Results and morbidity in a consecutive series of patients undergoing spinal fusion for neuromuscular scoliosis

Fifteen Years of Spinal Fusion Outcomes in Children With Cerebral Palsy: Are We Getting Better?

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVE

We reviewed 15-year trends in operative factors, radiographic and quality of life outcomes, and complication rates in children with cerebral palsy (CP)-related scoliosis who underwent spinal fusion.

SUMMARY OF BACKGROUND DATA

Over the past two decades, significant efforts have been made to decrease complications and improve outcomes of this population.

MATERIALS AND METHODS

We retrospectively reviewed a multicenter registry of pediatric CP patients who underwent spinal fusion from 2008 to 2020. We evaluated baseline and operative, hospitalization, and complication data as well as radiographic and quality of life outcomes at a minimum 2-year follow-up.

RESULTS

Mean estimated blood loss and transfusion volume declined from 2.7±2.0 L in 2008 to 0.71±0.34 L in 2020 and 1.0±0.5 L in 2008 to 0.5±0.2 L in 2020, respectively, with a concomitant increase in antifibrinolytic use from 58% to 97% (all, P <0.01). Unit rod and pelvic fusion use declined from 33% in 2008 to 0% in 2020 and 96% in 2008 to 79% in 2020, respectively (both, P <0.05). Mean postoperative intubation time declined from 2.5±2.6 to 0.42±0.63 days ( P< 0.01). No changes were observed in preoperative and postoperative coronal angle and pelvic obliquity, operative time, frequency of anterior/anterior-posterior approach, and durations of hospital and intensive care unit stays. Improvements in the Caregiver Priorities and Child Health Index of Life with Disabilities postoperatively did not change significantly over the study period. Complication rates, including reoperation, superficial and deep surgical site infection, and gastrointestinal and medical complications remained stable over the study period.

CONCLUSIONS

Over the past 15 years of CP scoliosis surgery, surgical blood loss, transfusion volumes, duration of postoperative intubation, and pelvic fusion rates have decreased. However, the degree of radiographic correction, the rates of surgical and medical complications (including infection), and health-related quality of life measures have broadly remained constant.

The Minimally Invasive Bipolar Fixation for Pediatric Spinal Deformities: A Narrative Review

Growing rod techniques are increasingly used for early-onset scoliosis in children. Unfortunately, they are associated with many complications, particularly neuromuscular scoliosis, favored by the poor general condition of these patients and the fragility of their osteoporotic bones. Furthermore, these interventions are often iterative and usually followed by vertebral fusion at the end of growth. This is a review of the literature on a recent fusionless technique, minimally invasive bipolar fixation, which is more stable than the traditional growing rod techniques and less aggressive than vertebral arthrodesis. It allows the avoidance of arthrodesis, owing to the solidity of the construct and the stability of the results, leading to progressive spinal stiffening that occurs over time. The results of this technique have been published with a long follow-up period and have confirmed that it can completely replace posterior vertebral arthrodesis, especially in the most complicated scoliosis. Because it preserves growth, this technique should be recommended for early-onset scoliosis before the age of 10 years. The use of a self-expanding rod can avoid the need for repeated surgery, thereby reducing the risk of complications and the overall cost of treatment.

Pelvic Fixation Technique Using the Ilio-Sacral Screw for 173 Neuromuscular Scoliosis Patients

Pelvic fixation remains one of the main challenging issues in non-ambulatory neuromuscular scoliosis (NMS) patients, between clinical effectiveness and a high complication rate. The objective of this multicenter and retrospective study was to evaluate the outcomes of a technique that was applied to treat 173 NMS patients. The technique is not well-known but promising; it uses the ilio-sacral screw, combined with either the posterior spinal fusion or fusionless bipolar technique, with a minimum follow-up of two years. The mean operative age of the patients was 13 ± 7 years. The mean preoperative main coronal curve was 64° and improved by a mean of -39° postoperatively. The mean preoperative pelvic obliquity was 23°, which improved by a mean of -14° postoperatively. No decrease in the frontal or sagittal correction was observed during the last follow-up. The sitting posture improved in all cases. Twenty-nine patients (17%) had a postoperative infection: twenty-six were treated with local debridement and antibiotics, and three required hardware removal. Fourteen mechanical complications (8%) occurred: screw malposition (n = 6), skin prominence (n = 1), and connector failure (n = 1). This type of surgery is associated with a high risk for infection. Comorbidities, rather than the surgery itself, were the main risk factors that led to complications. The ilio-sacral screw was reliable and effective in correcting pelvic obliquity in NMS patients. The introduction of intraoperative navigation should minimize the risk of screw misplacement and facilitate revision or primary fixation.

Long-term Observation in Patients with Duchenne Muscular Dystrophy with Early Introduction of a Standing Program Using Knee-ankle-foot Orthoses

Objectives

This study investigated the outcomes of the early introduction of a standing program for patients with Duchenne muscular dystrophy (DMD).

Methods

This was a retrospective observational study of 41 outpatients with DMD aged 15-20 years. We introduced the standing program using knee-ankle-foot orthoses (KAFO) to slow the progression of scoliosis when ankle dorsiflexion became less than 0° in the ambulatory period.

Results

Thirty-two patients with DMD were offered the standing program with KAFO; 12 continued the program until the age of 15 years (complete group) and 20 discontinued the program before the age of 15 years (incomplete group). The non-standing program group included 9 patients. The standing program with KAFO was significantly associated with the Cobb angle at the age of 15 years after adjustment for the duration of corticosteroid use and DMD mutation type (P=0.0004). At the age of 15 years, significant correlations were found between the ankle dorsiflexion range of motion (ROM) and non-ambulatory period (P=0.0010), non-ambulatory period and Cobb angle (P<0.0001), Cobb angle and percent predicted forced vital capacity (P=0.0004), and ankle dorsiflexion ROM and Cobb angle (P=0.0066). In the complete group, the age at ambulation loss (log-rank P=0.0015), scoliosis progression (log-rank P=0.0032), and pulmonary dysfunction (log-rank P=0.0006) were significantly higher than in the non-standing program group.

Conclusions

The early introduction of a standing program for DMD patients may prolong the ambulation period and slow the progression of scoliosis and pulmonary dysfunction.

Posterior Spinal Fusion Surgery for Neuromuscular Disease Patients with Severe Scoliosis Whose Cobb Angle Was over 100 Degrees

Background and objectives: Patients with neuromuscular diseases usually have progressive neuromuscular scoliosis (NMS), requiring invasive surgery. Some patients present with severe scoliosis at the time of consultation and are difficult to treat. Posterior spinal fusion (PSF) surgery combined with anterior release and pre- or intraoperative traction would be effective for severe spinal deformities but would be invasive. This study aimed to evaluate the outcomes of PSF-only surgery for patients with severe NMS with a Cobb angle > 100°. Materials and Methods: Thirty NMS patients (13 boys and 17 girls; mean age 13.8 years) who underwent PSF-only surgery for scoliosis with a Cobb angle > 100° were included. We reviewed the lower instrumented vertebra (LIV), duration of surgery, blood loss, perioperative complications, preoperative clinical findings, and radiographic findings, including Cobb angle and pelvic obliquity (PO) in the sitting position pre- and postoperatively. The correction rate and correction loss of the Cobb angle and PO were also calculated. Results: The mean duration of surgery was 338 min, intraoperative blood loss was 1440 mL, preoperative %VC was 34.1%, FEV1.0 (%) was 91.5%, and EF was 66.1%. There were eight cases of perioperative complications. The Cobb angle and PO correction rates were 48.5% and 42.0%, respectively. We divided the patients into two groups: the L5 group, in which the LIV was L5, and the pelvis group, in which the LIV was the pelvis. The duration of surgery and PO correction rate in the pelvis group were significantly higher than those in the L5 group. Conclusions: Patients with severe NMS demonstrated severe preoperative restrictive ventilatory impairments. PSF surgery without anterior release or any intra-/preoperative traction showed satisfactory outcomes, including acceptable scoliosis correction and improved clinical findings, even in patients with extremely severe NMS. Instrumentation and fusion to the pelvis for severe scoliosis in patients with NMS showed good PO correction and low correction loss of Cobb angle and PO, but a longer duration of surgery.

Plastic multilayered closure versus orthopedic surgeon closure after spinal instrumentation in pediatric neuromuscular scoliosis

Objective

To compare wound complication rates between orthopedic closure (OC) and plastic multilayered closure (PMC) in patients undergoing primary posterior spinal fusion for neuromuscular scoliosis (NMS). We hypothesize that multilayered closure will be associated with better postoperative outcomes.

Methods

We collected data on pediatric patients diagnosed with NMS who underwent first time spinal instrumentation between 1 January 2018 and 31 May 2021. Patient demographics, length of surgery, spinal levels fused and operative variables, wound complication rate, treatments, and need for wound washout were reviewed in depth and recorded.

Results

In total, 86 patients were reviewed: 46 with OC and 40 with PMC. There was a significant increase in operating room (OR) time with PMC compared with OC (6.7±1.2 vs 7.3±1.3, p=0.016). There was no difference in complication rate, mean postoperative day of complication or unplanned return to the OR for OC and PMC, respectively. There was a slightly significant increase in the number of patients going home with a drain in the PMC cohort compared with the OC cohort (2.1% vs 15%, p=0.046).

Conclusions

PMC demonstrated longer OR times than OC and did not demonstrate a statistically significant reduction in wound complications or unplanned returns to the OR. However, other studies have demonstrated statistical and clinical significance with these variables. Surgical programs should review internal patient volumes and outcomes for spinal fusion in NMS patients and consider if PMC after spinal fusions in pediatric patients with NMS or other scoliosis subtypes is an appropriate option in their institution to minimize postoperative wound complications.

Full-endoscopic spine surgery diminishes surgical site infections - a propensity score-matched analysis

BACKGROUND CONTEXT

Surgical site infections (SSI) are one the most frequent and costly complications following spinal surgery. The SSI rates of different surgical approaches need to be analyzed to successfully minimize SSI occurrence.

PURPOSE

The purpose of this study was to define the rate of SSIs in patients undergoing full-endoscopic spine surgery (FESS) and then to compare this rate against a propensity score-matched cohort from the National Surgical Quality Improvement Program (NSQIP) database.

DESIGN

This is a retrospective multicenter cohort study using a propensity score-matched analysis of prospectively maintained databases.

PATIENT SAMPLE

One thousand two hundred seventy-seven non-instrumented FESS cases between 2015 and 2021 were selected for analysis. In the nonendoscopic NSQIP cohort we selected data of 55,882 patients.

OUTCOME MEASURES

The occurrence of any SSI was the primary outcome. We also collected any other perioperative complications, demographic data, comorbidities, operative details, history of smoking, and chronic steroid intake.

