A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / Surgical correction of Adolescent Idiopathic Scoliosis (AIS) carries a substantial risk of complication. The literature supports improved perioperative outcomes through the two surgeon strategy in other complex orthopedic procedures. Does the presence of 2 versus 1 attending surgeons affect the perioperative morbidity of posterior spinal fusion (PSF) in patients with AIS curves greater than 70°? We reviewed the database from a large regional children’s hospital of all patients with AIS curves greater than 70° who underwent PSF from 2009‐2014 and divided the cohort into single versus 2‐surgeon groups (28 vs. 19 cases, respectively). We analyzed cases for length of surgery, estimated blood loss, and length of stay. The groups were identical when comparing age, gender, spinal levels fused, and average ASA score. However, the average Cobb angle in the single surgeon group was significantly less than in the 2 surgeon group at 78.4 vs 84.0 degrees, respectively (p=0.049). Mean operative time for single versus 2 surgeons was 238 (SD 48) vs 212 (SD 46) minutes (p=0.078). Mean percent estimated blood loss was 26% (SD 14.1) for single surgeon vs 31% (SD 14.9) for 2 surgeons (p=0.236), and mean estimated blood loss for single surgeon vs 2 surgeons was 830ml (SD 361) vs 1045ml (SD 346) (p=0.052). Mean length of stay was significantly decreased in the 2 surgeon group at 5.16 days (SD 1.7) versus the single surgeon group at 6.82 days (SD 6.82) (p=0.002). The use of 2 surgeons in AIS deformity correction at an experienced regional children’s hospital did not improve clinical outcomes. The average length of stay was reduced in the two‐surgeon group, but there was no significant impact on blood loss or operative time. However, this study does not rule out the potential for positive impact with a two‐surgeon strategy, and given previous supportive data in the literature, this approach should further evaluated to determine its effect on improving perioperative outcomes.

Concerns, Desires and Expectations Of Surgery For Adolescent Idiopathic Scoliosis: A Comparison Of Patients’, Parents’ & Surgeons’ Perspectives. Master of Science, 2008 Unni G. Narayanan Department of Health Policy, Management & Evaluation University of Toronto ABSTRACT This study explored the concerns, desires (goals) and expectations of adolescents undergoing surgery for idiopathic scoliosis, and contrasted their priorities with those of their parents and surgeons. Parents were more concerned than their children about the consequences of scoliosis and of surgery. With the exception of improving physical appearance, surgeons' goals of surgery were different from those of either the patients or parents. There was little agreement among surgeons about the natural history of scoliosis, other goals of surgery and the likelihood of specific outcomes. Parents wanted and expected more from surgery than their children. Parents and patients had greater expectations of surgery than surgeons. Although adolescents had different priorities from their parents, parents were aware of these differences and reliably predicted their children’s priorities. These findings have important implications on shared decision-making and informed consent, and might contribute to better understanding and measurement of outcomes that matter to patients.

Concerns, Desires and Expectations Of Surgery For Adolescent Idiopathic Scoliosis: A Comparison Of Patients’, Parents’ & Surgeons’ Perspectives. Master of Science, 2008 Unni G. Narayanan Department of Health Policy, Management & Evaluation University of Toronto ABSTRACT This study explored the concerns, desires (goals) and expectations of adolescents undergoing surgery for idiopathic scoliosis, and contrasted their priorities with those of their parents and surgeons. Parents were more concerned than their children about the consequences of scoliosis and of surgery. With the exception of improving physical appearance, surgeons' goals of surgery were different from those of either the patients or parents. There was little agreement among surgeons about the natural history of scoliosis, other goals of surgery and the likelihood of specific outcomes. Parents wanted and expected more from surgery than their children. Parents and patients had greater expectations of surgery than surgeons. Although adolescents had different priorities from their parents, parents were aware of these differences and reliably predicted their children’s priorities. These findings have important implications on shared decision-making and informed consent, and might contribute to better understanding and measurement of outcomes that matter to patients.

