis (ASLS) and to identify important clinical and radiographic determinants of change in patient-reported HRQOL. To accomplish these goals, a 5-year cooperative, multi-center longitudinal randomized study with a concurrent observational cohort is proposed.
Specific Aim #1: Compare the outcomes of surgery and nonoperative treatment in patients aged 40 to 80 with ASLS defined as a lumbar curve with a coronal Cobb measurement of 30° or more, and either of the following: Oswestry Disability Index (ODI) score of 20 or more; or Scoliosis Research Society Quality of Life (SRS-QOL) instrument score of 4.0 or less, in the domains of pain, function and/or appearance.
Null Hypothesis: Nonoperative and operative treatment groups will have similar outcomes at follow-up.
Specific Aim #2: Evaluate the impact of patient factors (age, gender, socioeconomic status, education) and comorbidities [mental health, body mass index (BMI) and bone mineral density (BMD)] on adverse events and treatment outcomes for both the nonoperative and operative arms. Incorporate these variables into a prediction model to help identify those patients most likely to benefit from either a surgical or nonoperative approach.
Hypothesis: Age, gender, socioeconomic status, education, and comorbidities will have an impact on the final result at 2-4 years post-intervention.

B) Ongoing Retrospective Research Projects
     1. Midline Preservation in Spinal Fusion Procedures:
Spinal fusions are performed for multiple reasons. Some of them are to  increase spinal stability,  correct spinal deformities, relieve back pain, restore  nerve function that has  been altered by compression etc. Different  surgical techniques  for spinal  fusion includes minimally invasive vs. open back procedures, the Wiltse procedure and midline preservation. With these techniques, there are associated complications such as infection, screw malposition and  pseudoarthrosis that may decrease fusion rates and eventually lead to  revision  surgeries. Prior to 2011, a traditional posterior exposure was performed. In 2011, we switched to a midline preservation technique in an attempt to deal with some of the complications we were observing.

The purpose of this study is to review charts retrospectively to compare the  technique used and determine if there is a significant difference in the overall   clinical outcome of complications  associated  with midline preservation compared to traditional open exposure in primary posterior spinal fusions.

     2. Resection and open vertebroplasty with instrumented reconstruction for C2 tumors: surgical technique and results in 4 patients:
C2 tumors are both rare and challenging lesion to treat.  There are few existing reports describing anterior resection and reconstruction and none involving open anterior vertebroplasty of the C2 body. Decision making regarding treatment of these lesions remains challenging.  Important factors include tumor histology, neurologic signs and symptoms, spinal instability and the extent of systemic disease and the prognosis of the individual patient.  Most are managed with either surgery or radiation or a combination of these modalities. Advanced cases may be managed in a purely palliative manner.  Surgical options for management of C2 body tumors include the anterior retropharyngeal approach or transoral approaches.  These approaches are often combined with added posterior reconstructive efforts.  Recently, case reports reporting both percutaneous and open transoral vertebroplasty have been described as adjuctive modalities to treat lytic tumors involving the C2 body. 

The objective of the study is to  describe a novel surgical technique involving open vertebroplasty and instrumented reconstrution for management of destructive lesions resulting in pathologic fractures at the C2 level. 

     3. Impaction Grafting in Lumbosacral Fusion
The lumbosacral region can often be difficult to obtain solid fusion. Cages and autograft have been the gold standard used for spinal fusion. But there are several issues with this current technology. The main issues are: the significant costs with cages, the surface area for bone contact with a cage limiting fusion, irregular endplate surfaces may not have a good fit with a cage, and delay in obtaining fusion. Others have added bone substitute to stimulate fusion and avoid the  use of allogenic tissue. This study will attempt to show the difference and quantify the quality in the fusion rate between different grafting materials.

     4. Posterior Column Reconstruction Improves Fusion Rates at the Level of the Osteotomy in Three Column Posterior Based Osteotomies:
Posterior based three column have been associated with significant correction of fixed spinal deformities. Resection of the posterior elements to achieve the required decompression can leave a posterior column defect that can lead to pseudarthrosis and early implant failure. While some authors have advised the use of cages or some other form of anterior column support to promote fusion at the osteotomy site, we feel reestablishing the integrity of the posterior column at this region to be a key factor in promoting local fusion.

The purpose of the study is to show that re-establishing the integrity of the posterior column at the osteotomy site is the key factor in promoting local fusion without the use of cages and other forms of anterior column support.