METHODS

All FESS cases from a multi-institutional group that underwent surgery from 2015 to 2021 were identified for analysis. A cohort of cases for comparison was identified from the NSQIP database using Current Procedural Terminology of nonendoscopic cervical, thoracic, and lumbar procedures from 2015 to 2019. Trauma cases as well as arthrodesis procedures, surgeries to treat pathologies affecting more than 4 levels or spine tumors that required surgical treatment were excluded. In addition, nonelective cases, and patients with wounds worse than class 1 were also not included. Patient demographics, comorbidities, and operative details were analyzed for propensity matching.

RESULTS

In the non-propensity-matched dataset, the endoscopic cohort had a significantly higher incidence of medical comorbidities. The SSI rates for nonendoscopic and endoscopic patients were 1.2% and 0.001%, respectively, in the nonpropensity match cohort (p-value <.011). Propensity score matching yielded 5936 nonendoscopic patients with excellent matching (standard mean difference of 0.007). The SSI rate in the matched population was 1.1%, compared to 0.001% in endoscopic patients with an odds ratio 0.063 (95% confidence interval (CI) 0.009-0.461, p=.006) favoring FESS.

CONCLUSIONS

FESS compares favorably for risk reduction in SSI following spinal decompression surgeries with similar operative characteristics. As a consequence, FESS may be considered the optimal strategy for minimizing SSI morbidity.

Effect of pelvic fixation on ambulation in children with neuromuscular scoliosis

BACKGROUND

The effect of posterior spinal fusion (PSF) incorporating the pelvis on an ambulatory patient’s ability to mobilize after the fusion is not well understood.

AIM

To see whether a posterior spinal fusion with pelvic fixation using iliac or sacral alar iliac screws in ambulatory neuromuscular scoliosis (NMS) patients influences postoperative ambulatory ability.

METHODS

A retrospective review of all patients with NMS that underwent PSF with fixation incorporating the pelvis between January 1, 2012 and February 29, 2019. A total of 118 patients were eligible, including 11 ambulatory patients. The primary outcome was the maintenance of ambulatory status postoperatively. Secondary outcomes included postoperative curve magnitude, pelvic obliquity, and complications, comprising infections, instrumentation failure, and any unplanned returns to the operative room.

RESULTS

The ambulatory function was maintained in all 11 ambulatory NMS patients. One patient had an improvement in functional status with equipment-free ambulation postoperatively. An average postoperative follow-up was 19 mo. The overall complication rate was 19.4% (n = 23) with no significant differences between the groups in infection (P = 0.365), hardware failure (P = 0.505), and reoperation rate (P = 1.0). Ambulatory status did not affect complication rate (P = 0.967).

CONCLUSION

Spinal fusion to the pelvis in ambulatory patients with NMS provides effective deformity correction without the reduction in ambulatory capabilities.

Spinal Deformity Surgery in Pediatric Patients With Cerebral Palsy: A National-Level Analysis of Inpatient and Postdischarge Outcomes

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To provide a national-level assessment of the short-term outcomes after spinal deformity surgery in pediatric patients with cerebral palsy.

METHODS

A national, prospectively collected database was queried to identify pediatric (≤18 years) patients with cerebral palsy, who underwent spinal fusion surgery from 2012 to 2017. Separate multivariate analyses were performed for the primary outcomes of interest including extended length of stay (>75th percentile, >8 days), and readmissions within 90 days after the index admission.

RESULTS

A total of 2856 patients were reviewed. The mean age ± standard deviation was 12.8 ± 2.9 years, and 49.4% of patients were female. The majority of patients underwent a posterior spinal fusion (97.0%) involving ≥8 levels (79.9%) at a teaching hospital (96.6%). Top medical complications (24.5%) included acute respiratory failure requiring mechanical ventilation (11.4%), paralytic ileus (8.2%), and urinary tract infections (4.6%). Top surgical complications (40.7%) included blood transfusion (35.6%), wound complication (4.9%), and mechanical complication (2.7%). The hospital cost for patients with a length of hospital stay >8 days ($113 669) was nearly double than that of those with a shorter length of stay ($68 411). The 90-day readmission rate was 17.6% (mean days to readmission: 30.2). The most common reason for readmission included wound dehiscence (21.1%), surgical site infection (19.1%), other infection (18.9%), dehydration (16.9%), feeding issues (14.5%), and acute respiratory failure (13.1%). Notable independent predictors for 90-day readmissions included preexisting pulmonary disease (odds ratio [OR] 1.5), obesity (OR 3.4), cachexia (OR 27), nonteaching hospital (OR 3.5), inpatient return to operating room (OR 1.9), and length of stay >8 days (OR 1.5).

CONCLUSIONS

Efforts focused on optimizing the perioperative pulmonary, hematological, and nutritional status as well as reducing wound complications appear to be the most important for improving clinical outcomes.

Predicting the impact of intraoperative halo-femoral traction from preoperative imaging in neuromuscular scoliosis

PURPOSE

Intraoperative traction (ITx) has been demonstrated to be a useful adjunct intervention at the time of posterior spinal fusion (PSF) for the treatment of severe neuromuscular scoliosis (NMS) to improve the coronal spinal deformity and pelvic obliquity. The purpose of this study is to determine if preoperative flexibility radiographs can predict the amount of spinal deformity and pelvic obliquity correction at final follow-up.

METHODS

This was a retrospective analysis of a single-surgeon series who underwent PSF to the pelvis with adjunct ITx for NMS. Database query identified 76 NMS patients, of which 41 met inclusion criteria. Demographic, radiographic and operative data were analyzed.

RESULTS

Of the 41 study patients, 56% (n = 23) were male and mean age at surgery was 13.6 years. Mean follow-up of 4.1 years (minimum follow-up 2 years). 35 patients had cerebral palsy, 5 patients were syndromic, and 1 patient had myelomeningocele. The average preoperative weight was 35 kg and all were wheelchair ambulators. Total traction applied on average was 49% of the preoperative body weight. Mean preoperative coronal deformity was 91° which improved to 43° at final follow-up (53% correction). Push-supine imaging had the strongest correlation to major coronal deformity outcome at final follow-up (r² = 0.87, p ≤ 0.0001). Compared to push-supine imaging, there was a mean greater coronal deformity correction of 18 ± 10° (p ≤ 0.0001) at final follow-up. To predict the final coronal deformity, the regression equation was final Cobb angle = 1.13085 + preop push-supine Cobb angle × 0.68830. Mean preoperative pelvic obliquity was 34° which improved to 12° at final follow-up (65% correction). Push-supine imaging had the strongest correlation to pelvic obliquity outcome at final follow-up (r² = 0.59, p = 0.0001). Compared to push-supine imaging, there was a mean greater pelvic obliquity correction of 3 ± 10° (p = 0.0857) at final follow-up. The regression equation was final POB = 6.42096 + preop push-supine POB × 0.36675. Mean preoperative kyphosis was 70° and 52° at final follow-up (26% correction).

CONCLUSION

The results of this study demonstrated for preoperative planning that the push-supine flexibility radiograph is most predictive of the coronal deformity and of the pelvic obliquity correction. At final follow-up in this NMS population, there was a mean greater improvement of 18° for coronal deformity versus preoperative push-supine imaging and 3° for pelvic obliquity versus preoperative push-supine imaging. At the time of PSF, ITx is an effective adjunct technique to improve coronal deformity and POB for NMS producing 53% coronal correction, 65% POB correction, and 26% kyphosis correction.

LEVEL OF EVIDENCE

IV.

Minimally Invasive Surgery for Neuromuscular Scoliosis: Results and Complications at a Minimal Follow-up of 5 Years

STUDY DESIGN

A prospective study.

OBJECTIVE

The aim of this study was to report the results of an alternative technique to growing rods (GR) for neuromuscular scoliosis using a minimally invasive fusionless surgery with a minimum of 5 years' follow-up.

SUMMARY OF BACKGROUND DATA

Conservative treatment is not effective in progressive neuromuscular scoliosis. Early surgery using GR is increasingly advocated to control the deformity while preserving spinal and thoracic growth before arthrodesis. These techniques still provide a high rate of complications.

METHODS

The technique relies on a bilateral double rod sliding instrumentation anchored proximally by four hooks claws and distally to the pelvis by iliosacral screws through a minimally invasive approach. The clinical and radiological outcomes of 100 consecutive patients with neuromuscular scoliosis who underwent this fusionless surgery with a minimum follow-up of 5 years were reviewed.

RESULTS

6.5 ± 0.7 years after initial surgery, six patients were lost of follow-up and 11 died of unrelated raison. Of the 83 remaining patients at latest follow-up, mean Cobb angle was stable to 35.0° which correspond to 61% correction of the initial deformation. Mean pelvic obliquity was 29.6° (0.3°-80.0°) preoperatively and 7.2 (0.2°-23.5°) at latest follow-up. Correction of the hyper kyphosis remained stable. Skeletal maturitywas reached in 42 of 83 patients (50.6%). None of these patients has required spinal fusion. The global complication rate was 31.3%.

CONCLUSION

The outcomes of this minimally invasive fusionless technique at 5 years follow-up showed a stable correction of spinal deformities and pelvic obliquity over time, with a reduced rate of complication. The arthrodesis was not required for all patients at skeletal maturity. This technique could be a good alternative to arthrodesis for neuromuscular scoliosis.Level of Evidence: 3.

Outcomes and Complications in Management of Congenital Myopathy Early-Onset Scoliosis

BACKGROUND

Congenital myopathies (CMs) are complex conditions often associated with early-onset scoliosis (EOS). The purpose of this study was to investigate radiographic outcomes in CM patients undergoing EOS instrumentation as well as complications. Secondarily, we sought to compare these patients to a population with higher prevalence, cerebral palsy (CP) EOS patients.

METHODS

This is a retrospective study of a prospectively collected multicenter registry. The registry was queried for EOS patients with growth-sparing instrumentation (vertical expandable prosthetic titanium ribs, magnetically controlled growing rods, traditional growing rod, or Shilla) and a CM or CP diagnosis with minimum 2 years follow-up. Outcomes included major curve magnitude, T1-S1 height, kyphosis, and complications.

RESULTS

Sixteen patients with CM were included. Six (37.5%) children with CM experienced 11 complications by 2 years. Mean major curve magnitude for CM patients was improved postoperatively and maintained at 2 years (P<0.01), with no significant increase in T1-S1 height or maximum kyphosis(P>0.05). Ninety-seven patients with CP EOS were included as a comparative cohort. Fewer CP patients required baseline respiratory support compared with CM patients (20.0% vs. 92.9%, P<0.01). Fifty-four (55.7%) CP patients experienced a total of 105 complications at 2 years. There was no evidence that the risk of complication or radiographic outcomes differs between cohorts at 2 years, though CP EOS patients experienced significant improvement in all measurements at 2 years.

