Adolescent idiopathic scoliosis (AIS) is a 3D spinal deformity affecting children between the ages of 11 and 18, without an identifiable etiology. The authors here reviewed the available literature to provide spine surgeons with a summary and update on current management options.Smaller thoracic and thoracolumbar curves can be managed conservatively with observation or bracing, but corrective surgery may be indicated for rapidly growing or larger curves. The authors summarize the atypical features to look for in patients who may warrant further investigation with MRI during diagnosis and review the fundamental principles of the surgical management of AIS.Patients with AIS can be managed very well with a combination of conservative and surgical options. Outcomes for these children are excellent with sustained longer-term results.

Congenital scoliosis is a complex spinal problem associated with many other anomalous findings. Treatment options are diverse but enable optimization of management and care of these children.

Osteomyelitis is an infection of the bone that can involve the vertebral column. A rare cause of vertebral osteomyelitis is Mycobacterium bovis after intravesical Bacillus Calmette-Guerin (BCG) therapy for transitional cell carcinoma of the bladder. In this report, we describe the case of a 64-year-old male presenting with constitutional symptoms, progressive thoracic kyphosis, and intractable T11 and T12 radiculopathies over the proceeding six months. A CT scan revealed erosive, lytic changes of the T12 and L1 vertebrae with compression of the T12 vertebra. An MRI demonstrated T11-12 osteomyelitis with intervening discitis and extensive paraspinal enhancement with a corresponding hyperintensity on a short tau inversion recovery (STIR) sequence. A needle aspiration grew out Mycobacterial tuberculosis complex that was pansensitive to all antimicrobial agent therapies, except pyrazinamide on culture, a finding consistent with an M. bovis infection. The patient’s infection and neurologic compromise resolved after transthoracic T11-12 vertebrectomies with decompression of the spinal cord and nerve roots as well as T10-L1 instrumented fusion and protracted antimicrobial therapy. The epidemiology and natural history of M. bovis osteomyelitis are reviewed and the authors emphasize a mechanism of vertebral inoculation to explain the predilection of M. bovis osteomyelitis in males after intravesical BCG therapy.

BACKGROUND Burnout is a negative workplace syndrome of emotional exhaustion, cynicism, and perceived professional inefficacy that risks the patient-provider relationship, patient care, and physician well-being. OBJECTIVE To assimilate the neurosurgical burnout literature in order to classify burnout among domestic and international neurosurgeons and trainees, identify contributory factors, and appraise the impact of wellness programs. METHODS A scoping review identified the available literature, which was reviewed for key factors related to burnout among neurosurgeons. Two researchers queried PubMed, Embase, Google Scholar, Cochrane, and Web of Science for articles on burnout in neurosurgery and reduced 1610 results to 32 articles. RESULTS A total of 32 studies examined burnout in neurosurgery. A total of 26 studies examined prevalence and 8 studies detailed impact of wellness programs. All were published after 2011. Burnout prevalence was measured mostly through the Maslach Burnout Inventory (n = 21). In 4 studies, participants defined their own understanding of “burnout.” Domestically, burnout prevalence was 11.2% to 67% among residents and 15% to 57% among attendings. Among trainees, poor operative experience, poor faculty relationships, and social stressors were burnout risks but not age, sex, or marital status. Among attendings, the literature identified financial or legal concerns, lack of intellectual stimulation, and poor work-life balance as risks. The impact of wellness programs on trainees is unclear but group exercises may offer the most benefit. CONCLUSION Noticeable methodological differences in studies on trainee and attending burnout contribute to a wide range of neurosurgery burnout estimates and yield significant knowledge gaps. Environment may have greater impact on trainee burnout than demographics. Wellness programs should emphasize solidarity.

