Tag Archive | AIS

Journal Club Resident Spotlight: Jui-Yo Hsu

JBJS is pleased to highlight the orthopaedic residents who help implement the Robert Bucholz Resident Journal Club Grants at their institutions. The grant program promotes career-long skills in evaluating the orthopaedic literatureClick here for more information.

Name: Jui-Yo Hsu

Affiliation: National Taiwan University Hospital

What was the topic of the most “dynamic” journal club meeting you have had so far this year?

In March 2021, we hosted a spine journal club focusing on adolescent idiopathic scoliosis (AIS). It was our pleasure to have Prof. Andrew J. Schoenfeld, deputy editor of JBJS, join our discussion. His remarkable advice and unique insight inspired in-depth discussion. Our advisor and moderator, Prof. Shu-Hua Yang (楊曙華), chairperson of Taiwan Spine Society, who is also a pioneer in the field of AIS research, also provided great support to our journal club. The paper we presented was “Selecting the ‘Touched Vertebra’ as the Lowest Instrumented Vertebra in Patients with Lenke Type-1 and 2 Curves” (J Bone Joint Surg Am. 2020 Nov 18;102(22):1966-1973.) by Beauchamp, et al. All the faculty and residents were highly involved in the discussion. Due to the high relevance of this topic to clinical decision making in surgical correction of AIS, both Prof. Schoenfeld and Prof. Yang shared their viewpoints and precious clinical and surgical experiences with the audience.

What are the top 3 characteristics of an engaging, enlightening journal club presentation?

First, it’s important to keep the journal club intriguing to the participants. Therefore, choosing a good topic plays a key role. Residents will be more involved if the topic is clinically important, related to a familiar surgery, or connects to their own ongoing research. Second, because knowledge of the topic may vary between senior and junior residents, we assign one of our senior residents to provide background knowledge before the discussion. Reading the article and preparing in advance are required for every participant, and we also encourage everyone to come up with several questions before the journal club. Finally, support and participation from the faculty are crucial to the journal club. They can provide clinical experiences to residents and provoke further discussion. It is even more beneficial if the participants discuss their own cases with both colleagues and instructors.

How has the COVID-19 pandemic affected your journal-club activities?

In Taiwan, fortunately we were able to maintain normal lives and all residents and staff were able to participate in the journal club in person, despite the global pandemic. However, due to a local outbreak in Taiwan in early May 2021, restrictions were imposed on indoor gatherings. We therefore decided to host our journal club online. In fact, residents were more engaged in online journal club. Using the chatroom feature, residents were able to ask question at any time without interrupting the speaker, and supplementary materials could be shared by anyone at any time. I believe online meetings may become mainstream in the post COVID-19 era.

Aside from orthopaedic content, what have you been reading lately?

I have been reading Cribsheet: A Data-Driven Guide to Better, More Relaxed Parenting, from Birth to Preschool, by Emily Oster. It is a remarkable and useful book for first-time parents. I just welcomed my first child in April 2021, and this book provides practical advice in parenting with enormous medical references. Surprisingly, it was written by an economist. I feel more relieved and confident in parenting my son after reading this book.

How has free access to JBJS Clinical Classroom benefitted you and your journal club?

JBJS Clinical Classroom is very helpful in terms of learning orthopaedic knowledge for both junior and senior residents. Its innovative design makes it very easy and efficient to review previously learned concepts. The content is also very neat but with wide coverage across different specialties, which is also very helpful for orthopaedic board exam preparation.

What’s New in Spine Surgery 2021 

Every month, JBJS publishes a review of the most pertinent and impactful studies reported in the orthopaedic literature during the previous year in 14 subspecialties. Click here for a collection of all such OrthoBuzz specialty-update summaries. 

This month, co-author Jacob M. Buchowski, MD, MS summarizes the 5 most compelling findings from the studies highlighted in the recently published “What’s New in Spine Surgery.” 

