Larson, A. Noelle

Purpose: To quantify the prevalence of neural axial abnormalities in congenital early-onset scoliosis (C-EOS) patients stratified by age group, correlate prevalence of treatment, and determine if a delay in MRIs affects outcomes. Methods: A multicenter registry with data on 751 C-EOS patients was retrospectively reviewed, of which 659 patients were included. Data included demographics, pre-index major coronal curve, age at first MRI, intraspinal MRI findings, neurosurgical interventions and scoliosis fixation performed, intraoperative and postoperative complications, and unplanned return to the operating room (UPROR) for orthopaedic complications. Patients were divided into 2 cohorts utilizing age 3 as a cutoff. This age cutoff was selected based on an FDA warning of the potential neurocognitive effects of anesthesia used for MRIs in patients younger than 3 years. Spearman Rho correlations, independent t tests, and χ 2 tests were used for statistical analysis. Results: Patients were divided into 2 groups: first MRI younger than or equal to 3 years of age (n=277) and older than 3 years of age (n=382). One hundred thirty-three abnormal MRIs were identified (20%). There was no significant correlation between age at MRI and abnormal intraspinal findings (rs= −0.018, P =0.64). Among patients with abnormal MRIs, no correlation existed between age at MRI and UPROR. In this cohort, 23 neurosurgical procedures were performed and no significant difference was found in UPROR between groups ( P =0.54). There were 3 neurologic complications in the younger than or equal to 3-year group and 0 in the older than 3-year group ( P =0.07). No significant difference was found in mean pre-index major coronal curve ( P =0.25). Conclusions: The prevalence of neural axis abnormalities in C-EOS was 20%. There was no significant correlation between age at first MRI and the chance of an abnormal MRI. There were no significant differences in neurological complications and UPROR between the younger than or equal to 3-year and older than 3-year groups. Thus, in C-EOS, MRI may be cautiously deferred until after the age of 3 in patients with normal neurological examinations and radiological findings.

Background: Vertebral body tethering (VBT) for adolescent idiopathic scoliosis (AIS) is an alternative to posterior fusion. There are limited prospective, multicenter data available on VBT following US Food and Drug Administration approval. We hypothesize that curve correction on first postoperative standing (first erect, FE) imaging is associated with higher rates of successful correction at final follow-up. Methods: All qualifying patients with AIS who underwent thoracic and lumbar VBT between 2019 and 2022 were prospectively enrolled from 9 institutions. Radiographic and clinical data were compared preoperatively, at FE, and at final follow-up with minimum of 2 years. Success was defined as major curve magnitude of ≤35° at final follow-up and no fusion surgery. Results: One hundred twenty-seven patients were enrolled (79.5% female), with mean follow-up 2.4 years. Mean age at surgery was 12.9 ± 1.4 years, most had bone age of Sanders 4 or lower (93/112, 83.0%). In average, 7.6 ± 1.7 levels were tethered. Mean preoperative major curve magnitude was 50 ± 8°, with mean initial correction at FE of 29 ± 8° (% correction, 39 ± 18%). At final follow-up, mean curve magnitude was maintained at 26 ± 11° (% correction, 45 ± 23%) despite 29% of tether breakage. Patients who had mean FE curve magnitude of ≤35° were 88% successful compared with only 60% in those with >35° on FE (p = 0.0021). Patients showed stable sagittal alignment across all timepoints. Scoliosis Research Society-22 scores improved significantly by 2 years (p < 0.0001). Conclusion: This was the first prospective, multicenter study to assess outcomes of VBT for patients with AIS. VBT shows promise, but optimal results may depend on careful patient selection and surgical technique. FE major curve magnitude of ≤35° was associated with 88% success rate compared with only 60% success for those with poor correction. Level of Evidence: Level II . See Instructions for Authors for a complete description of levels of evidence.

