Biomedical Engineering: AIS Anterior Approach Progress Report

This report presents a progress analysis on the anterior approach for treating Adolescent Idiopathic Scoliosis (AIS). It begins with an executive summary and table of contents, followed by an introduction that defines scoliosis and AIS, emphasizing the complexity of the three-dimensional deformity and the rationale for surgery. The report compares the anterior and posterior surgical methods, highlighting their advantages and disadvantages. It then details the anterior scoliosis surgery procedure, including patient positioning, incision techniques, and instrumentation. The report further explores management theories, including bureaucratic, human resource, patient-centered, and institutional theories, and how these approaches can be applied to reduce treatment costs, hospitalization duration, and improve patient outcomes. The methodology section outlines data collection and analysis, the work done so far, and future plans. The report concludes with a summary of findings and a list of references, including an appendix.

Running head: BIOMEDICAL ENGINEERING
Progress report on anterior approach to treat Adolescent Idiopathic Scoliosis (AIS)
Name of the Student
Name of the University
Author Note

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Executive summary
Scoliosis is a three-dimensional spine deformity. It can be categorized into different types like
syndromic, congenital and idiopathic. Adolescent idiopathic scoliosis (AIS) is one of the most
common spinal deformities. Metabolic, neuromuscular, genetic or hormonal cases are possible
reasons for these conditions. Though, there are certain disadvantages, anterior surgery is
generally preferred over posterior approach. This report is a progress report to demonstrate how
management strategies can be applied to reduce treatment cost, hospital stay duration, pain
sensation and healing after AIS anterior surgery. It will illustrate the process by which data can
be collected and analyzed to produce improved patient outcomes.

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Table of Contents
Introduction......................................................................................................................................3
Comparison of 2 methods................................................................................................................3
Anterior Scoliosis surgery...............................................................................................................5
Management theory.........................................................................................................................8
Methodology..................................................................................................................................13
Use of management approaches................................................................................................13
Data collection...........................................................................................................................14
Work done so far...........................................................................................................................14
Future plan.....................................................................................................................................15
Conclusion.....................................................................................................................................15
References......................................................................................................................................17
Appendix........................................................................................................................................21

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Introduction
Scoliosis deformity is defined by the Scoliosis Research Society as the lateral curvature
of the spine in the coronal plane. This deformity is detected by a radiograph of the spine, taken in
standing posture. The degree of the curve is measured as the angle between most inclined end-
plates of the vertebral column, at the end of each curve measures the degree of the curve and is
referred to as the Cobb angle (Weinstein et al., 2013). Adolescent idiopathic scoliosis (AIS)
manifests as a curvature of the lumbar and the thoracic spine. If there is a persistent lateral
curvature of more than 10 degrees between the lumbar and thoracic spine, in upright position, the
condition is termed AIS. It is a complex 3-dimensional deformity due to spine rotation and
various plane curvatures in addition to lateral curvature. Surgery is generally used to treat the
scoliotic deformity, which is likely to progress. AIS surgery is recommended for adolescents
with a spinal curve with Cobb angle values larger than 45°-50° (Konieczny, Senyurt & Krauspe,
2013). The surgical procedures aim to achieve a solid fusion, correct the deformity and improve
cosmetic appearance. Thereby, the curve progression gets arrested.. The main principle
underlying this technique is using the spine in the form of a structural scaffold to cement the
parts using a bone paste on the scaffold (Donzelli et al., 2014). Metal screws, rods and wires are
used to reinforce fusion stability. A posterior or an anterior approach can be used for this fusion
surgery.
Comparison of 2 methods
 Posterior approach- The process involves a straight incision along the midline. It is most
commonly used to treat all curvature defects.

