Effects of surgical correction of neuromuscular scoliosis on gastric myoelectrical activity, emptying, and upper gastrointestinal symptoms

The effects of gastrojejunostomy tube placement on pulmonary and gastrointestinal complications following spinal fusion for neuromuscular scoliosis

To evaluate whether preoperative conversion from a gastrostomy tube (G-tube) to a gastrojejunostomy tube (GJ-tube) decreases short-term postoperative aspiration pneumonia and gastrointestinal complications in children with neuromuscular scoliosis. We conducted a retrospective chart review from January 2006 to October 2021 of pediatric patients who had neuromuscular scoliosis and were fed with a G-tube before spinal fusion. Eligible patients were divided into two groups based on whether they were converted to a GJ-tube preoperatively. Preoperative characteristics and 30-day postoperative outcomes were compared between groups using Chi-square tests. Of 261 eligible patients, 205 were converted to a GJ-tube, while 56 underwent spinal fusion with a G-tube. Common complications following G-tube to GJ-tube conversion were feeding intolerance (25.2%), GJ-tube malfunction (17.7%), and at least one episode of vomiting (17.4%). Within 30 days of discharge, 12.5% of GJ-tube patients and 11.5% of G-tube patients experienced aspiration pneumonia ( P  = 0.85). The GJ-tube group received postoperative tube feeds 7 hours earlier than the G-tube group on average (51.6 h vs. 44.5 h, P  = 0.02). Within 30 days of discharge, one (0.5%) patient from the GJ-tube group died of gastrointestinal complications unrelated to conversion and two (3.6%) patients in the G-tube group died from aspiration pneumonia ( P  = 0.12). Results suggest that there were no appreciable differences in outcomes between patients converted to a GJ-tube preoperatively compared to those who continued to use a G-tube. However, preoperative characteristics indicate that a higher number of complex patients were converted to a GJ-tube, indicating potential selection bias in this retrospective sample. Level of evidence: Level III.

Mortality and Causes of Death in Children With Cerebral Palsy With Scoliosis Treated With and Without Surgery

BACKGROUND AND OBJECTIVES

To compare mortality and causes of death in scoliotic children with cerebral palsy (CP) with and without scoliosis surgery.

METHODS

National population-based registries were searched for children with CP and scoliosis with and without surgery for scoliosis and were analyzed for comorbidities, mortality, and causes of death.

RESULTS

Two hundred thirty-six had not been operated and 238 had been operated on for scoliosis during the median follow-up of 17.8 (interquartile range [IQR] 11.7-25.7) and 23.0 (IQR 18.4-28.2) years, respectively. Both groups had similar comorbidities. During the follow-up, mortality was higher in the nonsurgically treated group than in the surgically treated group (n = 38/236, 16% and 8.7 per 1,000 follow-up years vs n = 29/238, 12% and 5.3 per 1,000 follow-up years, p = 0.047). In patients with nonsurgical treatment, the cause of death was respiratory in 76.3% (29/38) and 37.9% (11/29) in patients with surgical treatment of scoliosis (6.6 and 2.0 per 1,000 follow-up years, p = 0.002). Neurologic causes of death were more common in surgically treated patients than in nonsurgically treated patients, 44.8% (13/29) and 15.8% (6/38), respectively (3.0 and 1.1 per 1,000 follow-up years, p = 0.009).

DISCUSSION

Surgical treatment of scoliosis associates to reduced mortality because of respiratory causes in children with CP and scoliosis.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence of the effects of spinal fusion on mortality of children with severe scoliosis due to CP.

The atonic stomach: a dangerous condition prior to scoliosis surgery

A dilated atonic stomach as part of neuromuscular or syndromic disorders can have devastating results after scoliosis surgery. Patients can be asymptomatic preoperatively and non-clinical signs can be easily overlooked. Awareness of the condition, however, can prevent severe complications such as aspiration.

Risk factors for gastrointestinal complications after spinal fusion in children with cerebral palsy

DESIGN

Prospective cerebral palsy (CP) registry review.

OBJECTIVES

(1) Evaluate the incidence/risk factors of gastrointestinal (GI) complications in CP patients after spinal fusion (SF); and (2) investigate the validity of the modified Clavien-Dindo-Sink classification.

BACKGROUND

Perioperative GI complications result in increased length of stay (LOS) and patient morbidity/mortality. However, none have analyzed the outcomes of GI complications using an objective classification system.

METHODS

A prospective/multicenter CP database identified 425 children (mean, 14.4 ± 2.9 years; range, 7.9-21 years) who underwent SF. GI complications were categorized using the modified Clavien-Dindo-Sink classification. Grades I-II were minor complications and grades III-V major. Patients with and without GI complications were compared.