Background: Scoliosis has various etiologies, ranging from idiopathic, congenital, to those with spinal cord abnormalities. Advanced imaging is not always feasible and limited by cost, low-yield, and anesthesia risks in children. Given artificial intelligence's potential, we hypothesize that a deep learning (DL)–based image classifier will demonstrate superior performance in radiographic classification of scoliosis etiology compared witht experienced spine surgeons based on spine radiographs. Methods: One thousand thirty-six pediatric patients from single institution with scoliosis diagnosis and paired anterior-posterior - lateral images were included. Patients were manually classified based on their scoliosis etiology from chart review, including previous spine imaging studies when available. Categories included idiopathic, congenital, and spinal cord pathology. Images were randomized and assigned for training, validation, and testing. A DL-classifier using EfficientNet B4 architecture was trained on the radiographs. Accuracy and positive predictive value as defined by precision, recall, and F1-score were calculated to assess final performance metrics. Results: The trained classifier performed well at identifying correct etiologies, with F1-Score (harmonic mean of precision-recall) of 0.97. Model precision was 0.99 for adolescent idiopathic scoliosis, 0.89 for congenital, and 0.78 for spinal cord pathology. Performance was higher on more common classes, with lower performance observed in class with fewer images. The algorithm has highest overall precision (0.96), recall (0.96), and F1 (0.96), while Surgeons 1 and 2 have lower accuracies (precision 0.80, recall 0.79, and F1 0.79 and precision 0.76, recall 0.67, and F10.71, respectively). There was no clear pattern identified regarding the surgeons' errors and poor agreement on which X-rays corresponded to underlying spinal cord pathology. Conclusion: A DL-convolutional-neural-network classifier has been trained to high degree of accuracy to distinguish between 3 scoliosis etiologies on pediatric spine radiographs. This model could provide a novel tool to clinicians to decide when to refer for axial imaging. It had superior diagnostic performance compared with experienced spine surgeons. After further validation and refinement, a clinician could put a patient's X-rays into the predictive tool for analysis and use the results to discuss with the family the risk of finding spinal cord pathology, helping them determine together the best timing for an MRI. Level of Evidence: Level III . See Instructions for Authors for a complete description of levels of evidence.

Artificial intelligence (AI) is increasingly shaping pediatric spine care, leveraging its rapid advancements in healthcare to improve efficiency, accuracy, and disease understanding. Moreover, machine learning and deep learning excel at detecting complex patterns. This holds promise in processing spinal deformity data, with the potential to surpass traditional statistical methods in predictive accuracy. Challenges persist, however, including unclear clinical implementation guidelines, limited model transparency, and ethical concerns surrounding data privacy and bias. Small sample sizes and the need for larger, diverse datasets further complicate integration. In order to realize AI’s transformative potential in pediatric spine care, these critical obstacles must be addressed for effective and ethical clinical adoption. This review examines the role of AI through applications such as image sorting, surgical outcome prediction, forecasting of spinal curve progression, and vertebral volumetric analysis using deep reasoning. It also explores possible intraoperative contributions from AI, including robotics and optimized screw trajectory planning, and the potential of large language models in clinical practice.

Background: Anterior vertebral body tethering (AVBT) is a promising fusionless alternative for treating idiopathic scoliosis; however, limited data exist on the learning curve for this procedure. Previous studies are limited by single-center and short-term complication data. This multicenter study assesses the learning curve by evaluating improvements in operative characteristics over time and radiographic measurements up to 2 years postoperatively. Methods: As recorded from a multicenter registry, surgeons with ≥10 index AVBT procedures for patients with idiopathic scoliosis aged 16 years and below were included. Relationships between case number and multiple surgical variables were determined using Pearson correlation and linear regression testing. For identification of an inflection point, consecutive cases were plotted against operative time per level and fitted with a locally weighted scatterplot smoothing curve. Independent samples t test and χ 2 test were used to compare outcomes between cases before and after the inflection point. Outcomes of interest included demographic, surgical, and radiographic information at the baseline, immediate postoperative, and 2-year timepointswhere available. Results: Eight surgeons and 325 index AVBT patients met the inclusion criteria. Inverse relationships were identified between case number and estimated blood loss, operative time, anesthesia time, and fluoroscopic time per level ( P < 0.005). The inflection point was identified at 15 cases. Operative time, anesthesia time, and fluoroscopy time per level were greater in the first 15 cases compared with those after ( P < 0.05). There were no significant differences in demographic variables, intraoperative complications, or length of stay between the early and late cases. Greater correction in the major coronal curve, minor coronal curve, and coronal balance occurred in the cases performed after the inflection point ( P < 0.05). Conclusions: AVBT is a safe alternative to posterior spinal fusion and demonstrates a predictable improvement in surgical performance over time. Large improvements can be expected during the first 15 AVBT cases performed with minimal differences in complications. Level of Evidence: Level III.