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ADVANTAGES DISADVANTAGES
It involves a simple exposure, where it is
relatively easy to reach the operative field.
Less disc space is removed.
There are negligible risks associated with
neurovascular compromise (Charosky et al.,
2012).
There is violation of the posterior musculature.
A good control is provided along the sagittal
plane of the vertebral column.
High infections rates are prevalent in this
approach due to absence or lack of soft tissue
coverages (Yilmaz et al., 2012).
It addresses deformity of the coronal plane
thoroughly and the hump is well controlled.
Increases risk of Crankshaft phenomenon
(curve gets worsened) among preadolescent
children.
The thoracic cage does not get affected and the
pulmonary functions are always preserved.
Hypokyphosis (normal outward curvature loss)
is not always corrected in the thoracic region of
the spine.
 Anterior approach- This process involves making a straight incision in front of the spine.
It is generally used in conditions where a single lumbar or thoracic curve deformity needs
to be treated.
ADVANTAGES DISADVANTAGES
Effectively prevents Crankshaft phenomenon. Screw pullout, rod breakage can occur due to
use of single cable or rod (Yagi, Patel &

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Boachie-Adjei, 2015).
It has the ability to correct thoracic
hypokyphosis.
A high risk of non-union or permanent failure
to heal the deformed spine exists due to its
recent development.
It corrects provides a comprehensive disc space
evacuation and increases fusion surface area
(Choudhry, Ahmad & Verma, 2016).
Increases risks of lumbar hypolordosis during
application of anterior instruments without
interbody device in lumbar spinal region.
Allows insertion of larger spinal implants and
leads to superior stabilization.
Wide chest incision can impair the chest
muscles and lead to poor lung functioning.
Anterior Scoliosis surgery
The anterior approach is increasingly becoming popular among surgeons to treat
curvature deformities in the spine. The process involves a thoracotomy operation through the
chest wall (Cho et al., 2014). The anterior spinal instrumentation for lumbar and thoraco-lumbar
adolescent idiopathic scoliosis (AIS) gained popularity during the 1970s. This approach is
usually preferred by surgeons owing to its ability to prevent the Crankshaft phenomenon. The
entire procedure takes several hours for its successful completion (Helenius, 2013). A person
undergoing an anterior spinal fusion surgery is first sedated, followed by administration of
general anesthesia. The person is rolled to his side, such that the operating side faces up. This is
called the lateral decubitus position (Ialenti et al., 2013).

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Figure 1 (a) - Standing radiograph showing right thoracic curve
1(b) - Lateral standing radiograph
Source- (Choudhry, Ahmad & Verma, 2016)
The steps that are carried out during this approach are as follows:
 An incision is initially made on the left or right side, over the abdomen or chest wall,
depending upon the region where the curve deformity is located in the spine.
 The lung is then deflated, followed by removal of a rib to reach the exact spine. A
detachment of the diaphragm follows in case of curves that are present in the lumbar and
thoraco-lumbar spine (Tao et al., 2012).
 There occurs removal of the disc material from the space between the vertebrae where the
curve is present. This removal of disc material increases flexibility of the curve.

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Furthermore, it also provides a greater surface area for the spinal fusion (Sudo et al.,
2013).
 The next step involves instrumentation to produce spine correction. The screws are
placed at the vertebral levels that are involved in the curve followed by attachment with a
single or double rod at each level. The rod is rotated and compressed simultaneously to
correct the spinal deformity.
 Bony surface present between the vertebral bodies is roughened. A bone graft or its
substitute is put into the space located between the vertebral bodies. This promotes
fusion. An allograft bone, removed rib or crest of pelvis may serve as the source for the
bone graft.
 The final step involves closure of the incision. Surgeries involving chest cavity include a
chest tube insertion through the chest side. This helps to expand the lings after the
surgery (Hasler, 2013).
It is argued by the proponents of anterior approach that it leads to better correction levels for
lumbar and thoracolumbar curves, offers a fast recovery time, requires fusion of fewer number of
lumbar vertebras and creates less pain among the patients. Moreover, the anterior approach is
preferred in surgeries that are limited to the lumbar area owing to the fact that saving a single
level of vertebra creates a substantial effect on the spinal flexibility of the patient. Furthermore,
historically, the anterior approach has reported producing better rib hump and curve corrections.
It produces better radiographic and pulmonary function outcomes. Thus, the above mentioned
advantages make the anterior approach a better surgical procedure for treating adolescent
idiopathic scoliosis compared to the posterior approach.