CONCLUSIONS

EOS CM children face a high risk of complication after growing instrumentation, with similar curve correction and risk of complication to CP patients.

LEVEL OF EVIDENCE

Level III.

Surgical pathway proposal for severe paralytic scoliosis in adolescents with myelomeningocele

PURPOSE

The increased life expectancy of patients with myelomeningocele led to the necessity of new management for addressing complex spine deformities with severe pelvic obliquity. Tethered cord release (TCR) and spinal fusion were described as treatment options. However, nowadays, the surgical strategy is not well defined and high rates of mechanical failures and complications are reported. Our aim was to propose a new two-stage surgical pathway to treat a selected group of severe myelomeningocele scoliosis.

METHODS

This is a retrospective series of myelomeningocele scoliosis in paralytic adolescent patients treated with concurrent TCR and posterior spinal fusion (PSF), followed by delayed anterior fusion (ASF) through minimally invasive lateral approach. Inclusion criteria were as follows: evolutive scoliosis in tethered cord syndrome and paraplegia, main curve >70°, pelvic obliquity >20°, and age between 10 and 18 years. Clinical, surgical, and radiographic parameters were evaluated preoperatively and at a mean follow-up (FU) of 2.8 years.

RESULTS

Six patients out of 58 met the inclusion criteria and were included in the study (mean age 12.3 years old). The mean curve and pelvic obliquity correction were 68.8% and 82%, respectively. No loss of correction was recorded at FU. One case of cerebrospinal fluid leakage requiring revision surgery was recorded.

CONCLUSION

To the best of our knowledge, this is the first study proposing a two-stage surgical pathway for severe MMC spinopelvic deformity treatment. Concurrent TCR and PSF with delayed minimally invasive ASF permitted to minimize complications providing good fusion rates without loss of correction and implant failure.

Iliac screw instrumentation to the pelvis in children with neuromuscular and syndromic scoliosis. No lateral connectors and respect sagittal balance

STUDY DESIGN

One-center retrospective cohort study.

BACKGROUND

Compared to the traditional iliac screw technique, the modified iliac screw technique has a lower rate of distal implant failure in the treatment of neuromuscular scoliosis patients with pelvic obliquity. However, the reasons for decreased failure with the modified iliac screw technique are controversial.

QUESTIONS/PURPOSES

(1) Is distal implant failure, as evident by implant breakage or disconnection, more likely to occur in patients receiving the traditional iliac screw technique (PSIS) compared to the modified S2AI (MODS2) technique? (2) After controlling for relevant confounding variables, are there other identifiable risk factors for distal implant failure?

METHODS

We identified patients who underwent pelvic screw fixation by three pediatric spine surgeons from January 2007 to July 2017. Based on the starting point of the iliac screws, patients were divided into two groups. Group 1 consisted of PSIS fixation with an offset connector. Group 2 consisted of modified S2AI fixation without an offset connector. Demographic, operative, and radiographic data were obtained.

RESULTS

Cobb angle, lumbar lordosis, and pelvic obliquity were not significantly different between the two groups. Overall distal implant failure was 40/100 (40%) and significant between Group 1 PSIS 29/53 (55%) and Group 2 MODS2 11/47 (23%) (p = 0.002). No other complications were significant. Three risk factors were identified with implant failure: high pelvic incidence (17-fold increase, 95% confidence interval [CI] = 5.5 to 53.1, p < 0.001), high angle rod contour (3.8-fold increase, 95% CI = 1.2 to 11.9, p = 0.023), and use of an offset connector (3.2-fold increase, 95% CI = 1.0 to 10.3, p = 0.049). Failure did not correlate with the use of a cross-link, iliac screw diameter, or screw density. Revision surgery related to distal implant failure did not significantly differ between the two groups.

CONCLUSIONS

Compared to the use of an offset connector with PSIS fixation, MODS2 fixation had a lower rate of implant failure. Sagittal balance parameters, namely pelvic incidence and angle of rod bend, were the major risk factors for implant failure.

LEVEL OF EVIDENCE

III.

Is Use of Topical Vancomycin in Pediatric Spine Surgeries a Safe Option in the Prevention of Surgical Site Infections? A Meta-analysis and Systematic Review of the Literature

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

To systematically review the available articles on topical vancomycin powder (TVP) use in pediatric spine surgeries exploring the usefulness and safety of such practice.

METHODS

We conducted an independent and duplicate electronic database search in PubMed, EMBASE, and Cochrane Library till March 2020 to identify all relevant literature on the use of TVP for pediatric spine surgeries. Surgical site infection (SSI) rate, specific reported complications, reoperation rate, microbial flora pattern in reported SSIs, and safety profile were the outcomes analyzed. Analysis was performed with the R platform using OpenMeta[Analyst] software.

RESULTS

No prospective studies were available to evaluate the use of TVP in pediatric spine surgeries for the prevention of SSIs. Neither standardized protocol, nor drug dosage, nor safety profile was established for pediatric use. Three retrospective cohort studies including 824 patients (TVP/control: 400/424) were included in the meta-analysis. There was low-quality evidence suggesting no significant difference between the 2 groups in SSI rate (RR = 0.474; 95% CI = [0.106,2.112]; P = .327) with significant heterogeneity (I² = 70.14; P = .035). The TVP group showed a significant benefit on cost analysis in one of the included studies. However, TVP did not prevent gram-negative coinfection on SSI in the TVP group.

CONCLUSION

From the literature available at present, TVP does not qualify to be recommended as a safe and useful option to prevent SSI following pediatric spine surgeries. High-quality prospective interventional studies are needed to arrive at a consensus on its use along with appropriate dosage and method of application.

Perioperative Optimization of Patients With Neuromuscular Disorders Undergoing Scoliosis Corrective Surgery: A Multidisciplinary Team Approach

STUDY DESIGN

Narrative review.

OBJECTIVE

The high rate of complications associated with the surgical management of neuromuscular spinal deformities is well documented in the literature. This is attributed to attenuated protective physiological responses in multiple organ systems.

METHODS

Review and synthesis of the literature pertaining to optimization of patients with neuromuscular scoliosis undergoing surgery. Our institutional practice in the perioperative assessment and management of neuromuscular scoliosis is also described along with a clinical vignette.

RESULTS

Respiratory complications are the most common to occur following surgery for neuromuscular disorders. Other categories include gastrointestinal, cardiac, genitourinary, blood loss, and wound complications. A multidisciplinary approach is required for perioperative optimization of these patients and numerous strategies are described, including respiratory management.

CONCLUSION

Perioperative optimization for patients with neuromuscular disorders undergoing corrective surgery for spinal deformity is multifaceted and complex. It requires a multidisciplinary evidence-based approach. Preadmission of patients in advance of surgery for assessment and optimization may be required in certain instances to identify key concerns and formulate a tailored treatment plan.

Improving Safety and Efficacy in the Surgical Management of Low-tone Neuromuscular Scoliosis: Integrated Approach With a 2-attending Surgeon Operative Team and Modified Anesthesia Protocol

BACKGROUND

Substantially increased operative time and amount of bleeding may complicate the course of surgical treatment in neuromuscular scoliosis. A well-organized team approach is required to reduce morbidity. The aim of this study is to review our early, short-term surgical outcomes with our new integrated approach that includes a 2-attending surgeon team and modifications in the anesthesia protocol in low-tone neuromuscular scoliosis and compare with a matched cohort of our historic patients.

METHODS

We retrospectively reviewed our patients with (1) neuromuscular scoliosis with collapsing spine deformity, (2) low-tone neuromuscular etiology, (3) multilevel posterior column osteotomies with posterior all pedicle screw spinal fusion, and (4) more than 1-year follow-up. Patients were grouped into 2: group 1 consisted of patients managed with the integrated surgical team approach, group 2 included the matched historic patients.

RESULTS

There were 16 patients in group 1 and 17 patients in group 2. There was no significant difference between the groups regarding age, sex, body mass index, number of levels fused, major coronal deformity magnitude, pelvic obliquity, number of posterior column osteotomies, or amount of deformity correction. However, significantly shorter operative time (241 vs. 297 min, P=0.006), less intraoperative bleeding (1082 vs. 1852 mL, P=0.001), less intraoperative blood transfusion (2.1 vs. 3.1 U, P=0.028), less postoperative intensive care unit admission (23% vs. 100%, P=0.001), and shorter hospital stay (4.7 vs. 5.9 d, P=0.013) were observed in group 1.

CONCLUSIONS

Our results indicate that spinal deformity surgery in patients with underlying low-tone neuromuscular disease may not be as intimidating as previously thought. Our surgical team approach integrating a 2-attending surgeon operative team, a new anesthetic protocol that includes a modification of perioperative blood management is effective in reducing operative times, blood loss, transfusion rates, intensive care unit admission, and length of hospital stay.

LEVELS OF EVIDENCE

Level III-retrospective comparative study.

Prolonged Postoperative Intubation After Spinal Fusion in Cerebral Palsy: Are There Modifiable Risk Factors and Associated Consequences?

BACKGROUND

Instrumented spinal fusion is performed to correct severe spinal deformity that commonly complicates cerebral palsy (CP). Prolonged intubation (PI) is a common perioperative complication, though little is known about the risk factors and consequences of this phenomenon.

QUESTIONS/PURPOSES

The purpose of this study was to determine (1) the preoperative and intraoperative risk factors associated with PI after spine surgery for CP; (2) the perioperative and postoperative complications associated with PI; and (3) any long-term impacts of PI with respect to health-related quality of life.

PATIENTS AND METHODS

A retrospective case-control analysis of prospectively collected, multicenter data was performed on patients with Gross Motor Function Classification System (GMFCS) 4 or 5 CP who underwent instrumented spinal fusion. Patients extubated on postoperative day (POD) 0 were in the early extubation (EE) cohort and those extubated on POD 3 or later were in the PI cohort. Comparisons were made between PI and EE groups with respect to several preoperative and intraoperative variables to identify risk factors for PI. Multivariate logistic regression was performed to identify independent predictors of this outcome. The postoperative hospital course, rate of complications, and health-related quality of life at 2 years were also compared.

RESULTS

This study included 217 patients (52% male individuals; mean age, 14.0±2.8 y) who underwent spinal fusion for CP. In this cohort, 52 patients (24%) had EE and 58 patients (27%) had PI. There were several independent predictors of PI including history of pneumonia [odds ratio (OR), 6.2; 95% confidence interval (CI), 1.6-24.3; P=0.01], estimated blood loss of >3000 mL (OR, 16.5; 95% CI, 2.0-134; P=0.01), weight of <37 kg (OR, 6.4; 95% CI, 1.5-27.1), and Child Health Index of Life with Disabilities (CPCHILD) Communication and Social Interaction score of <15 (OR, 10.8; 95% CI, 1.1-107.3; P=0.04). In addition, PI was associated with a higher rate of perioperative and postoperative respiratory (P<0.001), cardiovascular (P=0.014), gastrointestinal (P<0.001), and surgical site (0.027) complications, in addition to prolonged hospitalization (P<0.001) and intensive care unit stay (P<0.001).

