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Pediatric Pedicle Screws: Comparative Effectiveness and SafetyA Systematic Literature Review from the Scoliosis Research Society and the Pediatric Orthopaedic Society of North America Task Force
Charles Gerald T. Ledonio, MD1; David W. Polly, Jr., MD1; Michael G. Vitale, MD, MPH2; Qi Wang, MS3; B. Stephens Richards, MD4
1 Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue, Suite R200, Minneapolis, MN 55454. E-mail address for C.G.T. Ledonio: ledon001@umn.edu
2 Division of Pediatric Orthopaedics, Morgan Stanley Children's Hospital of New York–Presbyterian, Columbia University Medical Center, 3959 Broadway-8 North, New York, NY 10032
3 Biostatistical Design and Analysis Center (BDAC), Clinical and Translational Science Institute (CTSI), University of Minnesota, 717 Delaware Street SE, Minneapolis, MN 55414
4 Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390
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Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by the authors of this work are available with the online version of this article at jbjs.org.

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Investigation performed at the University of Minnesota, Minneapolis, Minnesota

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Jul 06;93(13):1227-1234. doi: 10.2106/JBJS.J.00678
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Abstract

Background: 

Pedicle screws are widely used in spinal surgery. There is extensive published literature concerning the use of pedicle screw instrumentation for spinal surgery in adults. Now there is a trend to use pedicle screws in pediatric patients, including the very young. A systematic review of the current English-language literature on the use of pedicle screw instrumentation in the pediatric age group was performed to specifically determine (1) the pedicle screw placement accuracy in patients with spine deformity and (2) the effect size of all-pedicle screw constructs compared with other methods of spinal instrumentation in terms of the percentage of scoliosis correction.

Methods: 

English-language studies of pedicle screw use in pediatric patients (defined as those younger than eighteen years of age) were included. Descriptive statistics synthesized the accuracy of pedicle screw placement. Accuracy rates were compared between pediatric and adult patients. The effect of pedicle screw instrumentation on scoliosis correction was calculated with use of Cobb angle measurements.

Results: 

On the basis of the literature search, 1181 articles were screened, 320 abstracts were examined, and ninety full-text articles representing 5761 patients were reviewed in detail. Seventeen studies met the inclusion criteria for the analysis of pedicle screw placement accuracy. A total of 13,536 pedicle screws were placed in 1353 pediatric patients. The overall placement accuracy rate in pediatric patients was 94.9%, which was higher than the rate of 91.5% reported for adults. The weighted, geometric, and 5% trimmed mean accuracy rates of pedicle screw placement were 91.9%, 88.5%, and 89.1%, respectively (standard deviation = 10%; interquartile range = 10%). Sixteen comparative studies met the inclusion criteria for the analysis of the effect of pedicle screw instrumentation on scoliosis correction. Pedicle screw constructs had a significantly larger percentage of Cobb angle correction compared with hooks (Cohen's d = 1.14) and hybrid constructs (Cohen's d = 0.49).

Conclusions: 

The accuracy of pedicle screw placement in the pediatric spine exceeds the accuracy rate reported in adults. Pedicle screw instrumentation constructs are significantly more effective for scoliosis correction, as determined on the basis of Cobb angle measurements, than are hook constructs and hybrid constructs.

Level of Evidence: 

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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