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. / Adolescent Idiopathic Scoliosis (AIS) is typically treated surgically by Posterior Spinal Fusion (PSF) surgery. Intravenous analgesics and oral opioids are commonly used for pain management. Several adjunct therapies are used in addition to the standard treatments. One of these therapies is the use of dexmedetomidine (dex). Though dex has been found to be an effective sedative for post‐operative patients, there are also several adverse effects that are associated with its use. The purpose of this study was to investigate the effectiveness and overall benefit of using dex for pain control for patients undergoing PSF for AIS. IRB approval was obtained. A group of 43 patients with AIS undergoing PSF and using Dex for adjunctive pain control were matched with 43 patients who did not use Dex. The groups were matched based on gender, age, height, weight, and level of spinal fusion. During the patients’ post‐operative hospital stay, the total opioid use and clinical pain scores were compared between the two groups using t‐tests, with significance set at p<0.05. Total opiate use was 239.6 morphine equivalent doses in the non‐Dex (control) group and 246.2 in the group that received Dex (p=0.72). The average pain score in the control group was 2.3, and the group that received Dex was 2.6 (p =0.43). There were no differences in the complication rate between the two groups, specifically the oversedation rates and pulmonary complications. Lastly, the average length of stay for the control group was 4.8 days compared to the dex group, which was 5.0 days (p=0.35). Although adjunctive pain modalities may be very useful in the treatment of postoperative pain after PSF in patients with AIS, the use of Dex in this cohort did not improve pain scores, lower opioid use, or lower the LOS. Based on these results, we do not recommend the routine use of dexmedetomidine as an adjunctive pain control modality. Adjunctive modalities are important in pain control in patients with AIS undergoing PSF, but the use of dexmedotomidine was not effective in improving pain control.

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.

Scoliosis is defined as a patological curvature of spinal cord of more than 10ř in frontal plane which is combined with rotation of vertebral bodies and also with disruption of fyziological curvatures in sagittal plane. Idiopathic scoliosis is the most frequent type of this diagnosis. The thesis deals with overal issue of this disease, theories of etiology, incidence, classification, types of examination, possibilities of new testing and therapy. The practical part describes rasterstereographic DIERS Formetric III 4D testing and coparison with RTG examination. The study was carried out with 17 girls and 1 boy with idiopathic scoliosis 11 - 46ř at the age of 11 - 17 years. Results of this testing were statistically analysed. Best results were found out in measurements by automatically set range for a group of patients with Cobb angle ≤ 25ř - for 95% differences the limits of correspondance were ± 4ř, the average error was 0,3ř. For group of all patients the limits of correspondance were ± 14ř, the average error was 1,5ř. The results confirmed, that with an increase of Cobb ange a bigger error and systematic error appears.

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.