CONCLUSIONS

Surgeons should seek to optimize nutritional status and pulmonary function, and minimize blood loss in patients with CP to decrease the risk of PI after spinal fusion. Efforts should be made to extubate patients on POD 0 to decrease the risk of complications associated with PI.

Evaluating Trends and Outcomes of Spinal Deformity Surgery in Cerebral Palsy Patients

Background

There is a paucity of literature examining surgical trends and outcomes in both child and adult cerebral palsy (CP) patients. We aimed to evaluate surgical trends, complications, length of stay, and charges for spinal deformity surgery in CP patients.

Methods

Using the Nationwide Inpatient Sample (NIS) from 2001 to 2013, patients with CP scoliosis who underwent spinal fusion surgery were identified. Patient characteristics and comorbidities were recorded. Trends in spinal fusion approaches were grouped as anterior (ASF), posterior (PSF), or combined anterior-posterior (ASF/PSF). Complication rates, length of stay, and charges for each approach were analyzed. Bivariate analyses using adjusted Wald tests and multivariate analyses using linear (logarithmic transformation) and logistic regressions were performed.

Results

Of the 5191 adult CP patients who underwent spinal fusion the majority underwent PSF (86.5%), followed by the ASF/PSF approach (9.3%). The rate of PSF for cerebral palsy patients with spinal deformity increased significantly per 1 million people in the US population (0.90 to 1.30; P = .048). Complication rate, hospital length of stay, and charges were higher for patients undergoing ASF/PSF (P < .05). The overall complication rate for all surgical approaches was 25.7%. Patient comorbidities and combined ASF/PSF increased the odds of complication. Combined ASF/PSF was also associated with an increased length of stay and charges.

Conclusion

Combined ASF/PSF in patients with CP accounted for only 9.3% of surgical cases but was associated with the longest hospital stay, highest charges, and increased complications. Further scrutiny of the surgical indications and preoperative risk stratification should be undertaken to minimize complications, reduce length of stay, and decrease charges for CP patients undergoing spinal fusion.

Level of Evidence

IV.

Sympathetic Outflow Disturbance After Posterior Deformity Correction: A Rare Complication

INTRODUCTION

Sympathetic system injury is a known but rare complication in scoliosis deformity correction. It is not common following posterior correction. We report a case of diastematomyelia with neuromuscular scoliosis with unusual complication of sympathetic outflow disturbance, after posterior instrumented correction.

CASE DESCRIPTION

A 13-year-old girl presented with complaints of deformity in the back first noticed 4 years ago. Roentgenogram revealed a right thoracolumbar kyphoscoliotic deformity of 105° with apex at T8 with non-structural lumbar and cervicothoracic curves with positive sagittal alignment. Magnetic resonance imaging showed split-cord malformation with bony crest near the apex of the curve. Detethering followed by removal of the bony crest and restoration of the dual dural sleeves of the split cord into single neural tube was done in the first stage. In the second stage, pedicle screw fixation with was done from D3 to L3. Deformity correction was achieved using multilevel Smith Peterson osteotomy and concave rib osteotomy. On the second postoperative day, intensive care unit staff noticed persistent sinus tachycardia and profuse sweating in both upper limbs, chest, and upper-back. Twenty-four-hour Holter monitoring did not reveal any abnormality. Patient improved gradually and was discharged on postoperative day 9 when both sinus tachycardia and hyperhidrosis resolved.

CONCLUSIONS

Sympathetic chain disturbances after surgery recover with time. The exact time duration needed for recovery is not yet defined, however. Spine surgeons should be aware of this postsurgical complication and identify it so that management can be initiated. The symptoms may be long and drawn out, thus the roles of communication with and counseling of the patient as cannot be underemphasized.

Infection in neuro-muscular scoliosis deformity correction

Assess the outcome of a standardised protocol for the treatment of post-operative wound infection in patients undergoing deformity correction for neuro-muscular scoliosis (NMS). Retrospective review of 443 consecutive patients with a minimum 18 months' follow-up, following a primary posterior deformity correction for NMS. In patients who developed a wound complication, the patient demographic and comorbidities, causative pathogen, number of re-operations, length of stay (LOS), rate of cure, and complications were analysed. Forty-four patients (9.9%) developed a wound infection. Marginally more infections were mono-microbial (23) than poly-microbial (21). Coagulase negative staphylococcus and Staphylococcus aureus were the most commonly cultured pathogens. Seventeen patients were treated with antibiotics alone, while 27 patients also required surgical debridement. The average LOS for those treated with antibiotics alone was 12 days (range: 9-15 days), in contrast to those requiring debridement, which was 35 days (range: 35-70 days). All patients were cured from their infection and ultimately achieved fusion. Infection is common in NMS deformity correction. This is marginally more common as a mono-microbial than poly-microbial infection with most pathogens being staphylococcal in origin. Our defined treatment strategy resulted in a cure for all patients and capacity for all patients to achieve fusion.

Technical aspects of surgical correction of spinal deformities in cerebral palsy

PURPOSE

Cerebral palsy (CP) is a disorder arising from a non-progressive lesion in the developing immature brain with an encephalopathy, that results in various levels of motor and sensory dysfunction. Motor disability of these children can be assessed by the Gross Motor Function Classification System in five levels, and depending on their motor functional capability, the most severely affected children fall into levels IV and V. Children in groups IV and V present a full spectrum of musculoskeletal deformities, among which, scoliosis is the most frequently found spinal deformity that most often requires surgical treatment. However, these are procedures that are usually technically demanding, requiring experienced surgical teams and a multidisciplinary approach.

METHODS

In order to overcome some of the technical pitfalls that may complicate these complex surgical procedures, the authors have gathered together different tips and tricks that may help surgeons performing surgical correction of spinal deformities in CP children.

CONCLUSION

Although for these children surgery is a major undertaking, with the multidisciplinary approach and advances of technology, anaesthesia and optimization of pre- and postoperative care, complications are manageable in most cases, improving not only the outcome of surgery but also the patient's quality of life and satisfaction of parents and caretakers.

Use of an Accelerated Discharge Pathway in Patients With Severe Cerebral Palsy Undergoing Posterior Spinal Fusion for Neuromuscular Scoliosis

BACKGROUND

Implementation of a coordinated multidisciplinary postoperative pathway has been shown to reduce length of stay after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis. This study sought to compare the outcomes of nonambulatory cerebral palsy (CP) patients treated with PSF and cared for using an accelerated discharge (AD) pathway with those using a more traditional discharge (TD) pathway.

METHODS

A total of 74 patients with Gross Motor Function Classification System (GMFCS) class 4/5 CP undergoing PSF were reviewed. Thirty consecutive patients were cared for using a TD pathway, and 44 patients were subsequently treated using an AD pathway. The cohorts were then evaluated for postoperative complications and length of stay.

RESULTS

Length of stay (LOS) was 19% shorter in patients managed with the AD pathway (AD 4.0 days [95% CI 2.5-5.5] vs. TD 4.9 days [95% CI 3.5-6.3], p = .01). There was no difference between groups with respect to age at surgery, GMFCS class, preoperative curve magnitude, pelvic obliquity, kyphosis, postoperative curve correction, fusion to the pelvis, or length of fusion between groups. Length of stay remained significantly shorter in the AD group by 0.9 days when controlling for estimated blood loss (EBL) and length of surgery. Complication rates trended lower in the AD group (33% AD vs. 52% TD, p = .12), including pulmonary complications (21% AD vs. 38% TD, p = .13). There was no significant difference in wound complications, return to the operating room, or medical readmissions between groups.

CONCLUSIONS

Adoption of a standardized postoperative pathway reduced LOS by 19% in nonambulatory CP patients. Overall, complications, including pulmonary, trended lower in the AD group. Early discharge appears to be possible in this challenging patient population. Although the AD pathway may not be appropriate for all patients, the utility of the AD pathway in optimizing care for more routine PSF for this patient subset appears to be worthwhile.

LEVEL OF EVIDENCE

Level III, therapeutic.

A Multicenter Study of the Epidemiology of Deep Surgical Site Infections in Children With Nonidiopathic Early-Onset Scoliosis Including Associated Pathogens

STUDY DESIGN

Retrospective descriptive.

OBJECTIVES

Identify incidence and risk of deep surgical site infections (SSIs), associated pathogens, and antibiotic susceptibility in patients with nonidiopathic early-onset scoliosis (EOS) undergoing growth-friendly (GF) spine surgery.

BACKGROUND

SSIs following GF procedures for EOS are well described, but epidemiologic trends in associated pathogens have not been well characterized.

METHODS

The Children's Spine Study Group database was queried for children ≤18 years of age undergoing GF procedures for nonidiopathic EOS at 11 institutions from September 2001 to January 2016. Deep SSIs reported within 90 days of procedures were reviewed for associated pathogens and their susceptibility profiles. Data were analyzed to calculate incidence and risk.

RESULTS

593 patients (median age 5.7 years, IQR 3.3-8.0 years) with scoliosis due to congenital (45%), neuromuscular (39%), and syndromic (16%) disorders underwent 5,072 procedures. The incidence of deep SSIs per patient was 12.6%; 75 patients had one or more deep SSIs. The risk of deep SSIs per procedure was 1.95% as 99 SSIs occurred after the 5072 procedures. Overall, 48% of deep SSIs followed expansion procedures. Pathogen(s) were cultured from 92% of SSIs including gram-positive cocci (GPC, 90.1%) and/or gram-negative rods (GNR, 17.6%). Methicillin-susceptible Staphylococcus aureus (48.4% of SSIs), methicillin-resistant S. aureus (23.1%), and coagulase negative staphylococci (CoNS, 8.8%) were the most common GPCs. Escherichia coli (5.5% of SSIs), Enterobacter cloacae (4.4%), and Pseudomonas aeruginosa (4.4%) were the most common among GNRs. GNR susceptibility to cefazolin was 41% during the study period, whereas GPC susceptibility to cefazolin was 59%.

CONCLUSION

The risk of SSIs can potentially be reduced for this vulnerable population by routinely reviewing the local epidemiology of SSIs, including the associated pathogens and their susceptibility patterns. As GNR susceptibility to cefazolin was only 41%, expanding prophylaxis to include aminoglycosides for GNR is prudent.

LEVEL OF EVIDENCE

Level IV.