RESULTS

87 GI complications developed in 69 patients (16.2%): 39 minor (57%) and 30 major (43%). Most common were pancreatitis (n = 45) and ileus (n = 22). Patients with preoperative G-tubes had 2.2 × odds of developing a GI complication compared to oral-only feeders (OR 2.2; 95% CI 0.98-4.78; p = 0.006). Similarly, combined G-tube/oral feeders had 6.7 × odds compared to oral-only (OR 6.7; 95% CI 3.10-14.66; p < 0.001). The likelihood of developing a GI complication was 3.4 × with normalized estimated blood loss (nEBL) ≥ 3 ml/kg/level fused (OR 3.41; 95% CI 1.95-5.95; p < 0.001). Patients with GI complications had more fundoplications (29% vs. 17%; p = 0.03) and longer G-tube fasting periods (3 days vs. 2 days; p < 0.001), oral fasting periods (5 days vs. 2 days; p < 0.001), ICU admissions (6 days vs. 3 days; p = 0.002), and LOS (15 days vs. 8 days; p < 0.001). LOS correlated with the Clavien-Dino-Sink classification.

CONCLUSION

Gastrointestinal complications such as pancreatitis and ileus are not uncommon after SF in children with CP. This is the first study to investigate the validity of the modified Clavien-Dindo-Sink classification in GI complications after SF. Our results suggest a correlation between complication severity grade and LOS. The complexity of perioperative enteral nutritional supplementation requires prospective studies dedicated to enteral feeding protocols.

LEVEL OF EVIDENCE

Therapeutic-level III.

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.

Superior Mesenteric Artery Syndrome Complicated by Gastric Mucosal Necrosis Following Congenital Scoliosis Surgery: A Case Report

CASE

This is a report of severe superior mesenteric artery (SMA) syndrome in an 11-year-old girl with congenital scoliosis following posterior spinal fusion and segmental spinal instrumentation. This was complicated by gastric mucosal necrosis but resolved satisfactory with prolonged nasogastric suction, intravenous fluids, and total parental nutrition.

CONCLUSIONS

All pediatric spine surgeons should be aware of SMA syndrome following spine surgery. This case demonstrates that although rare, significant complications such as gastric mucosal necrosis can occur. When present, it can be treated successfully with prolonged conservative management. Comanagement with pediatric gastroenterology and pediatric general surgery is recommended.

Complications following lengthening of spinal growing implants: is postoperative admission necessary?

OBJECTIVE The aim of this study was to evaluate the effect of postoperative admission status on 30-day perioperative complications in patients with growing spinal instrumentation undergoing surgical lengthening. METHODS This retrospective case-control study of records from the 2014-2015 National Surgical Quality Improvement Program-Pediatric database was performed to identify surgical lengthening procedures of spinal implants in patients with growing instrumentation by Current Procedural Terminology code. The 30-day postoperative complications were classified according to the Clavien-Dindo system. Patients were subdivided according to their postsurgical admission status. Admission status, American Society of Anesthesiologists (ASA) Physical Status classification, tracheostomy, neuromuscular diagnosis, ventilator dependence, and nutritional support were considered as possible risk factors in univariate and multivariate logistic regression analyses. RESULTS A total of 796 patients were identified (mean age 9.09 ± 3.44 years; 54% of patients were female), of whom 73% underwent lengthening on an inpatient basis. Patients with a tracheostomy or ventilator dependence were more likely to be admitted postoperatively. The overall rate of major complications was 3.5% and did not differ based on admission status (2.8% inpatient vs 3.8% outpatient, p = 0.517). On univariate analysis, ventilator dependence (9.5% vs 2.7%, p = 0.002), need for nutritional support (7.1% vs 2.5%, p = 0.006), and ASA class > II (4.8% vs 1.3%, p = 0.04) placed patients at a higher risk for any postoperative complications. Multivariate analysis identified only ventilator dependence as an independent risk factor for any perioperative complication. CONCLUSIONS Postoperative admission status did not affect the rate of 30-day perioperative complications, readmission, or rate of unplanned operations following lengthening of growing spinal instrumentation. Outpatient lengthening appears to be safe; however, consideration for postoperative admission should be given for those who are ventilator dependent.

Risk Factors for Postoperative Ileus after Scoliosis Surgery

INTRODUCTION

One complication after scoliosis surgery is ileus; however, few reports have described the frequency of and risk factors for this complication. We conducted a retrospective clinical study with logistic regression analysis to confirm the frequency of and risk factors for ileus after scoliosis surgery.

METHODS

After a retrospective review of data from patients who underwent surgical correction of spinal deformity from 2009 to 2014, 110 cases (age range, 4-73 yr; median, 14 yr) were included in the study. We defined postoperative ileus (POI) as a surgical complication characterized by decreased intestinal peristalsis and the absence of stool for more than 3 days postoperatively. Various parameters were compared between patients with POI and those without POI. Logistic regression analysis was performed to assess the risk factors associated with ileus; a P value of <0.05 was considered statistically significant.