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Management theory
Surgeries are generally applied in cases of severe scoliosis. The cost of scoliosis
treatment or surgery varies across regions but can be quite high. The general costs do not include
the additional costs for recovery time, revision surgeries or treatment of unforeseen
complications. Healthcare challenges will create the need for new managerial approaches
(Yoder-Wise, 2014). A large number of organizational theories can be used in this context of
healthcare that will help in improving the health outcome of patients who are undergoing the
anterior surgical approach. The first approach to be used is the Bureaucratic Theory. This is one
of the oldest theories of management that is still in practice. It is used by institutions or
organizations of all sizes. This management involves presence of few people at the higher levels
of hierarchy, who are entitled to make decisions (Tummers & Bekkers, 2014). A chain of middle
and lower managers are responsible for efficiently executing the tasks. These people have limited
authority. The orders are sent from the highest levels in a manner that mimics the military. The
lines of authority and responsibility are clearly established and there is formal distribution of the
duties (Figure 2). The theory works by allocating individuals in positions that best fit their
technical competence. Procedure adherence is of utmost priority in this model.

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Figure 2- Bureaucracy theory
IdealBureaucracyDivisionoflabourManagerssubjecttoproceduresandrulesSelectionbasedontechnicalcompetencePositionsorganisedinhierarchyManagementandownershipisseparateDecisionsrecordedinwriting

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This theory has proved effective in generating as sense of predictability and stability by
careful management approaches and consistent decision making, as evident from several studies.
Results from other studies confirm that professionals control the administrative framework of the
concerned organization by utilizing this theory. The dominance of professional bureaucratic
management among healthcare organizations has been proved by the prevalence of parallel
administrative and professional hierarchies, which play a role in clarifying responsibilities and
operating procedures (Gittell, Godfrey & Thistlethwaite, 2013). However, the inherent internal
focus and closed system perspective of this theory makes it problematic. The assumption of
static external environment and external influences lead to several problems while validating this
theory across healthcare system.
The human resource/relation theory is of prime importance. Showing consistency with
the aforementioned theory, a closed system perspective is adopted here as well. Studies suggest
that this theory highlights contribution of creative potential towards betterment of organization in
presence of adequate supportive management resources. The theory recognizes individual
involvement and motivation as essential features (Jiang et al., 2012). It has proved effective in
supporting and encouraging harmonious social relations and fostering development of
organizations (Figure 3). This theory involves development of interpersonal collaboration and
communication skills in maximizing individual contribution and motivation (Kramar, 2014). Its
pervasive impact on the specialized and professional healthcare workforce has been proved (S.
Y. D & Weiner, 2012). It promotes high entry-level education and continuous professional
development among all groups that finally create positive patient outcomes (Alfes et al., 2013).

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However, this model also predicts a stable environment. Therefore, application of the framework
alone is not sufficient in complex healthcare situations.
Figure 3- Human resource theory
Patient centered management is another model. A change in attitude towards patient care
and healthcare business environment has resulted in many organizations adopting a patient-
centered management approach to management. Top managers often consider some systems to
be more effective and easy (Figure 4). However, proper organization according to the demands
of the patient-specific health condition helps in delivering best patient care (Cipolle, Strand &
Morley, 2012). This theory promotes best financial results through excellence in medical
services. Studies have shown that the framework is adopted by top managers to promote
collaboration between interdisciplinary approaches and departments in medicine, by ways that
are not described in the traditional style of bureaucratic management (Hudon et al., 2012).
Human Resource
Management

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Figure 4- Patient centered management
The Institutional theory explains the way by which organizations prosper on obtaining a
good fit with the external environment. The theory states that key stakeholders help an
organization to gain legitimacy by adoption of norms and values that are reflective of the beliefs
of stakeholders (Thornton, Ocasio & Lounsbury, 2015). Results suggest that expectations and
socialization pressures from expert referents like management consultants or professional bodies
have governed the functioning of healthcare systems since many decades (Hörisch et al., 2014).
Thus it can be stated that all the above mentioned theories have a role in improving the
healthcare industry.
PatientcenteredmanagementFosteringhealingrelationshipRespondingtopatientemotionsExchanginginformationaboutpatientneedsEnablingself-managementEngagingincollaborativeshareddecisionmaking