     5. Peri-Operative and Intra-Operative Management of Patients Undergoing Spinal Surgery:    
Instrumentation of the spinal column is a major surgery with complex intra-operative and peri-operative care.  The management of these patients during and immediately following their operation can have significant impact on their post-operative course.  One recent study in a different spine operation identified factors associated with prolonged length of stay: these included pre-operative status, intraoperative and post-operative fluid balance, the volume of intra-operative crystalloids and amount of opioid.

We set out to document our local practices with respect to the intra- and peri-operative management of patients undergoing spine instrumentation and determine the impact of these practices on clinical outcomes.  We anticipate the identification of factors associated with prolonged length of stay and unfavourable clinical outcomes will provide targets for quality improvement interventions with the hope of improving the care of patients in the future.

The study objective is to determine the impact of perioperative management, particularly of fluid management, on clinical outcomes in patients undergoing spinal instrumentation admitted to the ICU.

     6. Efficacy of Smith-Petersen Osteotomies for Correction of Adult Idiopathic Scoliosis  in Patients with Previous Posterior Fusion.
Spinal deformity correction in previously fused spine is technically challenging. Three-column osteotomies for the fusion mass have been reported but they are associated with high risk of complications and pseudarthorosis. On the other hand, most of the idiopathic scoliosis has been treated by posterior fusion and anterior column remains usually unfused. Therefore the revision correction for these cases only needs posterior column osteotomy (Smith-Petersen osteotomies).

The primary objective is to determine how much correction each Smith-Petersen osteotomy (SPO) is able to achieve, and also whether this can be performed safely. To do so, the author will retrospectively review a consecutive series of patients having undergone Smith-Petersen osteotomies who also have had previous posterior fusion. The degree of deformity will be measured preoperatively and postoperatively and then compared to determine the extent of correction. These patients will be compared to a similar group of patients who underwent pedicle subtraction osteotomies (PSO), a more complicated osteotomy, for the same condition, which was the method of preference performed in the past. Patient charts will also be reviewed do determine the number of osteotomies performed in each surgery, as well as any complications that resulted perioperatively and in the months following surgery.

Safe and effective correction of residual coronal plane deformity can be achieved via posterior based osteotomies in patients with previous spinal fusions. Secondary hypothesis will relate to the complications and magnitude of correction that can be achieved through the two different techniques (SPO and PSO).   

     7. The effect of the use of intraoperative Skull-Femoral traction on the correction of pelvic obliquity in neuromuscular scoliosis.
The surgical treatment of neuromuscular scoliosis is well established. For instance, posterior spinal fusion typically from the upper thoracic vertebrae to the pelvis is a well studied treatment, but preservation of some movement at the lumbo-sacaral junction in ambulatory patients is advisable.  The correction of pelvic obliquity is considered to be part of the surgical treatment of neuromuscular scoliosis. By correcting the pelvic obliquity, patients with neuromuscular scoliosis can obtain a better sitting position and better balance of the trunk. However, correction of pelvic obliquity can be difficult to perform and control intraoperativelly. The use of SF traction using the Gardener-Wells tongue and unilateral femoral traction and smooth insertion of Steinmann pin into the distal femur of the elevated pelvis can help level the pelvis and thus gives better and easier correction of the pelvic obliquity.  In the ambulatory group, it can be more difficult to obtain and preserve a good correction of the obliquity. This can be explained by the fact that the fixation is not involving the pelvis.  

Study Objectives:
To analyze the effect of the intraoperative use of SF traction and it is usefulness in correcting the pelvic obliquity in the CP patients with scoliosis.

Email: Michael.fehlings@uhn.ca; Stephen.Lewis@uhn.ca; uoft.spine@utoronto.ca with proposals

Italian Scientific Spine Institute (ISICO): Stefano Negrini, MD

Site Location:
Via Roberto Bellarmino 13/1
Milan, Italy 20141

Contact: Sabrina Donzelli sabrina.donzelli@isico.it

Site Description:
ISICO is a private clinical practice, fully dedicated to the conservative treatment of  spinal deformities and diseases, in adults and growing patients.

There is the possibility for reaserch support by a team of expert researchers.

The team of experts include all the professionals involved in the treatment of spinal deformities, and all its member are very experienced in this field.Every week there are outpatints activities, orthotists activities, and phisiotherapic sessions.

Every week one of the clinicians is dedicate to research. The Italian Scientific Spine Institute is dedicated to conservative treatment only, and patients needing  surgery are invited to go to spine surgery centers.

Preferred Fellowship:

• Luque
• OrthoPediatrics