Treatment of pediatric spine disorders

Idiopathic scoliosis treatment options include bracing and surgery. Because of the great growth potential of the spine in juvenile idiopathic scoliosis (JIS) the right length of the fusion remains unknown. In adolescent idiopathic scoliosis (AIS) it is not yet established which is the best rod alternative. Surgery of the cervical spine is rare and complicated. The goals of this thesis were to study: (1) which brace treatment is more effective in main thoracic AIS, a night-time or full-time brace (Study I)? (2) Does posterior spinal fusion extended to the stable vertebra provide similar outcome in JIS patients compared with AIS patients with fusion to the last central sacral line touched vertebra (Study II)? (3) Which is the optimal rod alternative in deformity correction in adolescents operated for idiopathic scoliosis (Study III)? (4) To review the indications and outcomes of instrumented cervical spinal fusion in children (Study IV). In this study, the Providence night-time brace was as effective in the conservative treatment of main thoracic AIS as the Boston full-time brace. Posterior spinal fusion extended to the stable vertebra provides similar outcomes in JIS patients compared with AIS with fusion to the touched vertebra. Both circular and sagittal reinforced 6.0mm Cobalt-Chromium rods provide adequate coronal correction for adolescents operated for idiopathic scoliosis. The use of sagittal reinforced rods provides better thoracic kyphosis restoration. Skeletal dysplasia associated cervical instability and cervical spine injuries represented the most common indications for instrumented cervical spinal fusion in children. Occipitocervical (OC) spinal fusion and spinal fusion before the age of ten years are associated with higher risk of surgical complications and increased mortality than non-OC fusions and cervical spinal fusions at an older age

Preemptive Pregabalin in Children and Adolescents Undergoing Posterior Instrumented Spinal Fusion A Double-Blinded, Placebo-Controlled, Randomized Clinical Trial

Background: Pregabalin as part of a multimodal pain-management regimen has been shown to reduce opioid consumption after spinal surgery in adults but it is unclear whether this is also true in adolescents. Pregabalin has been found to have neuroprotective effects and therefore could have a positive impact on pain after spinal deformity surgery. We conducted a randomized, double-blinded, placebo-controlled clinical trial of adolescent patients undergoing spinal fusion to evaluate the short-term effects of pregabalin on postoperative pain and opioid consumption. Methods: Adolescents with adolescent idiopathic scoliosis, Scheuermann kyphosis, or spondylolisthesis who were scheduled for posterior spinal fusion with all-pedicle-screw instrumentation were randomized to receive either pregabalin (2 mg/kg twice daily) or placebo preoperatively and for 5 days after surgery. The patients ranged from 10 to 21 years of age. The primary outcome was total opioid consumption as measured with use of patient-controlled analgesia. Postoperative pain scores and opioid-related adverse effects were evaluated. Results: Sixty-three of 77 eligible patients were included and analyzed. Cumulative oxycodone consumption per kilogram did not differ between the study groups during the first 48 hours postoperatively, with a median of 1.44 mg/kg (95% confidence interval [CI],1.32 to 1.67 mg/kg) in the pregabalin group and 1.50 mg/kg (95% CI, 1.39 to 1.79 mg/kg) in the placebo group (p = 0.433). A subgroup analysis of 51 patients with adolescent idiopathic scoliosis showed the same result, with a mean of 1.45 mg/kg (95% CI, 1.24 to 1.65 mg/kg) in the pregabalin group and 1.59 mg/kg (95% CI, 1.37 to 1.82 mg/kg) in the placebo group (p = 0.289). Total oxycodone consumption per hour (mg/kg/hr) was not different between the groups over the time points (p = 0.752). The postoperative pain scores did not differ significantly between the groups (p = 0.196). Conclusions: The use of perioperative pregabalin does not reduce the postoperative opioid consumption or pain scores in adolescents after posterior spinal fusion surgery.Peer reviewe

Cast immobilisation in situ versus open reduction and internal fixation of displaced medial epicondyle fractures in children between 7 and 16 years old. A study protocol for a randomised controlled trial

Introduction Medial epicondyle fracture of the humerus is a common injury in childhood. There is uniform agreement that minimally displaced fractures (dislocation 2 mm dislocation without joint incarceration or ulnar nerve dysfunction. We hypothesise that there is no difference in treatment outcomes between nonoperative and operative treatment.Methods and analysis This is a multicentre, controlled, prospective, randomised noninferiority study comparing operative treatment to non-operative treatment of >2 mm dislocated paediatric medial epicondyle fractures without joint incarceration or ulnar nerve dysfunction. A total of 120 patients will be randomised in 1:1 ratio to either operative or nonoperative treatment. The study will have a parallel nonrandomised patient preference arm. Operative treatment will be open reduction and internal fixation. Nonoperative treatment will be upper limb immobilisation in long arm cast for 4 weeks. Data will be collected at baseline and at each follow-up up to 2 years. Quick-DASH is used as primary outcome measure. Secondary outcomes are patient-reported pain, differences in range of motion, Pediatric Quality of Life Inventory, cosmetic visual analogue scale and Mayo Elbow Performance Score.Ethics and dissemination Ethical approval has been obtained from Helsinki University Hospital (HUS) ethical board HUS/1443/2019. Each study centre has obtained their own permission for the study. A written authorisation from legal guardian will be acquired and the child will be informed about the trial. Results of the trial will be disseminated as published articles in peer-reviewed journals.</div

Cast immobilisation in situ versus open reduction and internal fixation of displaced medial epicondyle fractures in children between 7 and 16 years old. A study protocol for a randomised controlled trial

Introduction Medial epicondyle fracture of the humerus is a common injury in childhood. There is uniform agreement that minimally displaced fractures (dislocation ≤2 mm) can be treated nonoperatively with immobilisation. Open fractures, fractures with joint incarceration or ulnar nerve dysfunction require surgery. There is no common consensus in treatment of closed medial epicondyle fractures with &gt;2 mm dislocation without joint incarceration or ulnar nerve dysfunction. We hypothesise that there is no difference in treatment outcomes between nonoperative and operative treatment.Methods and analysis This is a multicentre, controlled, prospective, randomised noninferiority study comparing operative treatment to non-operative treatment of &gt;2 mm dislocated paediatric medial epicondyle fractures without joint incarceration or ulnar nerve dysfunction. A total of 120 patients will be randomised in 1:1 ratio to either operative or nonoperative treatment. The study will have a parallel nonrandomised patient preference arm. Operative treatment will be open reduction and internal fixation. Nonoperative treatment will be upper limb immobilisation in long arm cast for 4 weeks. Data will be collected at baseline and at each follow-up up to 2 years. Quick-DASH is used as primary outcome measure. Secondary outcomes are patient-reported pain, differences in range of motion, Pediatric Quality of Life Inventory, cosmetic visual analogue scale and Mayo Elbow Performance Score.Ethics and dissemination Ethical approval has been obtained from Helsinki University Hospital (HUS) ethical board HUS/1443/2019. Each study centre has obtained their own permission for the study. A written authorisation from legal guardian will be acquired and the child will be informed about the trial. Results of the trial will be disseminated as published articles in peer-reviewed journals.Trial registration The trial has been registered at clinicaltrials.gov with registration number NCT04531085