Degenerative Cervical Myelopathy

–In a multicenter, double-blinded, placebo-controlled, randomized phase-3 trial, investigators found no additional benefit from riluzole use with regard to functional outcome scores among patients who underwent decompression and fusion for cervical myelopathy1. The primary outcome of interest was the change in the modified Japanese Orthopaedic Association (mJOA) score at 6 months. 

Dysphagia After Multilevel ACDF

–A Level-I double-blinded randomized controlled trial demonstrated a significant decrease in the severity of dysphagia after multilevel anterior cervical discectomy and fusion (ACDF) among patients who received local intraoperative corticosteroids (56 in the treatment group vs 53 in the control group)2. 

Preop. Epidural Steroid Injection and Postop. Infection 

–A retrospective study of patients who underwent lumbar spine surgical procedures for radiculopathy and/or spinal stenosis3 found that: 

  • In the decompression group, there was no significant difference in the postoperative infection rate between those who had a preoperative epidural steroid injection (2,957 of 9,903) and those who did not.  
  • Among those who underwent fusion, there was a significantly higher rate of infection (2.68%) for those who had preoperative epidural steroid injection (1,383 of 5,108) vs those who did not (1.69%).  
  • In the fusion group, there was a significantly higher rate of infection for those who had a steroid injection within 30 days or >90 days preoperatively, but patients with injection between 30 and 90 days preoperatively had no increased risk of postoperative infection. 

Adolescent Idiopathic Scoliosis (AIS)

–In a Level-IV study, investigators examined the relationship between thoracic morphology and pulmonary function in patients with AIS (mean age, 15.6 years)4. They found a strong positive correlation between the costophrenic angle distance and forced vital capacity, FEV1, vital capacity, and total lung capacity, suggesting that the costophrenic angle distance can be used to assess pulmonary function outcome. Their findings also suggest that an apical vertebral deviation ratio of >0.2 is associated with moderate to severe impairment of lung function. 

Early-Onset Scoliosis (EOS) 

–In a cross-sectional study of prospectively enrolled patients across multiple centers, investigators examined the influence of the classification of EOS etiology, radiographic parameters, and medical comorbidities on the Early Onset Scoliosis Questionnaire (EOSQ), a measure of health-related quality of life. Scores were lower in many EOSQ domains for patients with neuromuscular and syndromic etiologies. The total and subdomain scores were similar between patients with congenital and idiopathic EOS.  

References 

  1. Fehlings MG, Badhiwala JH, Ahn H, Farhadi HF, Shaffrey CI, Nassr A, Mummaneni P, Arnold PM, Jacobs WB, Riew KD, Kelly M, Brodke DS, Vaccaro AR, Hilibrand AS, Wilson J, Harrop JS, Yoon ST, Kim KD, Fourney DR, Santaguida C, Massicotte EM, Kopjar B. Safety and efficacy of riluzole in patients undergoing decompressive surgery for degenerative cervical myelopathy (CSM-Protect): a multicentre, double-blind, placebo-controlled, randomised, phase 3 trial. Lancet Neurol. 2021 Feb;20(2):98-106. Epub 2020 Dec 22. 
  2. Kim HJ, Alluri R, Stein D, Lebl D, Huang R, Lafage R, Bennett T, Lafage V, Albert T. Effect of topical steroid on swallowing following ACDF: results of a prospective double-blind randomized control trial. Spine (Phila Pa 1976). 2021 Apr 1;46(7):413-20.  
  3. Kreitz TM, Mangan J, Schroeder GD, Kepler CK, Kurd MF, Radcliff KE, Woods BI, Rihn JA, Anderson DG, Vaccaro AR, Hilibrand AS. Do preoperative epidural steroid injections increase the risk of infection after lumbar spine surgery? Spine (Phila Pa 1976). 2021 Feb 1;46(3):E197-202. 
  4. Deng Z, Luo M, Zhou Q, Yang X, Liu L, Song Y. Relationship between pulmonary function and thoracic morphology in adolescent idiopathic scoliosis: a new index, the “apical vertebra deviation ratio”, as a predictive factor for pulmonary function impairment. Spine (Phila Pa 1976). 2021 Jan 15;46(2):87-94. 