OBJECTIVE: The objective of this study is to determine the different biological, psychological, and social factors that affect patient adherence in bracing treatment for adolescent idiopathic scoliosis. By comparing adherent and non-adherent bracing patients, we hope to gain insight into how to improve patient adherence in bracing as a means of primary treatment and to avoid secondary and tertiary treatments such as surgery. METHODS: Of the 19 patients (15 adherent, 4 non-adherent) who were examined for this study, the majority of them completed all psychosocial surveys at one time point in their bracing treatment. Patients answered surveys for multidimensional anxiety, generalized anxiety, pain-related fear and avoidance, pain catastrophizing, and quality of life. Quantitative sensory testing was performed on only 5 of the 19 patients at the time of writing. Sensory testing was conducted to gather information on thermal sensitivities and thresholds. Statistical t-test significance was determined for all surveys distributed to adherent and non-adherent bracing groups, and scaled T-scores were calculated for each survey measure to determine clinical significance. RESULTS: There were no statistically significant differences in any measures examined between adherent and non-adherent bracing patients. The only statistically significant difference was the number of hours of brace wearing, with the adherent group wearing their brace over 11 hours more than the non-adherent group (p < 0.0004). CONCLUSIONS: Because of the underpowered nature of this study, measures for multidimensional anxiety, generalized anxiety, pain-related fear and avoidance, pain catastrophizing, and quality of life should be reexamined for potential differences between adherent and non-adherent bracing patients. Quantitative sensory testing should be included as a measure of possible sensory differences between the two groups. A future study with a larger sample size may provide greater understanding into the motivations for bracing adherence in an effort to help patients avoid more invasive means of intervention in treating adolescent idiopathic scoliosis.

Adolescent idiopathic scoliosis (AIS) is an extremely common three-dimensional (3-D) deformity of the spine, affecting the population between 10 and 18 years of age. Early detection of AIS is critical, as the earlier that the spinal deformity can be identified, the more likely it is that curve progression can be minimized or arrested using conservative treatment options. However, today much of the responsibility for detecting AIS falls on untrained parents. Therefore, the purpose of this thesis project is to use images taken with a smartphone containing a depth sensor to create a simple and effective machine learning (ML) algorithm that can detect the absence or presence of scoliosis. Secondarily, this thesis project aims to 1) provide a proof of concept for a regression-based ML algorithm that can predict the main curvature of the scoliotic spine and 2) to determine if the depth information from the smartphone contains additional features or information that can improve the performance of the ML algorithm when compared to regular red-green-blue (RGB) images. Thirty-three participants (28 AIS; 5 Control) were recruited from the Children’s Hospital of Eastern Ontario (CHEO). Images of the unclothed backs of participants were taken with a smartphone (Samsung S20 Ultra 5G) containing a depth sensor, while participants assumed two positions: an upright standing posterior-anterior (PA; mirroring the position participants are in when getting an EOS scan) and a forward bending position. A convolutional-neural-network (CNN)-backed decision tree algorithm was developed and trained using three different data streams: a red-green-blue-depth (RGB-D), a Colourized depth map, and an RGB data stream. It was determined that the model trained with the Colourized forward bending images had the highest overall accuracy. The CNN backed decision tree was able to classify images of participants in a forward bend posture with an accuracy of 93%, specificity of 75%, and a sensitivity of 99%. Additionally, it was found that all algorithms trained with the varying data streams were able to predict the Cobb angle of the spine within 16° of the ground truth Cobb angles. The lowest root mean square error (RMSE) values were obtained from the RGB images when the participants were in the PA position. The PA RGB dataset had RMSE values of 7.17° between the ground truth and predicted Cobb angles. Inter-rater reliability errors typically range between 5-7° for manually measured Cobb angles. Therefore, given the calculated RMSE for the PA RGB dataset were close to this range, there is the potential to use this smartphone technology to screen for scoliosis and predict the curvature of the spine (Morrison et al., 2015). While these results are promising, the dataset is small compared to other studies; therefore, this thesis provides a proof of concept, and more work needs to be done to increase the robustness of the model and to further improve the ability of the model to predict the Cobb angle of the spine.

Title Gait Analysis in Adolescents with Idiopathic Scoliosis: A Systematic Review. Aim The role of spine is vital as a gait stabilizer. Gait analysis may provide a more holistic view of how the body behaves to idiopathic scoliosis among adolescents. The aim of this thesis is to review the effectiveness and validity of gait analysis in examining AIS, and secondly to assess how the gait of AIS patients differ from adolescents without scoliosis. Method A systematic review of the topic was conducted. Information was gathered from six e-databases, and seventeen articles were selected, of which seven focusing solely on AIS subjects (i.e. non-comparative) and ten were focusing on AIS in relation to control subjects (i.e. comparative). Results Spatio-temporal (STP), kinematic, kinetic and EMG parameters show significant changes in AIS subjects during walking. But variations between results, lack of data for certain parameters and no significant relationship between gait parameters and scoliosis was also seen. Furthermore, AIS subjects differ in performance compared to non-scoliosis adolescents in at least one gait parameter across all studies. This includes abnormalities in muscle activity, less economical use of the body, poorer performance in kinematic parameters and differences in STP such as step...