Sacropelvic Fixation: A Comprehensive Review

Sacropelvic fixation is indicated in various clinical settings, most notably long spinal arthrodesis, reduction of high-grade spondylolisthesis, and complex sacral fractures. The sacropelvis is characterized by complex regional anatomy and poor bone quality. These factors make achieving solid fusion across the lumbosacral junction challenging. However, a better understanding of spinal biomechanics at that level has led to much higher fusion rates than those of the past. The newer fixation techniques are biomechanically superior to previous methods mainly because they achieve bony purchase anterior to the pivot point-first described by McCord et al. in 1994. Today, the two most widely used fixation techniques are iliac screws and S2-alar-iliac screws. Although these techniques are associated with very high rates of fusion, instrumentation-related pain and reoperation remain problematic. This review provides an overview of the regional anatomy and biomechanics at the lumbosacral junction, as well as a summary of fixation techniques with an emphasis on the most widely used techniques today. LEVEL OF EVIDENCE: IV.

The modified Kostuik transilial bar technique has acceptable results in neuromuscular spinal deformity correction

The aim of this study is to evaluate the results of the modified Kostuik transilial bar technique for neuromuscular scoliosis (NS). We reviewed the records of 21 patients treated for NS with this instrumentation. There were 14 females and seven males, with an average age of 15.6 years (range: 9-21 years). We determined patients' demographics, correction ratio of both curve and pelvic obliquity, loss of correction, screw loosening at first sacral vertebra, and clinical outcomes. Mean follow-up was 56 months (range: 34-96 months). There were no reoperations, no screw breakage, and no significant loss of correction. The mean preoperative coronal Cobb angle was 71.4°±8.7°, the initial postoperative measurements had a mean Cobb angle of 19.2°±7.2°, and at the last follow-up, the mean Cobb angle was 23.6°±6.9° (P<0.001). Pelvic obliquity decreased from 27.7°±12.4° to 9.1°±5.3° at follow-up and to 11.9°±6.3° at the last follow-up (P<0.001). The preoperative pelvic obliquity angle was significantly higher at the patients with screw loosening (P=0.016). There was one established as well as one possible pseudoarthrosis in our patients. The new technique does appear to possibly become an alternative to conventional lumbosacral fixation techniques. Integration of the bar with pipe-type connector onto the long spinal instrumentation with oblique connectors can prevent the most unenviable complications such as wide exposure, hardware prominence, reoperation, and pseudoarthrosis.

Plastic Multilayered Closure in Pediatric Nonidiopathic Scoliosis Is Associated With a Lower Than Expected Incidence of Wound Complications and Surgical Site Infections

OBJECTIVE

To compare the incidence of surgical site infection (SSI) and wound complications between standard and plastic multilayered closure (PMC) in patients with pediatric nonidiopathic scoliosis undergoing primary or revision instrumentation or fusion.

STUDY DESIGN

Retrospective cohort study.

SUMMARY OF BACKGROUND DATA

Although PMC has been used for adult spine patients as well as infected spinal wound closure, it has not been reported as routine closure in the pediatric nonidiopathic scoliosis population.

METHODS

Patients with nonidiopathic scoliosis undergoing primary or revision instrumentation or fusion between 2013 and 2016 were enrolled. Clinical charts and operative reports were reviewed. Following September 2015, all patients with nonidiopathic scoliosis received PMC closure by plastic or orthopedic surgery. The SSI and wound complication incidence in patients undergoing PMC was compared to standard closure. The mean Risk Severity Score (RSS) for SSI, which uses patient characteristics to calculate the excepted SSI probability, was compared to the observed (actual) incidence. The CDC definition of SSI (infection ≤90 days of surgery) was used.

RESULTS

115 patients were identified, including 56 standard closure and 59 PMC (mean age of 10.6 years; 54.8% female; mean preoperative major curve = 57.5°). There was no significant difference in age, sex, race, preoperative major curve, BMI, hemoglobin, blood loss, mean RSS score, or etiology between both groups (p > .05). Following PMC implementation, the observed incidence of wound complications decreased significantly from 19.6% in standard closures to 5.1% in the PMC group (p = .02), and the SSI incidence decreased from 8.9% to 1.7% (p = .11). The overall change in the observed (actual) incidence versus expected (RSS score) incidence of SSI indicated a 7.1% reduction following PMC.

CONCLUSION

Utilizing PMC in patients undergoing spinal surgery for nonidiopathic scoliosis significantly decreases the incidence of wound complications. Surgeons should consider using PMC in patients with nonidiopathic scoliosis.

LEVEL OF EVIDENCE

Level II.

Implementing a Multidisciplinary Clinical Pathway Can Reduce the Deep Surgical Site Infection Rate After Posterior Spinal Fusion in High-Risk Patients

DESIGN

Retrospective comparative study.

OBJECTIVE

The purpose of this study is to measure SSI outcomes before and after implementation of our center's multidisciplinary clinical pathway protocol for high-risk spinal surgery.

BACKGROUND

Surgical site infections (SSIs) after spinal fusion harm patients and are associated with significant health care costs. Given the high rate of SSI in neuromuscular populations, there is a rationale to develop infection prevention strategies.

METHODS

An institutional clinical pathway was created in 2012 and based on nationally published Best Practice Guidelines as well as hospital practices with a goal of reducing the rate of deep SSI in high-risk patients. Patient and procedure characteristics were compared prior to (2008-2011) and after (2012-2016) implementation of the pathway. Logistic regression using penalized maximum likelihood was used to assess differences in rate of infection before and after implementation.

RESULTS

Cohorts of 132 and 115 high-risk patients were analyzed before and after pathway implementation. Rate of deep infections decreased from 8% to 1% of patients (p = .005). Preoperative antibiotics were dosed within 1 hour in 90% of the postpathway cohort. Redosing was successful in 94% of patients for first redose and 79% for second redose. Betadine irrigation was used in 76% of cases and vancomycin administered in 86%. Multivariable analysis determined that instances of compliant antibiotics dosing had 63% lower odds of infection compared with instances of noncompliance (p = .04).

CONCLUSIONS

Implementation of a multidisciplinary pathway aimed to reduce infection in patients at high risk for SSI after spinal fusion led to a significant reduction in deep SSI rate. It is impossible to attribute the drop in the deep SSI rate to any one factor. Our results demonstrate that adherence to a protocol using multiple strategies to reduce infection results in a lower SSI rate, lower care costs, and improved patient-related outcomes.

LEVEL OF EVIDENCE

Level III.

Risk Factors for Wound Infections after Deformity Correction Surgery in Neuromuscular Scoliosis

OBJECTIVE

This study aims to elucidate surgical risk factors in neuromuscular scoliosis (NMS) with respect to wound site infection after spinal fusion.

METHODS

A retrospective review was performed of all patients treated surgically for NMS between January 2008 and December 2016 (minimum 6 months' follow-up). A sub-cohort of 60 patients with minimum 2 years of follow-up data was also analyzed.

RESULTS

In 102 patients (53 boys and 49 girls), the mean age at surgery was 14.0 years (SD ±2.7). Mean follow-up was 2.53 years (±1.66), and mean time to presentation of infection was 2.14 months (±4.95). The overall perioperative complication rate was 26.5%, with 14.7% of patients developing deep wound infection. Gram-negative bacteria were responsible for 60% of infections; 20% were Gram positive, and 20% involved both types. Pulmonary comorbidities (p = 0.007), pre- to postoperative increase in weight (p = 0.010), exaggerated lumbar lordosis at follow-up (p = 0.008), history of seizures (p = 0.046), previous myelomeningocele repair (p = 0.046), and previous operations (p = 0.013) were significant risk factors for infection.

CONCLUSION

Our data suggest that in the pediatric population treated surgically for NMS, wound infection is strongly associated with postoperative increase in body weight, residual lumbar lordosis, pulmonary comorbidity, history of myelomeningocele repair, seizures, and previous operations.

Does Reoperation Risk Vary for Different Types of Pediatric Scoliosis?

STUDY DESIGN

Retrospective cohort study of spine fusion surgery utilizing the New York State Inpatient Database.

OBJECTIVE

The objective was to determine whether there were differences in reoperation rates among pediatric scoliosis associated with various etiologies compared with idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

The incidence of postoperative complications and reoperations is known to vary among patients with diverse scoliosis pathologies. As these are heterogeneous conditions and often with rare occurrence, it is difficult to compare them in a single study. We aimed to assess reoperation events after fusion for several etiologies of pediatric scoliosis.

METHODS

The 2008 to 2011 New York State Inpatient Database was queried using International Classification of Diseases (ICD-9-CM) codes for patients with in-hospital stays including a spine arthrodesis for scoliosis. All approaches, all fusion lengths, and ages 10 to 21 were included. Patient identifiers and linkage variables were used to identify revisits. The relative risk of reoperation was calculated for several rare conditions associated with scoliosis.

RESULTS

Two thousand three hundred fifty-six pediatric scoliosis fusion surgeries were identified in 2008 in the state of New York. The 1- and 4-year reoperation rate for idiopathic scoliosis was 0.9% and 1.6%, respectively. For nonidiopathic scoliosis, the 1- and 4-year rates were 4.2% and 20.4%, respectively. Of the nonidiopathic scoliosis subtypes, congenital scoliosis (4.7% risk at 1 y, 41.6% at 4 y), the neuromuscular disease arthrogryposis (7.3% risk at 1 y, 28.6% at 4 y), and syndrome neurofibromatosis (9.1% at 1 y, 32.3% at 4 y) showed the highest risk for reoperation. Length of stay and hospital charges were higher for reoperations.

CONCLUSIONS

Using a large administrative database, we identified neuromuscular, syndromic, and congenital forms of scoliosis that have the highest relative risk for a reoperation within 1 year. At-risk populations should be identified and resources allocated and preventative measures instituted accordingly to prevent these costly events.

LEVEL OF EVIDENCE

Level III.

Posterolateral Diskectomies for Treatment of Pediatric Spinal Deformities

STUDY DESIGN

Retrospective.

OBJECTIVE

To investigate the indications, radiographic outcomes, and complications in children with spinal deformities treated with posterolateral diskectomy with posterior fusion (PLDF), and to compare them against those of patients treated with anteroposterior spinal fusion (APSF).

SUMMARY OF BACKGROUND DATA

A novel technique for treating large, rigid spinal deformities in children has been proposed, consisting of PLDF at the apex of the deformity using an all-posterior approach.

METHODS

We evaluated records of all patients 21 years or younger who underwent treatment for spinal deformity between 2010 and 2015 by one surgeon using PLDF (n = 56) or APSF (n = 21).

RESULTS

The indications for PLDF were large, rigid curves (37 patients); focal curves with severe rotation (10 patients); or large curves with open triradiate cartilage (nine patients). PLDF patients had a mean (± standard deviation) of 3 ± 1 diskectomies and 14 ± 3 posterior spinal levels fused. Compared with the APSF group, the PLDF group had significantly greater major curve correction (86% vs. 57%, P = 0.006), less blood transfused (mean, 2.5 ± 2.6 vs. 4.0 ± 3.3 units, P = 0.038), and a lower rate of staged surgery (1.8% vs. 86%, P < 0.001). There were no significant differences between the PLDF and APSF groups in T1-S1 length gained (mean, 6.2 ± 3.4 vs. 6.6 ± 8.8 cm, respectively; P = 0.77) or in the rate of major complications (P = 0.557).