OBJECTIVE The authors performed a study to identify clinical characteristics of pediatric patients diagnosed with Chiari I malformation and scoliosis associated with a need for spinal fusion after posterior fossa decompression when managing the scoliotic curve. METHODS The authors conducted a multicenter retrospective review of 44 patients, aged 18 years or younger, diagnosed with Chiari I malformation and scoliosis who underwent posterior fossa decompression from 2000 to 2010. The outcome of interest was the need for spinal fusion after decompression. RESULTS Overall, 18 patients (40%) underwent posterior fossa decompression alone, and 26 patients (60%) required a spinal fusion after the decompression. The mean Cobb angle at presentation and the proportion of patients with curves > 35° differed between the decompression-only and fusion cohorts (30.7° ± 11.8° vs 52.1° ± 26.3°, p = 0.002; 5 of 18 vs 17 of 26, p = 0.031). An odds ratio of 1.0625 favoring a need for fusion was established for each 1° of increase in Cobb angle (p = 0.012, OR 1.0625, 95% CI 1.0135-1.1138). Among the 14 patients older than 10 years of age with a primary Cobb angle exceeding 35°, 13 (93%) ultimately required fusion. Patients with at least 1 year of follow-up whose curves progressed more 10° after decompression were younger than those without curve progression (6.1 ± 3.0 years vs 13.7 ± 3.2 years, p = 0.001, Mann-Whitney U-test). Left apical thoracic curves constituted a higher proportion of curves in the decompression-only group (8 of 16 vs 1 of 21, p = 0.002). CONCLUSIONS The need for fusion after posterior fossa decompression reflected the curve severity at clinical presentation. Patients presenting with curves measuring > 35°, as well as those greater than 10 years of age, may be at greater risk for requiring fusion after posterior fossa decompression, while patients less than 10 years of age may require routine monitoring for curve progression. Left apical thoracic curves may have a better response to Chiari malformation decompression.

OBJECTIVEThe authors reviewed the transfer requests for isolated pediatric traumatic brain injuries (TBIs) at a Level I/II facility with the goal of identifying clinical and radiographic traits associated with potentially avoidable transfers that could be safely managed in a non–tertiary care setting.METHODSThe authors conducted a retrospective study of patients < 18 years of age classified as having TBI and transferred to their Level I tertiary care center over a 12-year period. The primary outcome of interest was identifying potentially avoidable transfers, defined as transfers of patients not requiring any neurosurgical intervention and discharged 1 hospital day after admission.RESULTSOverall, 70.8% of pediatric patients with isolated TBI did not require neurosurgical intervention or monitoring, indicating an avoidable transfer. Potentially avoidable transfers were associated with outside hospital imaging that was negative (86%) or showed isolated, nondisplaced skull fractures (86%) compared to patients with cranial pathology (53.8%, p < 0.001) as well as age ≤ 6 years (81% [negative imaging/isolated, nondisplaced fractures] vs 54% [positive cranial pathology], p < 0.001). The presence of headaches, nonfocal deficits, and loss of consciousness were associated with necessary transfer (p < 0.05). Patients with potentially avoidable transfers underwent frequent repeat CT studies (19.1%) and admissions to the pediatric intensive care unit (55.9%) but at a lower rate than those whose transfers were necessary (p < 0.001). Neurosurgical interventions occurred in 11% of patients with cranial pathology, which accounted for 17.9% of necessary transfers and 5.2% of all transfers.CONCLUSIONSIn the authors’ region, potentially up to 70% of interfacility transfers for pediatric brain trauma in the absence of other systemic injuries warranting surgical intervention may not require neurosurgical intervention and could be managed locally. No patients transferred with isolated, nondisplaced skull fractures or negative CT scans required neurosurgical intervention, and 86% were discharged the day after admission. In contrast, 11% of patients with CT scans indicative of cranial pathology required neurosurgical intervention. Age > 6 years, loss of consciousness, and nonfocal deficits were associated with a greater likelihood of needing a transfer. Further studies are required to clarify which patients can be managed at local institutions, but referring centers should practice overcaution given the potential risks.

Background/Aims: To characterize the impact of cranial asymmetry and age at initiation of therapy on final cranial asymmetry in infants with deformational plagiocephaly treated with helmet orthotics. Methods: We conducted a single-center retrospective review of 45 pediatric patients <12 months of age with deformational plagiocephaly who underwent STARband cranial orthotic helmet treatment. Cranial asymmetry was measured using a 3-dimensional laser surface scanner and defined as a cranial vault asymmetry index (CVAI) >3.5%. Results: Twenty-one patients (47%) were <6 months of age at the start of helmet therapy. A greater initial CVAI or age at therapy initiation correlated with a greater final CVAI (univariate analysis, r = 0.53, p < 0.001; r = 0.42, p = 0.004). Subgroup analysis of 18 patients beginning therapy at 4-5 months of age and 20 patients beginning therapy at 6-8 months of age revealed that only a change in the initial CVAI was associated with a change in the final CVAI (r = 0.43, p = 0.007). Conclusion: In a comparison of patients who initiated helmet therapy at 4-5 and 6-8 months of age, only cranial asymmetry at the outset of therapy was correlated with final cranial asymmetry (r = 0.43, p = 0.007).

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