Objective: Research on the role of acute post-surgical pain in children is extremely important in order to have a positive influence on pre-surgical preparation and post-surgical care and to prevent pain from becoming chronic, which can extend decades into adulthood. This project aims to identify predictors of acute post-surgical pain in adolescents with idiopathic scoliosis undergoing spinal fusion by utilizing sensory thresholds obtained through quantitative sensory testing (QST). Methods: Eligible candidates were Adolescent Idiopathic Scoliosis (AIS) patients ages 10-17 who have been recommended to receive elected spinal fusion surgery at Boston Children's Hospital (BCH). 9 successfully recruited and enrolled participants underwent a full series of QST tests on their palmar thenar eminence (non-surgical site), and their lower back (surgical site). Patients' Light Touch Detection Threshold (LTDT) and Pain Detection Threshold (PDT) scores were determined using Von Frey Hairs. Patients' Pressure-Pain Sensation Threshold (PPST) scores were determined using a pressure algometer. Patients' Warm/Cool and Hot/Cold Pain Detection Thresholds were detected using a calibrated thermode strapped to the skin. Following the full-series of QST tests, and after the patient was discharged from the hospital, a retrospective chart review was conducted to determine the patients': Age at Surgery, Gender, Number of Vertebrae Fused (Fusion Length), Length of Surgery, Pre-Operative Self-Identified Pain Level (NRS 0-10), Average Post-Operative Acute-Phase Self-Identified Pain Level (NRS 0-10), and daily Pain Medication Doses (Opiate Vs. Non-Opiate Vs. Total). Correlation calculations were done between each variable, including those determined through QST as well as retrospective chart review. For every QST test, each patient's individual score was compared to the cohort's median score, which helped determine whether the patient was either hyper- or hyposensitive for that particular test. For each QST test, these hyper- and hyposensitive groups were then compared to see if there were any significant differences in post-operative pain experienced. Results: Due to the low number of participants (N = 9), the results should be considered preliminary. Correlation studies demonstrate that pre-operative pain was significantly positively correlated with post-operative pain (r = 0.81, p <0.05), indicating that patients who are pre-operatively already in pain, will consequently experience the most pain post-operatively. Additionally, fusion length had a strong positive correlation to acute post-operative opiate pain medication administration (r = 0.71, P < 0.05), indicating that patients who had more vertebrae fused were given more opiates. Through the use of QST, we discovered that patients hypersensitive in the LTDT-Spine QST test experienced significantly less pain post-operatively (3.22 NRS 0-10) than that experienced by hyposensitive patients (5.52 NRS 0-10) from the same test. Identical results were discovered in patients determined hyper- and hyposensitive using the PPST-Spine test, respectively. Retrospective chart review data show that these hyposensitive patients were experiencing greater pain pre-operatively (0.75 NRS 0-10) than that experienced by the hypersensitive patients (0 NRS 0-10), which may have contributed to the hyposensitive cohort's greater post-operative pain. Although insignificant, patients hypersensitive in the Hot Pain - Spine QST test experienced greater post-operative pain (4.72 NRS 0-10) than that experienced by hyposensitive patients in the same test (4.06 NRS 0-10). Conclusions: The goal of this study was to determine a substantiated hypothesis to test in the future, using larger pediatric cohorts. Even though it initially appears that the hyposensitive patients, as determined by the LTDT-Spine and PPST-Spine QST tests, experienced greater post-operative pain, one must consider the fact that this hyposensitive group experienced a significantly greater amount of pre-operative pain. Not only has pre-operative pain been proven to have a strong correlation to post-operative pain in this study, it has also been proven in other larger studies as well. Other studies have identified a test similar to the Hot Pain - Spine QST test as a potential predictor of post-operative pain. The present study's results, although insignificant, share the same conclusion that hypersensitive patients determined through Hot Pain - Spine QST test experience greater post-operative pain. Therefore, the hypothesis to test in the future in pediatric cohorts should read: AIS patients with no pre-operative pain who demonstrate increased sensitivity to hot pain on their surgical site via thermal stimulation (QST) will experience greater post-operative pain in the acute-recovery phase.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) surgery is the most common reason for elective pediatric orthopaedic surgery. Minimization of adverse events is an important goal. Institute of Medicine (IOM) outlined 6 facets of healthcare quality improvement within the acronym STEEEP. Two of these facets, Safety and Timeliness for AIS surgery in Canada, are examined in this thesis. METHODS: A three - part study, using clinical records at the largest Canadian pediatric hospital and CIHI national administrative data, determined i) the relationship between surgical wait times and rates of adverse events, along with determination of an empirically derived access target, ii) accuracy of ICD-10 coding of surgical AIS cases along with an optimal search strategy to identify surgical AIS cases, and iii) the volume – outcome relationships for scoliosis surgery using hierarchical and conventional single level multi-variate regression analysis. RESULTS: Access target of 3 months minimized the adverse events related to waiting. Optimal search strategy for AIS surgical cases using ICD-10 coding required combination of codes as each code in isolation was inaccurate due to limitations in coding definitions. There was no significant volume – outcome relationship using appropriate modeling strategies. CONCLUSIONS: Ensuring timeliness of surgical treatment of less than 3 months is important in surgical cases of AIS given the potential for curve progression in higher risk individuals who are skeletally immature with large magnitude curves at time of surgical consent. At the administrative database level, knowledge of coding accuracy and optimal search strategies are needed to capture a complete cohort for analysis. In AIS, several ICD-10 codes need to be combined. AIS surgery cases captured through this optimal search strategy, revealed no significant volume-outcome relationships with appropriate modeling. Based on these results, minimum volume thresholds and regionalization of care for AIS surgery does not appear to be justified. However, a larger sample size was needed to determine whether there was a clinically significant difference in wound infection and blood transfusion rates. Furthermore, clinical variables, not part of an administrative database such as curve pattern were not included.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) surgery is the most common reason for elective pediatric orthopaedic surgery. Minimization of adverse events is an important goal. Institute of Medicine (IOM) outlined 6 facets of healthcare quality improvement within the acronym STEEEP. Two of these facets, Safety and Timeliness for AIS surgery in Canada, are examined in this thesis. METHODS: A three - part study, using clinical records at the largest Canadian pediatric hospital and CIHI national administrative data, determined i) the relationship between surgical wait times and rates of adverse events, along with determination of an empirically derived access target, ii) accuracy of ICD-10 coding of surgical AIS cases along with an optimal search strategy to identify surgical AIS cases, and iii) the volume – outcome relationships for scoliosis surgery using hierarchical and conventional single level multi-variate regression analysis. RESULTS: Access target of 3 months minimized the adverse events related to waiting. Optimal search strategy for AIS surgical cases using ICD-10 coding required combination of codes as each code in isolation was inaccurate due to limitations in coding definitions. There was no significant volume – outcome relationship using appropriate modeling strategies. CONCLUSIONS: Ensuring timeliness of surgical treatment of less than 3 months is important in surgical cases of AIS given the potential for curve progression in higher risk individuals who are skeletally immature with large magnitude curves at time of surgical consent. At the administrative database level, knowledge of coding accuracy and optimal search strategies are needed to capture a complete cohort for analysis. In AIS, several ICD-10 codes need to be combined. AIS surgery cases captured through this optimal search strategy, revealed no significant volume-outcome relationships with appropriate modeling. Based on these results, minimum volume thresholds and regionalization of care for AIS surgery does not appear to be justified. However, a larger sample size was needed to determine whether there was a clinically significant difference in wound infection and blood transfusion rates. Furthermore, clinical variables, not part of an administrative database such as curve pattern were not included.