CONCLUSION

PLDF is an effective alternative to APSF for treating children with severe spinal deformities. It is effective for treating large, rigid curves with severe rotation and may be useful for treating large curves in children with open triradiate cartilage.

LEVEL OF EVIDENCE

4.

Minimally Invasive Surgery for Neuromuscular Scoliosis: Results and Complications in a Series of One Hundred Patients

STUDY DESIGN

A retrospective review.

OBJECTIVE

To report the results of an alternative technique using a minimally invasive fusionless surgery. The originality is based on the progressive correction of the deformities with proximal and distal fixation and on the reliability of the pelvic fixation using iliosacral screws on osteoporotic bones.

SUMMARY OF BACKGROUND DATA

Spinal deformities are common in neuromuscular diseases. Conventional treatment involves bracing, followed by spinal instrumented fusion. Growing rod techniques are increasingly advocated but have a high rate of complications.

METHODS

The technique relies on a bilateral double rod sliding construct anchored proximally by four hooks claws and distally to the pelvis by iliosacral screws through a minimally invasive approach. Hundred patients with neuromuscular scoliosis underwent the same fusionless surgery extended from T1 to the pelvis. The average age at initial surgery was 11 + 6 years. Diagnoses included cerebral palsy (61), spinal muscular atrophy (22), muscular dystrophy (10), and other neurological etiologies (7). Cobb angle and pelvic obliquity were measured before and after initial surgery, and at final follow-up. Complications were reviewed.

RESULTS

At latest follow-up 3 + 9 years (range 2 yr-6 + 3 yr), the mean Cobb angle improved from 89° to 35° which corresponds to 61% correction. Mean pelvic obliquity improved from 29° to 5°, which corresponds to 83% correction. Mean T1-S1 length increased from 30.02 to 37.28 cm. Mean preoperative hyper kyphosis was reduced from 68.44° to 33.29°. Complications occurred in 26 patients including mechanical complications (12) and wound infections (16). No arthrodesis was required at last follow-up.

CONCLUSION

This original fusionless technique is safe and effective, preserving spinal and thoracic growth. It provides a significant correction of spinal deformities and pelvic obliquity with a reduced complications rate. The strength and stability of this modular construct over time allow the avoidance of final arthrodesis.

LEVEL OF EVIDENCE

4.

Complication rates for preexisting baclofen pumps and ventricular shunts following scoliosis correction: a preliminary study

OBJECTIVE Many patients undergoing spinal fusion for neuromuscular scoliosis have preexisting neurosurgical implants, including ventricular shunts (VSs) for hydrocephalus and baclofen pumps (BPs) for spastic cerebral palsy. Recent studies have discussed a possible increase in implant complication rates following spinal fusion, but published data are inconclusive. The authors therefore, sought to investigate: 1) the rate of implant complications following fusion, 2) possible causes of these complications, and 3) factors that place patients at higher risk for implant-related complications. METHODS Cases involving pediatric patients with a preexisting VS or BP who underwent spinal fusion for scoliosis correction between 2005 and 2016 at a single tertiary children's hospital were retrospectively analyzed. Patient demographics, implant characteristics, spinal fusion details, neurosurgical follow-up, and implant complications in the 180 days following fusion were recorded and analyzed. RESULTS Overall, 75 patients who underwent scoliosis correction had preexisting implants: 39 had BPs, 31 VSs, and 5 both. The patients' mean age at fusion was 13.49 ± 2.78 years (range 3.62-18.81 years), and the mean time from the most recent previous implant surgery to fusion was 5.70 ± 4.65 years (range 0.10-17.3 years). The mean preoperative and postoperative Cobb angles were 62.4° ± 18.9° degrees (range 20.9°-109.0°) and 23.5° ± 13.3° degrees (range 2.00°-67.3°), respectively. No VS complications were identified. Two patients with BPs were found to have complications (unintentional cutting of their BP catheter during posterior spinal fusion) within 180 days postfusion. There were no recorded neurosurgical implant infections, failures, fractures, or dislodgements. Although 10 patients required at least 1 surgical procedure for irrigation and debridement of the spine wound following fusion, there were no abdominal or cranial implant wound infections requiring revision, and no implants required removal. CONCLUSIONS The results of this study suggest that spinal fusion for scoliosis correction does not increase the rates of complications involving previously placed neurosurgical implants. A large-scale, prospective, multicenter study is needed to fully explore and confirm this finding.

Safety and Efficacy of Treatment for Scolios Is Secondary to Spinal Muscular Atrophy Fused to Lumbar 5 Level

Introduction

Patients with spinal muscular atrophy (SMA) usually have progressive scoliosis. Although fusion of the sacrum or pelvis has been recommended for correcting pelvic obliquity (PO), the procedure is invasive. This study determined as to whether performing instrumentation to the fifth lumbar vertebra (L5) is safe and effective for scoliosis in patients with SMA.

Methods

Twelve patients with SMA underwent posterior spinal fusion and stopping instrumentation at the L5 level. We evaluated age at surgery, the duration of surgery, blood loss, complications, preoperative and postoperative Cobb angles, and PO.

Results

The mean age at surgery was 11.4 years; the mean duration of surgery was 319 minutes, and the mean blood loss was 1170 mL. The Cobb angle improved from 97.3° to 39.1° at 1 month postoperatively (correction rate, 60.9%) and to 42.3° at the final follow-up. PO was corrected from 27.8° to 13.1° at 1 month postoperatively (correction rate, 51.7%) and to 19.8° at the final follow-up. No complications were reported. All patients showed improvement in low back pain, with reduced difficulty while sitting. However, >10% correction loss of PO was observed in 6 patients with high preoperative PO.

Conclusions

The correction rate of scoliosis in SMA patients with posterior spinal fusion and instrumentation to the L5 level was acceptable, and no complications occurred. Scoliosis associated with SMA was more rigid and severer than scoliosis associated with Duchenne muscular dystrophy. Correction rates of the Cobb angle and PO in SMA patients with instrumentation to L5 were similar to those in SMA patients with instrumentation to the sacrum or pelvis. Correction loss of PO was greater in patients with high preoperative PO than in those with low preoperative PO. Instrumentation and fusion to L5 for scoliosis in patients with SMA seems safe and effective, except in cases of high preoperative PO.

Perioperative Complications in Posterior Spinal Fusion Surgery for Neuromuscular Scoliosis

Introduction

Patients with neuromuscular disorders sometimes show progressive spinal scoliosis. The surgery for neuromuscular scoliosis (NMS) has high rates of complications. In this study, we elucidated the perioperative complications in patients with NMS.

Methods

We included 83 patients with NMS (58 boys and 25 girls; 61 with muscular dystrophy, 18 with spinal muscular atrophy, and 4 others) who had undergone posterior fusion surgery for scoliosis. We evaluated the perioperative complications (within 3 months), age at time of surgery, operative time, blood loss, preoperative %VC and FEV_1.0 (%) for pulmonary function, and preoperative ejection fraction (EF) for cardiac function.

Results

There were 5 (6%) major complications, including pneumonia and a cardiovascular complication requiring intensive care unit (ICU) care, and 15 (18%) minor complications including viral enteritis and a urinary tract infection. Overall, there were 20 (24%) complications. Three of the 5 major complications were pulmonary. The mean age at the time of surgery was 13.7 y, operative time was 304 min, and blood loss was 1530 ml. The mean preoperative %VC was 41%, FEV_1.0 was 91%, and EF was 60%. When we separated the patients into a group with major complications (n = 5) and a group without major complications (n = 78), the preoperative %VC in the group with major complications (23%) was significantly lower than that in the group without (42%) (p < 0.05). However, operative time, blood loss, preoperative FEV_1.0 (%) and EF between the two groups were not significantly different (p > 0.05).

Conclusions

Compared with the previous findings of the perioperative complication rate (45%-74%) for NMS, the complication rate was remarkably low in this case series. Because of advances in medical skills, including anesthesia and surgical instruments, surgery for NMS appears to be safe. However, patients with NMS with complications demonstrated severe restrictive ventilatory impairment preoperatively. Therefore, we should be vigilant for perioperative pulmonary complications especially in patients with NMS and preoperative severe restrictive ventilatory impairment.

Assessing the Risk-Benefit Ratio of Scoliosis Surgery in Cerebral Palsy: Surgery Is Worth It

BACKGROUND

The true benefits of scoliosis surgery in cerebral palsy (CP) remain uncertain. Our aims were to determine the benefits of spinal fusion according to health-related quality of life (HRQoL) improvement at long-term follow-up and to explore the effect of surgery-related complications on clinical outcomes.

METHODS

The cases of consecutive patients who had Gross Motor Function Classification System (GMFCS) level-IV or V cerebral palsy with 5-year follow-up from a prospective, longitudinal, multicenter database were analyzed. Caregivers completed the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaire and 4 Likert-type anchor questions preoperatively and at 1, 2, and 5 years of follow-up. Data on complications were collected prospectively. Preoperative CPCHILD scores were compared with postoperative scores at the 1, 2, and 5-year follow-up evaluations. Preoperative CPCHILD scores were compared with postoperative scores at the 1, 2, and 5-year follow-up evaluations using repeated-measures analysis of variance (ANOVA). Spearman correlation coefficient was used to explore the association between changes in the CPCHILD at 1, 2, and 5-year follow-up and the reported complications within the follow-up period. Similarly, a comparative analysis between the percentage distribution of the answers to the 4 anchor questions and the reported complications was also performed.

RESULTS

Sixty-nine patients with a mean age (and standard deviation) of 13.4 ± 2.6 years at enrollment were analyzed. The major Cobb angle was a mean of 81.9° ± 26.7° preoperatively and improved to a mean of 28.7° ± 14.4° at 2 years and 30.7° ± 15.3° at 5 years postoperatively. Significant improvements in CPCHILD personal care, positioning, and comfort domains were noted at all time points. The mean increase in the total score was 7.19 (p < 0.001) at 1 year, and the score gain was maintained at 2 and 5 years postoperatively. The overall complication rate was 46.4% at 1 year, 1.4% between 1 and 2 years, and 4.3% at 2 to 5 years postoperatively, with surgical intervention required in 6 patients within 1 year and in 2 additional patients within 5 years following scoliosis surgery. There was no correlation between complications and CPCHILD scores postoperatively at all time points, with the only exception of a weak correlation (ρ = -0.450, p = 0.002) with CPCHILD comfort score at 1 year after surgery.

CONCLUSIONS

Scoliosis surgery in patients with CP leads to a significant improvement in HRQoL, which is maintained 5 years following surgery. The substantial complication rate does not correlate with HRQoL changes postoperatively, suggesting that the benefits of surgery outweigh the risks in this fragile population.