Background: Motion-sparing approaches to scoliosis surgery such as vertebral body tethering (VBT) are growing in popularity. There is limited data evaluating motion preserving after the different tether approaches. We hypothesized that spinal motion would be preserved in both the sagittal and coronal planes in patients after thoracic, lumbar, and bilateral vertebral body tethering procedures. Methods: This was a retrospective comparison study of adolescent idiopathic scoliosis (AIS) patients who underwent VBT. Preoperative and postoperative coronal range of motion across the instrumented levels were compared using a standing microdose slot-scanning protocol. Flexion/extension radiographs were evaluated postoperatively to assess preserved sagittal arc of motion. Patients with known cord breakage were excluded. Results: The mean age at surgery was 12.9 years (range: 9.4 to 16.5) with mean follow-up period of 2.8 years. Skeletal maturity, defined as Risser sign ≥5, was observed in 29 patients. (26.9%). Overall, mean thoracic coronal arc of motion for postoperative VBT patients was 10 degrees in the thoracic spine and 20 degrees in the lumbar. This was a 59% (24 to 10 deg.) decrease in thoracic range of motion and a 51% (40 to 20 deg.) decrease in lumbar range of motion. Right-sided motion was greater in patients with thoracic instrumentation, whereas left-sided motion was greater in patients with lumbar instrumentation. In addition, patients also retained sagittal motion. Patients with single thoracic tethers had a total arc of motion of 22 degrees, whereas patients with single lumbar tethers had a total arc of motion of 25 degrees. It was noted that both groups had a greater degree of flexion than extension. Conclusions: Patients with single thoracic tethers saw a 60% decrease in the total coronal arc of motion. Patients with single lumbar tethers saw a 57% decrease in coronal motion. Patients had around 20 to 25-degree arc of motion preserved over the instrumented segments in the sagittal plane. Further work is needed to outline the functional benefits of motion preservation after VBT. Level of Evidence: Level III (retrospective cohort study).

Background: Pediatric orthopaedic surgery encompasses many areas of subspecialization. To improve patient care, quality improvement efforts should focus on high-volume procedures with high complication rates. This study aims to identify these procedures to better target research and quality-improvement initiatives. Methods: Patients undergoing one of the 30 most common orthopaedic procedures in NSQIP pediatric data from 2012 to 2022 were analyzed for 30-day complications, infections, unplanned reoperations, and unplanned readmissions. Multivariable models assessed associations between procedure type and adverse events, adjusted for patient characteristics. Tibial osteotomy (TO) was defined as the reference category for procedure in each model as it is a common procedure with a moderate risk profile and a similar complication rate across the cohort. Results: 191,381 patients were included in the analysis (median: 10 y, IQR: 5 to 13; 48.7% male). The 30-day overall complication rate was 2.3% (n=4401), with infections occurring in 1.6% of cases (n=3005). Unplanned reoperations occurred in 1.7% (n=3207), and the unplanned readmission rate was 2.0% per 30 person-days. The most performed procedures were posterior spine fusion (PSF; n=45,542; 23.8%), supracondylar humeral fracture (SCHfx) repair (n=45,479; 23.8%). Complication rates were highest for PSF in non-idiopathic cases (10.3%), followed by pelvic and femoral osteotomy (4.9%). Infectious complications were most frequent in PSF for non-idiopathic cases (6.1%) and tibial osteotomy (3.1%). Unplanned reoperation rates were elevated for non-idiopathic PSF (5.6%) and pelvic/femoral osteotomy (4.9%). On multivariable analysis, PSF for adolescent idiopathic scoliosis (OR=1.39; 95% CI: 1.05-1.86) and non-idiopathic causes (OR=2.16; 95% CI: 1.61-1.89) demonstrated increased odds of complications compared with TO. Factors associated with higher complication rates included BMI >95th percentile (OR=1.52; 95% CI: 1.40-1.65), developmental delay (OR=1.57; 95% CI: 1.43-1.73), seizure disorder (OR=1.41; 95% CI: 1.27-1.56), and ASA ≥2 (OR=2.14;95% CI: 1.90-2.41). Although PSF for non-idiopathic causes had the highest unplanned readmission rates (9.4% per 30 person-days), adjusted analysis showed a strong association with increased readmissions for pelvic/femoral osteotomy (HR=2.52; 95% CI: 1.58-4.03) compared with TO. SCHfx repair and calcaneal osteotomy consistently had lower rates of complications, infections, reoperations, and readmissions. Conclusions: After adjusting for covariates, PSF and tibial and femoral osteotomies, demonstrated significantly higher risks for adverse surgical outcomes compared with TO. Our findings identify SCHfx repair as a high-volume procedure with low complication, infection, reoperation, and readmission rates in contrast to PSF, one of the most common procedures with the highest complication rate.