 

Postop Dexamethasone Cuts Opioid Use after AIS Surgery

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Impact Science, in response to a recent article in JBJS.

Pain management is an important aspect of postoperative care after posterior spinal fusion for the treatment of adolescent idiopathic scoliosis (AIS). Opioid medications, while highly effective and commonly used for postoperative analgesia, have many well-documented adverse effects. Several recent studies have suggested that dexamethasone, a glucocorticoid, is an effective adjunct for postoperative pain management after many adult orthopaedic procedures, but its use after AIS surgery has not been well studied.

Beginning in 2017, doctors at Children’s Healthcare of Atlanta added dexamethasone to their postoperative pain control pathway for adolescent spinal-fusion patients. In the October 21, 2020 issue of The Journal of Bone & Joint Surgery, Fletcher et al. report findings from a cohort study that investigated the postoperative outcomes of 113 patients (median age of 14 years) who underwent posterior spinal fusion between 2015 and 2018. The main outcome of interest—opioid consumption while hospitalized—was determined by converting all postoperative opioids given into morphine milligram equivalents (MME).

Because dexamethasone entered their institution’s standardized pathway for this operation in 2017, it was easy for the authors to divide these patients into two groups; 65 of the study patients did not receive postoperative steroids, while 48 patients were managed with 3 doses of steroids postoperatively. Relative to the former group, the latter group showed a 39.6% decrease in total MME used and a 29.5% decrease in weight-based MME. Patients who received postoperative dexamethasone were also more likely to walk at the time of initial physical therapy evaluation. Notably, the authors found no differences between the groups with regard to wound dihescence or 90-day infection rates—2 complications that have been associated with chronic use of perioperative steroids.

In commenting on these findings, Amy L. McIntosh, MD from Texas Scottish Rite Hospital for Children writes that she was so impressed that she plans “on adding dexamethasone to our institution’s standardized AIS care pathway.”

Impact Science is a team of highly specialized subject-area experts (Life Sciences, Physical Sciences, Medicine & Humanities), who collaborate with authors, societies, libraries, universities, and various other stakeholders for services to enhance research impact. Through research engagement and science communication, Impact Science aims at democratizing science by making research-backed content accessible to the world.

Is the Tethering Juice Worth the Squeeze in AIS?

The tried-and-true treatment for progressive adolescent idiopathic scoliosis (AIS) is a posterior spinal fusion (PSF). However, for skeletally immature patients, there is increasing interest in motion-sparing growth modulation, specifically anterior vertebral body tethering (AVBT). Early reports on tethering looked promising, but the long-term prognosis remains fuzzy.

Newton et al. clarify this somewhat in the May 6, 2020 issue of JBJS. They retrospectively compared outcomes among a cohort of 23 AVBT patients followed for a mean of 3.4 years with those among a matched cohort of 26 PSF patients followed for a mean of 3.6 years. The groups were well-matched in terms of demographics and preoperative curve measurements, but the AVBT group was slightly less skeletally mature based on triradiate cartilage status and Sanders classification.

The authors found that both groups experienced significant postoperative curve correction, but the PSF group had significantly greater immediate correction of the main thoracic curve (78%) than the AVBT group (36%). Smaller immediate correction is to be expected in a growth-modulation procedure, which allows the spine to “grow straighter” over time with the tether. But at the final follow-up, the AVBT group had only a 43% curve correction versus 69% final follow-up correction in the PSF group. In addition, 9 revision procedures occurred in the AVBT group, versus none in the PSF group. Twelve patients (52%) in the AVBT group had evidence of broken tethers, with 3 of those patients undergoing revision surgery due to curve progression linked to tether breakage.

Overall, 12 of 23 patients in the AVBT group (52%) were deemed a “clinical success” at the end of the study (defined as a thoracic curve <35° without a need for a secondary fusion) while all 26 patients in the PSF group were deemed a clinical success. Anterior vertebral body tethering may have a role in the treatment of scoliosis in the growing spine, but the results to date, including these from Newton et al., lead me to question whether the tethering “juice” in its current form is worth the “squeeze.”

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media