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Comparison of Outcomes After Posterior Spinal Fusion for Adolescent Idiopathic and Neuromuscular Scoliosis: Does the Surgical First Assistant's Level of Training Matter?

Heffernan, Michael J. MD*; Seehausen, Derek A. BA; Andras, Lindsay M. MD; Skaggs, David L. MD, MMM

doi: 10.1097/BRS.0000000000000233
Clinical Case Series

Study Design. This was a retrospective review of posterior spinal fusion surgical procedures in patients diagnosed with adolescent idiopathic scoliosis (AIS) or neuromuscular scoliosis (NMS).

Objective. The purpose was to determine if the first assistant's training experience is associated with outcomes in AIS and NMS surgical procedures.

Summary of Background Data. A previous study found that patients with AIS undergoing posterior spinal fusion with 2 attendings had similar operating times, blood loss, and complication rates compared with those with a resident or fellow first assistant. NMS cases are more complex than AIS cases, but to our knowledge, no previous studies have examined the impact of the first assistant's level of training on NMS outcomes.

Methods. This was a single-center retrospective review of 200 patients, 120 with AIS and 80 with NMS, undergoing primary posterior spinal fusion. Minimum follow-up was 2 years. For each diagnosis group, cases assisted by junior orthopedic residents were compared with those assisted by orthopedic fellows.

Results. NMS cases were more complex and had higher complication rates than AIS cases (P < 0.05). AIS and NMS cases were similarly distributed among the fellow and junior resident groups (P = 0.63). AIS cases in the fellow and junior resident groups had similar operating times, estimated blood loss (EBL), complications, lengths of stay, and reoperation rates (P > 0.05). In NMS cases, the fellow group had shorter operating times (320 ± 73 min vs. 367 ± 104 min, P = 0.035) and greater percent correction at initial and 2-year follow-up (58 ± 15% vs. 42 ± 19%, P < 0.001). EBL, complications, lengths of stay, and reoperation rates were similar between the assistant groups in NMS cases (P > 0.05).

Conclusion. NMS surgical procedures in which fellows serve as the first assistants were associated with shorter operating times and greater percent correction than surgical procedures with junior resident first assistants.

Level of Evidence: 3

Single-center retrospective review of neuromuscular scoliosis and adolescent idiopathic scoliosis cases who underwent posterior spinal fusion and had a minimum follow-up of 2 years. Neuromuscular scoliosis cases assisted by fellows were faster and achieved greater percent correction than those assisted by junior residents.

*Orthopaedic Department, Children's Hospital New Orleans/Louisiana State University Health Science Center, New Orleans, LA; and

Children's Hospital Los Angeles, Children's Orthopaedic Center, Los Angeles, CA.

Address correspondence and reprint requests to David Skaggs, MD, MMM, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mailstop 69, Los Angeles, CA 90027; E-mail:

Acknowledgment date: August 9, 2013. First revision date: December 6, 2013. Acceptance date: January 9, 2014.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

Relevant financial activities outside the submitted work: board membership, consultancy, expert testimony, grants/grants pending, payment for lectures, payment for development of educational presentations, patents, royalties and fellowship program.

© 2014 by Lippincott Williams & Wilkins