The purpose of this study was to investigate whether there is an association between developmental milestones of babies and the prevalence of spinal deformities in adolescents in Middelburg, Mpumalanga. The relationship between spinal deformities in a cross-sectional group of adolescents and parental recall was the focus of the study. One hundred and four adolescents were evaluated to determine if a spinal deformity was present. The subjects were then allocated to either the case (those with spinal deformities) or the control (subjects without spinal deformities) groups. The mothers of the subjects were then interviewed with regard to some of the developmental milestones of their offspring, and other factors which may have had an influence on the development of adolescent spinal deformities. The results showed that a perfectly "normal spine" was seldom found and that even in the control group some minor deviations, within normal limits, were present. Most of the mothers of subjects from the case group did not realise that their offspring had a deformity. There was a non¬significant trend for more crawlers to be present in the control group. Subjects who did not crawl, and who were also late walkers appeared to have an increased tendency to develop adolescent spinal deformities. Despite the fact that the schools approached were multi-racial, only white parents responded to the request for participation in this trial. The possible reasons for this should be investigated and a trial comparing the prevalence of spinal deformities amongst adolescents from all ethnic groups in South Africa should be conducted. Due to the possible recall bias of this study, it is recommended that a longitudinal study, commencing with the babies attending baby clinics in South Africa (representative of the South Africa population), be conducted to determine the influence of developmental milestones on the prevalence of spinal deformities in adolescence. / Dissertation (MPhysiotherapy)--University of Pretoria, 2010. / Physiotherapy / unrestricted