RESULTS

Fifteen of 110 (13.6%) cases developed POI. The median height, weight, operation time, and blood loss volume of the patients with versus without POI were 146 versus 152 cm, 39.0 versus 44.0 kg, 387 versus 359 min, and 1590 versus 1170 g, respectively. There were no significant differences between patients with versus without POI in the measured parameters, with the exception of patient height, bed rest period, and presence of neuromuscular scoliosis. Multiple logistic regression analysis revealed neuromuscular scoliosis as a significant risk factor for POI (odds ratio, 4.21; 95% CI, 1.23-14.40).

CONCLUSIONS

Our findings indicate a high probability of POI after scoliosis surgery, with an incidence of 13.6%. Neurogenic scoliosis, but not lowest instrumented vertebra or correction rate, was a risk factor for POI after scoliosis surgery. Digestive symptoms should be carefully monitored after surgery, particularly in patients with neuromuscular scoliosis.

Gastrointestinal Complications After Surgical Correction of Neuromuscular Scoliosis: A Retrospective Cohort Study

STUDY DESIGN

A retrospective cohort study of consecutively operated neuromuscular scoliosis patients.

BACKGROUND AND AIM

Surgical correction of neuromuscular scoliosis can be complicated by early gastrointestinal complications, but data on the extent and severity of them is scarce. The aim of the study was to determine the incidence, course, and risk factors of gastrointestinal complications after neuromuscular scoliosis correction.

MATERIAL AND METHODS

Ninety-one patients (<21 years of age) were consecutively operated on for neuropathic neuromuscular scoliosis during 2000-2011. Patients who developed marked postoperative gastrointestinal complications were identified and clinical, operative, and radiographic records, death certificates, and post-mortem reports were examined.

RESULTS

The average age at surgery was 14.5 (SD 2.9) and follow-up time was 4.9 (SD 2.3) years. Gastrointestinal complications occurred in 12 (13%) patients and included prolonged paralytic ileus (7%, 6/91), dysphagia (7%, 6/91), and gastroparesis (1%, 1/91). Hospital stay was 22 (SD 11) days in patients with gastrointestinal complications and 16 (SD 20) days in non-complicated patients (p = 0.005). Dysphagia required permanent feeding gastrostomy in one patient whereas other complications were transient and none caused death. The risk factors for postoperative gastrointestinal complications were preoperative main curve correction <30% in traction/bending radiographs (Relative Risk (RR) = 28 (95% Confidence Interval (CI) 4.4-180); p < 0.001), preoperative main curve >90° (RR = 5.5 (95% CI 1.3-23); p = 0.020), disturbance in intraoperative spinal cord monitoring (RR = 6.0 (95% CI 1.1-34); p = 0.043), and intravenous opioid medication over 5 days postoperatively (RR = 7.9 (95% CI 1.8-35), p = 0.006).

CONCLUSION

Gastrointestinal complications occurred in 13% of patients after neuromuscular scoliosis correction. Marked gastrointestinal complications extended postoperative hospitalization period, but they were transient in majority (92%) of cases and none caused death. Rigid scoliosis was the most significant risk factor for gastrointestinal complications. Gastrointestinal complications appear to be less frequent after posterior only spinal fusion with total pedicle screw instrumentation and Ponte osteotomies.

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.

The lifetime risk of pneumonia in patients with neuromuscular scoliosis at a mean age of 21 years: the role of spinal deformity surgery

BACKGROUND

Patients with neuromuscular disorders often have an increased risk of pneumonia and decreased lung function, which may further be compromised by scoliosis. Scoliosis surgery may improve pulmonary function in otherwise healthy patients, but no study has evaluated its effect on the risk of pneumonia in patients with neuromuscular scoliosis (NMS).

METHODS

The patient charts of 42 patients (mean age 14.6 years) who had undergone surgery for severe NMS (mean scoliosis 86°) were retrospectively reviewed from birth to a mean of 6.1 years (range 2.8-9.5) after scoliosis surgery. The main outcome was radiographically confirmed pneumonia as a primary cause for hospitalization. We excluded postoperative (3 months) pneumonia from the analyses.

RESULTS

The lifetime annual incidence of pneumonia was 8.0/100 before and 13.4/100 after scoliosis surgery (p > 0.10). The mean number of hospital days per year due to pneumonia were 0.59 (SD 2.3) before scoliosis surgery and 2.24 (SD 6.9) after surgery (p > 0.10). Multivariate analysis demonstrated that lifetime risk factors for pneumonia were epilepsy (RR 15.2, 95 % CI 1.3-176.8, p = 0.027), non-cerebral palsy (CP) etiology (RR = 10.2, 95 % CI 3.2-32.7, p < 0.001) and major scoliosis (main curve >70°; RR = 11.3, 95 % CI 1.8-70.7, p = 0.01).

CONCLUSIONS

Epilepsy, non-CP etiology and major scoliosis are significant risk factors for pneumonia in patients with NMS. Scoliosis surgery does not decrease the incidence of pneumonia in patients with severe NMS.

LEVEL OF EVIDENCE

Retrospective comparative study, Level III.