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Η εφαρμογή κηδεμόνα αποτελεί την πιο αποτελεσματική, μη χειρουργική, μέθοδο αντιμετώπισης μετρίων παραμορφώσεων της σπονδυλικής στήλης στους εφήβους. Φαίνεται όμως να έχει σημαντικές επιπτώσεις στην καθημερινή δραστηριότητα των εφήβων. Με την παρούσα μελέτη διερευνήθηκε η αυτοεκτίμηση της κατάστασης της υγείας των εφήβων με τις δύο πιο κοινές παραμορφώσεις της σπονδυλικής στήλης, οι οποίες αντιμετωπίστηκαν με την χρήση κηδεμόνα. Σε εβδομήντα εννέα εφήβους με παραμόρφωση σπονδυλικής στήλης ( ιδιοπαθής σκολίωση, θωρακική κύφωση Scheuermann ) και εξήντα δύο εφήβους χωρίς παραμόρφωση της σπονδυλικής στήλης (ομάδα ελέγχου) τους ζητήθηκε και συμπλήρωσαν το ερωτηματολόγιο Quality Of Life Profile for Spine Deformities. Η παρούσα μελέτη έδειξε ότι οι έφηβοι με παραμόρφωση της σπονδυλικής στήλης είναι, στατιστικώς σημαντικά, λιγότερο πιθανόν να έχουν πόνο στην ράχη όταν αθλούνται σε σχέση με την ομάδα ελέγχου αλλά περισσότερο πιθανό να έχουν δυσκολίες τόσο όταν σκύβουν όσο και στις καθημερινές δραστηριότητές τους και ενώ φορούν τον κηδεμόνα. Οι έφηβοι αυτοί ( με την παραμόρφωση) παραπονούνται ότι ξυπνούν εξ’ αιτίας πόνου στην ράχη και εκνευρίζονται με την εξωτερική τους εμφάνιση. Οι ασθενείς αυτοί αντιμετωπίζουν, συχνά, προβλήματα στις σχέσεις με τους φίλους τους ενώ αναφέρουν δυσκολίες κατά την έγερσή τους από το κρεβάτι αλλά και στον ύπνο κατά τη διάρκεια της νύχτας, συγκριτικά με τους εφήβους χωρίς παραμόρφωση. Επιπλέον καθώς μεγαλώνουν ηλικιακά αισθάνονται μεγαλύτερη ντροπή για το σώμα τους και ανησυχούν για το μελλοντικό αποτέλεσμα της παραμόρφωσης. Όσο δε ο συνολικός χρόνος 56 εφαρμογής του κηδεμόνα αυξάνεται οι έφηβοι με παραμόρφωση έχουν περισσότερες πιθανότητες να εμφανίσουν μειωμένο πόνο στην οσφύ σε σχέση με τους εφήβους της ομάδας ελέγχου. Τα κορίτσια συγκρινόμενα με τα αγόρια, στις ομάδες με παραμόρφωση, έχουν περισσότερες πιθανότητες να εμφανίσουν πόνο στην οσφύ μετά από τις καθημερινές δραστηριότητες στο σπίτι ή μετά από την γυμναστική. Οι ασθενείς με τα μεγαλύτερα κυρτώματα δυσκολεύονται πιο πολύ στο να σκύψουν ενώ πονούν πιο συχνά στην ράχη. Οι ψυχολογικές επιπτώσεις από τη εφαρμογή του κηδεμόνα στους εφήβους με παραμόρφωση της σπονδυλικής τους στήλης σχετίζονται κυρίως με τις συναναστροφές των παιδιών στο χώρο του σχολείου και σε συνδυασμό με τον πόνο στην ράχη αποτελούν τις κυριότερες αιτίες χαμηλής συμμόρφωσης. Λεπτομερείς συστάσεις και ψυχολογική υποστήριξη απαιτείται για όλους τους ασθενείς που υποβάλλονται σε θεραπεία με κηδεμόνα ενώ κρίνεται απαραίτητη και η σωματική άσκηση, ιδιαίτερα για τα μεγαλύτερης ηλικίας κορίτσια και όλα αυτά με σκοπό να επιτευχθεί η καλύτερη δυνατή συμμόρφωση στην θεραπεία. / Bracing is the most effective non-operative treatment for mild progressive spinal deformities in adolescence but it has shown a considerable impact on several aspects of adolescents’ functioning. This cross-sectional study investigated the self-perceived health status of adolescents with the two most common deformities, treated with body orthosis. Seventy-nine adolescents with spinal deformities (idiopathic adolescent scoliosis, thoracic Scheuermann kyphosis) and 62 adolescents without spinal deformities were asked to complete the Quality of Life profile for Spine Deformities Instrument. This study showed that adolescents with deformities are significantly less likely to have back pain in training than controls, but more likely to have difficulty in forward bending, and in the most common daily activities while in brace. These individuals claim they wake up because of back pain and feel quite nervous with the external appearance of their body. These patients face often problems with their relations with friends, while they reported difficulties in getting up from bed and sleep at night more often than their counterparts without deformities. As they grow older, patients feel increasing ashamed of their body, as they are more concerned about the future effect of the deformity on their body. As the bracing time increases, patients have much more probability than controls to get low back pain. Girls with deformity have a higher probability than boys to get low back pain while working in the house and while training. Individuals 57 with larger spinal curvatures have more difficulties in bending and increased incidence of back pain than their counterparts with smaller curvatures. Psychological reasons associated mainly with relations at school and back pain are the main causes for low compliance in adolescents with spinal deformities treated with body orthosis. Careful instructions for all individuals who will undergo brace therapy, psychological support for all patients who develop psychological reactions and physical training particularly for older girls should be recommended to increase bracing compliance

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.