Background/Objectives: Accurate assessment of spinal bone density is essential for evaluating bone health, particularly in preoperative planning. Conventional manual methods for Hounsfield unit (HU) measurements rely on single-slice measurements within the region of interest, limiting their precision and reproducibility in patients with severe vertebral deformities. We hypothesize that a novel deep-reasoning and learning model (DR-AI) can fully automate spinal bone density assessment volumetrically, with high correlations to spinal bone mineral density (BMD) obtained from dual-energy X-ray absorptiometry (DXA), as well as to the T- and Z-scores. Methods: A cross-sectional study was conducted on patients who had BMD assessment of their lumbar spine and lumbar CT scans within 1 year. The fully-automated DR model was utilized to analyze the soft-tissue window of the lumbar vertebrae CT scans. Spearman correlation coefficients were calculated to assess the strength of relationships between the computed volumetric HUs and the BMD, T-, and Z-scores from each vertebra. Results: 84 patients (67 females, mean age 74.1 ± 10.3 years; 17 males, mean age 68.1 ± 12.4 years) meeting inclusion criteria. Correlation analyses for L1 to L4 showed significant positive relationships (p < 0.0001), with the strongest correlation at L2 between HU and BMD (ρ = 0.75). Conclusions: the DR model for automated assessment of volumetric HUs offers a highly reliable, efficient, and precise alternative to DXA measurements.

Background/Objectives: Traditional fusion leads to a loss of spine mobility across the fused vertebrae. Vertebral body tethering (VBT) was developed with the goal of increasing flexibility and maintaining some spinal mobility. However, it is not known if the additional mobility leads to significant functional improvement. This prospective motion analysis study evaluates functional outcomes, specifically gait stability, in pre-operative, post-fusion, and post-VBT patients by using postural perturbations on a treadmill. Methods: Overall, 79 subjects underwent a computer-controlled treadmill study with postural perturbations, which simulated trips and slips. The subjects were harnessed for safety. Overall, 21 subjects were healthy controls, 18 patients were at least one-year post-VBT, 15 patients were at least one-year post-fusion, and 25 were pre-operative scoliosis patients. Subject weight, height, and treadmill acceleration were recorded and used to determine anteroposterior single (ASSTs, PSSTs) and multiple (AMSTs, PMSTs) stepping thresholds to describe the maximum torque a patient could withstand before failing to recover from the simulated trip. Independent t-tests were run to compare groups under the advice of a master statistician with expertise in orthopedic surgery. Results: Pre-operative scoliosis patients had lower PSSTs than healthy controls (uncorrected p = 0.036). No significant differences were observed between pre-operative and post-operative groups for both fusion and VBT. There was no significant difference in ASST, AMST, or PMST between any of the groups. Conclusions: The lower PSST in pre-operative scoliosis patients compared to healthy controls may reflect impaired reactive balance and potentially increased fall risk. Interestingly, there was no significant difference in reactive balance measures between pre-operative and post-operative scoliosis patients or between post-fusion and post-VBT patients.