Purpose: The administration of tranexamic acid (TXA) has been shown to be beneficial in reducing blood loss during surgery for adolescent idiopathic scoliosis (AIS), but optimal dosing has yet to be defined. This retrospective study compared high versus low dose TXA as part of a Patient Blood Management strategy for reducing blood loss in patients undergoing posterior spine fusion surgery. Methods: Clinical records were reviewed for 223 patients with AIS who underwent posterior spinal fusion of five or more levels during a six-year time period. We compared normalized blood loss, total estimated blood loss (EBL), and the need for transfusion between patients receiving high dose TXA (loading dose of ≥30 mg/kg) versus low dose TXA (loading dose <30 mg/kg). Both groups received maintenance TXA infusions of 10 mg/kg/hr until skin closure. Results: Patient demographics, curves, and surgical characteristics were similar in both groups. The high dose TXA group had a 36% reduction in normalized blood loss (1.8 cc/kg/level fused versus 2.8 cc/kg/level fused, p<0.001) and a 37.5% reduction in total EBL (1000 cc versus 1600 cc, p<0.001). Patients in the high dose group had a 48% reduction in PRBC transfusion, with only 19% receiving a transfusion of PRBC compared to 67% in the low dose group (p<0.001). Conclusion: When combined with other proven Patient Blood Management strategies, the use of high dose TXA compared to low dose TXA may be beneficial in reducing blood loss for patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion surgery. Level of Evidence: Level III, retrospective cohort

Pain management in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion can be challenging. Various analgesic techniques are currently used, including enhanced recovery after surgery principles, spinal opioids or continuous epidural infusion, intravenous methadone, or surgical site infiltration of local anesthetic. Another recently developed technique, ultrasound-guided erector spinae plane blockade (ESPB), has been used successfully in spine surgery and may offer advantages because of its ease of placement, excellent safety profile, and opioid sparing qualities. Liposomal bupivacaine is a long-acting local anesthetic that was recently approved for infiltration and fascial plane blocks in pediatric patients of ages 6 years and older. This medication may prove to be beneficial when administered through ESPB in patients with AIS undergoing posterior spinal fusion because it can provide prolonged analgesia after a single injection. Here, we present a case report of two such patients, and we compare outcomes with a retrospective cohort of 13 patients with AIS who received IV methadone instead of ESPB. ESPB patients seemed to have less opioid use and shorter length of stay but higher pain scores, although the sample size is too small for meaningful statistical analysis. Future prospective trials are needed to see if differences in outcomes truly exist.