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Methodology
Use of management approaches
Several approaches can be taken to reduce hospitalization costs and or stay duration.
Offering a consumer-directed health plan that includes health savings account or health
reimbursement arrangements focus on making the employees become better healthcare
consumers. Management strategies will be used to persuade the employees to carry out healthful
choices. Adequate training and tools will be provided to ensure that the healthcare employees are
aware of the costs associated with the surgical procedure. Providing them incentives to reduce
treatment costs will act as a motivation and bring desired results. Effective communication
strategies will enable the participants to engage in healthful behavior (Knapp, Vangelisti &
Caughlin, 2014). The other approach involves application of consume directed health designs
(Fischer, 2015).
This will promote healthcare consumerism and will help in keeping costs down.
Developing a health savings account, linked to high deductible health plans will also prove
effective. Pain management is critical to the recovery of a patient. A pain control policy will be
initiated (McQuay et al., 2013). Professionals will discuss about pain control with their patients
and will provide a chance to the latte to voice their opinion. The hands-on providers will be
educated about cohesive-pain management. Lack of timely medication delivery post surgery will
be avoided by utilizing efficient human resource coordination.
Keeping a record of the average daily admissions, managing of elective admissions,
discharging patients as soon as it is clinically feasible and initiating multidisciplinary rounding
will help to reduce hospital stay. 2-4 weeks post surgery; the incision part can come in contact

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with water. Patients will be taken off opioids and narcotics and a switch to weaker pain
medication like acetaminophen will aid in quick healing. X-rays will be taken around 6 weeks
after surgery to assess the surgical healing and efficiency of fusion process. Administration of
physical therapy in the patients can also improve surgical healing.
Data collection
Data collection involves administration of the Scoliosis Research Society-30 (SRS-30)
outcome questionnaire to all 30 patients during preoperative, postoperative and final follow-up
period. This questionnaire measures the health-related quality of life (HRQoL) among patients
with adolescent idiopathic scoliosis, who had undergone anterior approach surgery or was not
under surgical intervention (Carriço, Meves & Avanzi, 2012). The individual domain and total
scores for self-image, pain, mental health, function, and satisfaction will be compared between
the control and patient group. The responses will be evaluated and analyzed using the SPSS 21
version.
Work done so far
The questionnaire has been prepared. It has been given to the respondents who are about
to undergo anterior scoliosis fusion surgery. They have been made to fill their responsiveness to
the surgical treatment prior to the surgery, in the questionnaire. Every possible measure has been
taken to protect their privacy. Post-surgical intervention, the questionnaire is again being sent to
the respondents currently.

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Future plan
The plan for the next semester includes a follow up where responses will be taken from
the participants for a follow-up of 4 months. The data will then be analyzed using the SPSS 21
statistical software. The simulation modeling will improve decision making related to the
anterior approach of adolescent idiopathic scoliosis. Thus, the study will help us to compare the
fusion rates among patients who reported AIS. The analysis will help in reviewing major
neurological or vascular complications that occur post-surgical intervention. Moreover, the data
will give an insight into the financial condition, current physical activity level, medication
management and patient satisfaction, which will provide a deeper understanding of the
management frameworks that need to be put to practice for reducing the duration of hospital
stays, lowering healthcare costs, managing pain and increasing overall satisfaction.
Conclusion
Thus, scoliosis is a three-dimensional deformity of the spinal axis. Adolescent idiopathic
scoliosis occurs among patients, 10 years or above. It leads to the occurrence of an idiopathic
structural lateral curve. The angle of the curvature is at least 10 degrees and is measured using
the Cobb technique. A longitudinal radiograph based vertebral rotation of the spine helps in its
diagnosis. Surgery is generally regarded as a preferred option for all skeletally immature patients
who have a progressing 40 degree scoliosis or for skeletally mature patients who report of
progressive or painful spine curvature greater than 45 degrees. An anterior growth among
skeletally immature patients after a posterior fusion surgery leads to Crankshaft phenomenon.
This generally manifests in the form of an increase in rib hump among post-surgical patients. An
anterior fusion surgery is therefore used to prevent this phenomenon. The goals of anterior

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surgery include pain-free spinal fusion, restoration of truncal balance, improved cosmesis and
shoulder, rib hump and hip symmetry.
The progress report utilized several management theories that can be used across
healthcare system for efficient care service delivery. The application of these management
frameworks will help in improving patient outcome, reducing hospital stay and lowering
treatment costs. Moreover, they will also assist in pain management and increasing healing
capabilities post the surgery. The data will be collected based on a questionnaire. Thus, it can be
concluded that an analysis of the questionnaire responses will act as valuable means of managing
patients with adolescent idiopathic scoliosis.

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Appendix

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