LEVEL OF EVIDENCE

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

Intrathecal Baclofen Therapy Prior to Spinal Fusion for Patients With Gross Motor Function Classification System IV-V Cerebral Palsy

BACKGROUND

Patients with Gross Motor Function Classification System (GMFCS) IV-V cerebral palsy (CP) have significant spasticity and frequently develop scoliosis. Intrathecal baclofen (ITB) pumps are effective in managing spasticity. The effect of ITB therapy on the postoperative course following spinal fusion in patients with GMFCS IV-V CP has not been described. This study sought to compare postoperative recovery, including complications, in patients using ITB therapy with those with no ITB therapy.

PURPOSE

Evaluate the effect of ITB on the postoperative recovery for patients with GMFCS IV-V CP who undergo spinal fusion for scoliosis.

METHODS

Health records for patients with GMFCS IV-V CP who underwent a spinal fusion for scoliosis at a major quaternary-care children's hospital from January 2009 to October 2015 were reviewed and relevant data were abstracted. Descriptive statistics and regression models were used to compare patients.

RESULTS

Sixty-nine patients were included-19 ITB therapy and 50 no ITB therapy. Demographic and operative characteristics were similar across groups. The mean length of stay for patients in the ITB therapy group was 11.2 days and 14.3 days for the no ITB therapy group, with no difference between groups (p = .12). Pain scores in both groups decreased at the same rate, with scores in the ITB therapy group averaging one-half point lower (p = .32). The average amount of morphine equivalents (p = .71) and benzodiazepine equivalents (p = .53) used were similar between groups. Complication rates were significantly different between groups. Four (21%) of the ITB therapy patients had 1 or more complications whereas 28 (56%, p = .01) in the no ITB therapy group had 1 or more complications. The average number of complications per patient in the ITB therapy group was 0.3 (SD: 0.075, range: 0-3) and the no ITB therapy group was 1.1 (SD: 1.1, range: 0-6, p = .01).

CONCLUSIONS

There was no significant difference in length of stay, pain scores, or pain/spasticity medication use between groups after spinal fusion, but there was a significantly lower incidence of complications in the ITB therapy group.

Segmental Pedicle Screw Instrumentation and Fusion Only to L5 in the Surgical Treatment of Flaccid Neuromuscular Scoliosis

STUDY DESIGN

A retrospective cohort study was performed.

OBJECTIVE

The purpose of this study was to determine the efficacy and safety of stopping segmental pedicle screw instrumentation constructs at L5 in the treatment of neuromuscular scoliosis.

SUMMARY OF BACKGROUND DATA

Duchenne muscular dystrophy and spinal muscular atrophy are flaccid neuromuscular disorders in which gradual deterioration is the hallmark and have a lot of characteristics in common despite differences in etiology. Instrumentation and fusion to the sacrum/pelvis has been a mainstay in the surgical treatment of flaccid neuromuscular scoliosis and recommended to correct pelvic obliquity. However, the caudal extent of instrumentation and fusion in the surgical treatment of flaccid neuromuscular scoliosis has remained a matter of considerable debate and there have been few studies on the use of segmental pedicle screw instrumentation for flaccid neuromuscular scoliosis.

METHOD

From 2005 to 2007, a total of 27 consecutive patients with neuromuscular disorders (20 Duchenne muscular dystrophy and 7 spinal muscular atrophy), aged 11 to 17 years, underwent segmental pedicle screw instrumentation and fusion only to L5. Assessment was performed clinically and with radiologic measurements. Minimum 2-year follow-up was required for inclusion in this study.

RESULTS

Twenty patients were enrolled in this study. No patient was lost to follow-up. All patients had L5 tilt of less than 15° and a coronal curve with apex L2 or higher preoperatively. Preoperative coronal curve averaged 70° (range: 51°-88°), with a postoperative mean of 15° (range: 5°-25°) and 17° (range: 6°-27°) at the last follow-up. The pelvic obliquity improved from 15° (range: 9°-25°) preoperatively to 5° (range: 3°-8°) postoperatively and 6° (range: 3°-8°) at the last follow-up. The L5 tilt improved from 9° (range: 2°-14°) preoperatively to 2° (range: 0°-4°) postoperatively and 2° (range: 0°-5°) at the last follow-up. Physiologic sagittal plane alignment was recreated after surgery and maintained long-term. There was no significant loss of correction of coronal curve and pelvic obliquity. There was no major complication.

CONCLUSION

Segmental pedicle screw instrumentation and fusion to L5 was safe and effective in patients with flaccid neuromuscular scoliosis with apex L2 or higher and minimal L5 tilt of less than 15°. Segmental pedicle screw instrumentation ending at L5 offered the ability to correct spinal deformity and pelvic obliquity initially, intermediate and even long-term, with no major complications. This method in appropriate patients can be a viable alternative to instrumentation and fusion to the sacrum/pelvis in the surgical treatment of flaccid neuromuscular scoliosis.

LEVEL OF EVIDENCE

N/A.

Evaluation of postoperative fever after surgical correction of neuromuscular scoliosis: implication on management

BACKGROUND

Scoliosis is a common deformity in patients with neuromuscular disorders which usually necessitates surgical correction. Patients with neuromuscular scoliosis are characterized by increased incidence of associated medical co-morbidities and higher postoperative complication rate; therefore, these patients are often managed with a wide multidisciplinary care team. Postoperative fever is a frequent complication after surgery which is often routinely investigated using different workup tests to rule out infection. These tests lack clear evidence on how they impact the patient care and are associated with increased cost and burden on the health system.

OBJECTIVE

The objective of our study was to evaluate the incidence of postoperative fever after surgical correction of neuromuscular scoliosis and evaluate the clinical usefulness of fever diagnostic workup.

METHODS

Demographic and clinical data on patients who underwent neuromuscular scoliosis corrective surgery between March 1, 2014 and February 28, 2017 were reviewed at a single institution. The occurrence of postoperative fever (defined by body temperature ≥ 38 °C during the 1st week after surgery) was characterized by maximum temperature (T max), postoperative day of occurrence (POD), and frequency as described by either single or multiple temperature spikes. The diagnostic tests performed for the assessment of postoperative fever were reviewed. The cost per health effect was calculated by dividing the total costs of performed fever workup tests by the number of tests that resulted in change of the patient care.

RESULTS

Seventy-six patients (47 females and 29 males) were identified. Cerebral palsy was the most common aetiology in 40 patients (52.6%). The mean age at surgery was 13.5 years (range 3-18 years). The operative time was 490.34 ± 127.21 min. The intraoperative blood loss was 912.3 ± 627.8 cc. The hospital stay was 9.79 ± 5.3 days and the intensive care unit (ICU) stay was 3.26 ± 3.7 days. Wound drains were used in 71 patients for a period of 3.6 ± 2.3 days. Urinary catheters were used for a period of 3.6 ± 1.8 days. Forty-nine patients (64.5%) developed postoperative fever with a temperature of 38.7° ± 0.45° (range 38.10°-39.9°). The most frequent POD for occurrence of fever was the 2nd day in 22 patients (44.9%) The frequency of fever was in the form of multiple temperature spikes in 32 patients (65.3%) or in the form of a single spike in 17 patients (34.7%). There were a total of 20 positive tests out of 132 performed fever workup tests (15.2%). These included nine positive urine analysis (n = 32), five positive urine cultures (n = 28), one positive blood culture (n = 23), and two positive chest X-ray (n = 24). The occurrence of postoperative fever was statistically correlated with the operative time and increased hospital stay and ICU days. The most common identified cause of infection was urinary tract infection in 11 patients followed by respiratory tract infection in four patients and wound infection in one patient. The calculated cost per health effect was $3763.

CONCLUSION

Sixty-four percent of patients who underwent surgical correction of neuromuscular scoliosis developed postoperative fever. Postoperative fever was sign of infection in 32.7% of patients and urinary tract infection was the most frequent finding. Only 15.2% of fever diagnostic workup tests were positive. Diagnostic urine tests account for 70% of the positive diagnostic workup. The routine use of blood cultures for the assessment of postoperative fever in such population should be avoided due to the low rate of positive tests and the associated high cost.

Deep Surgical Site Infections Following Pediatric Cervical Spine Surgery

OF BACKGROUND DATA

This is the first reported series looking specifically at factors associated with deep surgical site infections (SSI) following pediatric cervical spine surgery.

OBJECTIVE

To identify risk factors present in pediatric patients who are at risk for SSI following cervical spine surgery.

DESIGN

Level of evidence: level IV-retrospective case series.

INTRODUCTION

To date there are no studies regarding SSI in pediatric cervical spine surgery and thus no benchmark data or risk factors have been identified.

METHODS

Patients with acute deep SSIs occurring within 90 days of the index operation were identified. Patient and surgical characteristics were analyzed for possible predictors of SSI outcome using penalized likelihood logistic regression analysis. Characteristics analyzed included: age, diagnosis, comorbidity, levels fused, approach, implants used, allograft, halo, body mass index, revision, antibiotic dosing, and occipital plating.

RESULTS

A total of 112 patients were included in the study at a mean age of 12.5 years (2 to 18 y). Comorbidities were present in 51 (46%) patients, 15 patients had a documented connective tissue disorder (CTD). The mean number of levels fused was 3.7 (2 to 7) and mean number of screws was 4.4 (2 to 11). Allograft was used alone in 48 patients, occipital plating in 28 patients, and a halo in 39 patients. Deep SSI occurred in 3 patients: two of which had a CTD (1 Trisomy 21, 1 Ehlers-Danlos) and 1 patient with postradiation cervical kyphosis. All were gram-positive infections requiring return to operating room with prolonged IV antibiotics. All patients recovered and fused with spinal implant retention. The incidence of deep SSI was 2.7%. It was determined that a CTD was the only significant predictor of SSI. Subjects with a CTD had 12 times the odds of SSI [odds ratio=12 (1.5, 137.0); P=0.02].

CONCLUSIONS

In our series of pediatric patients the incidence of a deep SSI was 2.7%. The only predictor of SSI was the presence of a CTD.

[Characteristics of neuromuscular scoliosis]

Usually, neuromuscular scolioses become clinically symptomatic relatively early and are rapidly progressive even after the end of growth. Without sufficient treatment they lead to a severe reduction of quality of life, to a loss of the ability of walking, standing or sitting as well as to an impairment of the cardiopulmonary system resulting in an increased mortality. Therefore, an intensive interdisciplinary treatment by physio- and ergotherapists, internists, pediatricians, orthotists, and orthopedists is indispensable. In contrast to idiopathic scoliosis the treatment of patients with neuromuscular scoliosis with orthosis is controversially discussed, whereas physiotherapy is established and essential to prevent contractures and to maintain the residual sensorimotor function.Frequently, the surgical treatment of the scoliosis is indicated. It should be noted that only long-segment posterior correction and fusion of the whole deformity leads to a significant improvement of the quality of life as well as to a prevention of a progression of the scoliosis and the development of junctional problems. The surgical intervention is usually performed before the end of growth. A prolonged delay of surgical intervention does not result in an increased height but only in a deformity progression and is therefore not justifiable. In early onset neuromuscular scolioses guided-growth implants are used to guarantee the adequat development. Because of the high complication rates, further optimization of these implant systems with regard to efficiency and safety have to be addressed in future research.

Outcomes after scoliosis surgery for children with cerebral palsy: a systematic review

AIM

This study aims (1) to evaluate and synthesize the evidence for the postoperative outcomes after scoliosis surgery for children with cerebral palsy (CP), and (2) to identify preoperative risk factors for adverse outcomes after surgery.

METHOD

Medline, EMBASE, CINAHL, and PubMed were searched for relevant literature. Included studies were assessed for risk of bias using the Cochrane Effective Practice and Organisation of Care tool. Quality of evidence for overall function, quality of life (QoL), gross motor function, caregiver outcomes, deformity correction, and postoperative complications were assessed using GRADE (Grades of Recommendation, Assessment, Development and Evaluation).

RESULTS

Fifty-one studies met inclusion criteria, including 35 case series designs. Risk of bias was high across all studies. On average good deformity correction was achieved, the trend appears positive for caregiver and QoL outcomes, but there was minimal to no change for gross motor or overall function. Inconsistent measurement limited synthesis. A mean overall complication rate of 38.1% (95% confidence interval 27.3-53.3) was found. The quality of evidence was very low across all functional outcomes.

INTERPRETATION

Limited high-quality evidence exists for outcomes after scoliosis surgery in children with CP, a procedure associated with a moderately high complication rate. The intervention appears indicated for deformity correction, but currently there is insufficient evidence to make recommendations for this surgery as a way to also improve functional outcomes, caregiver outcomes, and quality of life.

The surgical treatment of spinal deformity in children with myelomeningocele: the role of personalized three-dimensional printed models

This study was carried out to evaluate the benefits of personalized three-dimensional printing as an aid to the performance of surgery for the correction of spinal deformity in children with myelomeningocele. We performed a retrospective review to include all such children for whom personalized three-dimensional spine models were used for surgical planning (group A) and compared them through subjective and objective criteria to a similar group that had no models (group B). The seven children in group A were younger and had more complex deformities than the 10 children in group B. The models provided a markedly improved appreciation of the complex anatomy and enabled the planning and performance of patient-specific spinal instrumentation that was secure and low profile. The efficiency of the surgery as measured by intraoperative fluoroscopy time and blood loss and the extent of the deformity correction was comparable or superior in group A.

Wound Closure in Nonidiopathic Scoliosis: Does Closure Matter?

BACKGROUND

Postoperative wound complications after posterior spinal fusion are difficult to manage. The incidence in the nonidiopathic patient population is significantly higher than the adolescent idiopathic population. A comparison of wound complications after posterior spinal fusion for nonidiopathic scoliosis between the utilization of the orthopaedic surgical team at the time of closure performing a nonstandardized wound closure versus a plastic surgeon with a plastic multilayered closure technique and rotational flap coverage when needed had not previously been evaluated. The purpose of this study was to compare the complication rate between nonstandardized and plastic multilayered closure of the surgical incision in patients undergoing posterior spinal fusion for nonidiopathic scoliosis.

METHODS

The charts of 76 patients with a primary diagnosis of scoliosis associated with a syndrome or neuromuscular disease and who underwent a posterior spinal fusion were reviewed. Forty-two patients had their incisions closed using the nonstandardized technique and 34 using the plastic multilayered technique. These 2 groups were compared for age, sex, primary diagnosis, number of levels fused, estimated blood loss, number of units transfused, operating room time, wound complication, and return to operating room.

RESULTS

The wound complication rate in the nonstandardized closure group was 19% (8/42) compared with 0% (0/34) in the plastic multilayered closure group (P=0.007). The unanticipated return to the operating room rate was 11.9% (5/42) for the nonstandardized closure patients versus 0% (0/34) for the plastic multilayered closure patients (P=0.061).

CONCLUSIONS

The use of the plastic multilayered closure technique in this patient population is important in an effort to decrease postoperative wound complications. The ability of the surgical team to decrease the infection rate of nonidiopathic scoliosis cannot be overstated. The method of wound closure plays a major role in lowering this incidence.

LEVEL OF EVIDENCE

Level III-therapeutic.

Predictive factors of intraoperative cell salvage during pediatric scoliosis surgery. Cell saver during scoliosis surgery in children

INTRODUCTION

Blood-saving strategy during spinal surgery in children often includes recombinant erythropoietin (rEPO) and antifibrinolytic therapapy (AFT). The aim of this study was to investigate the efficacy of intraoperative blood salvage in decreasing homologous blood transfusion.

MATERIAL AND METHODS

Using the prospective data from patients operated during a one year period for scoliosis correction, we calculate the predictable hematocrit at day postoperative 1 without the use of blood salvage and compare it to the target hematocrit transfusion according to patient's status. Predictors analyzed were: age, weight, surgical indication, Cobb's angle, ASA status, preoperative hemoglobin, number of level fused, sacral fusion and thoracoplasty. Statistical analyses were performed using a classification tree analysis.

RESULTS

This study included 147 patients. Blood salvage was estimated avoiding homologous blood transfusion in 17 patients. Predictors of the efficacy of blood salvage were: neuromuscular indications, number of level fused and BMI. Blood salvage was found totally ineffective in: patients with no neuromuscular diseases with either: surgeries interesting<13 levels fused or surgeries interesting>13 levels with a preoperative BMI ≥ 21. In all other cases, blood salvage can decrease homologous transfusion. The model exhibited 97% of accurate for the prediction if the inefficacy of blood salvage. The AUCROC of the model was 0.93 [95% confidence interval 0.9 to 0.99] and the overall validation was 60.1% of explained variability.

CONCLUSION

The present study indicates that blood salvage is ineffective under certain circumstances. More studies are mandatory to confirm these results.

Rate of complications due to neuromuscular scoliosis spine surgery in a 30-years consecutive series

PURPOSE

The aim of this study was to evaluate the rate of intraoperative and postoperative complications in a large series of patients affected by neuromuscular scoliosis.

METHODS

It was a monocentric retrospective study. In this study have been considered complications those events that significantly affected the course of treatment, such as getting the hospital stay longer, or requiring a subsequent surgical procedure, or corrupting the final result of the treatment.

RESULTS

Of the 358 patients affected by neuromuscular scoliosis treated from January 1985 to December 2010, 185 that met the inclusion criteria were included in the study. There were recorded 66 complications in 55/185 patients. Of that 66 complications, 54 complications occurred in 46/120 patients with Luque's instrumentation, while only 12 complications occurred in 9/65 patients with hybrid instrumentation and this difference was statistically significant (p < 0.05); 11/126 patients with pelvic fixation and 5/59 without pelvic fixation, as well as 45/156 patients treated by posterior approach alone and 10/29 patient that underwent combined anterior-posterior approach suffered complications but both this did not result in a statistical significant difference (p > 0.05).

CONCLUSIONS

The surgical treatment in neuromuscular scoliosis is burdened by a large number of complications. An accurate knowledge of possible complications is mandatory to prepare strategies due to prevent adverse events. A difference in definitions could completely change results in good or bad as well as in our same series the adverse events amounted at almost 30% of cases, but complications that due to complete failure would amount at 9.19% of patients.

Experience in Perioperative Management of Patients Undergoing Posterior Spine Fusion for Neuromuscular Scoliosis

The objective of this investigation was to determine the outcome of spine fusion for neuromuscular (NM) scoliosis, using Unit Rod technique, with emphasis on complications related to preoperative general health. Between 1997 and 2007, 96 consecutive patients with neuromuscular scoliosis operated on with Unit Rod instrumentation were retrospectively reviewed. The inclusion criteria were diagnosis of NM scoliosis due to cerebral palsy (CP) and muscular dystrophy (DMD). Patient's preoperative general health, weight, and nutrition were collected. Different radiographic and clinical parameters were evaluated. There were 66 CP patients (59 nonwalking) and 30 DMD patients (24 nonwalking). Mean age at surgery was 16.5 years and 13.9 years, respectively. All radiographic measurements improved significantly. Wound infection rate was 16.7% (11% of reoperation rate in CP; 10% in DMD; 3 hardware removal cases). No pelvic fracture due to rod irritation was observed. Unit Rod technique provides good radiographic and clinical outcomes even if this surgery is associated with a high complication rate. It is a quick, simple, and reliable technique. Perioperative management strategy should decrease postoperative complications and increases outcome. A standardized preoperative patient evaluation and preparation including respiratory capacity and nutritional, digestive, and musculoskeletal status are mandatory prior to surgery.

The management of scoliosis in children with cerebral palsy: a review

Children who suffer with cerebral palsy (CP) have a significant chance of developing scoliosis during their early years and adolescence. The behavior of this scoliosis is closely associated with the severity of the CP disability and unlike idiopathic scoliosis, it continues to progress beyond skeletal maturity. Conservative measures may slow the progression of the curve, however, surgery remains the only definitive management option. Advances in surgical technique over the last 50 years have provided methods to effectively treat the deformity while also reducing complication rates. The increased risk of surgical complications with these complex patients make decisions about treatment challenging, however with careful pre-operative optimization and post-operative care, surgery can offer a significant improvement in quality of life. This review discusses the development of scoliosis in CP patient, evaluates conservative and surgical treatment options and assesses post-operative outcome.

Factors influencing the evaluation and management of neuromuscular scoliosis: A review of the literature

Neuromuscular scoliosis (NMS) is the second most prevalent spinal deformity (after idiopathic scoliosis) and is usually first identified during early childhood. Cerebral palsy (CP) is the most common cause of NMS, followed by Duchenne muscular dystrophy (DMD). Progressive spinal deformity causes difficulty with daily care, walking and sitting, and can lead to back and rib pain, cardiac and pulmonary complications, altered seizure thresholds, and skin compromise. Early referral to specialist spinal services and early diagnosis of NMS is essential to ensure appropriate multidisciplinary patient management. The most important goals for patients are preservation of function, facilitation of daily care, and alleviation of pain. Non-operative management includes observation or bracing for less severe and flexible deformity in young patients as a temporising measure to provide postural support. Surgical correction and stabilisation of NMS is considered for patients with a deformity >40-50°, but may be performed for less severe deformity in patients with DMD. Post-operative intensive care, early mobilisation and nutritional supplementation aim to minimise the rate of post-surgical complications, which are relatively common in this patient group. However, surgical management of NMS is associated with good long-term outcomes and high satisfaction rates for patients, their relatives and carers.