The Effect of Prolonged Pre-Operative Halo Gravity Traction for Severe Spinal Deformities on the Cervical Spine Radiographs

STUDY DESIGN

Retrospective review of consecutive series.

OBJECTIVE

The study sought to assess the effect of prolonged pre-operative halo gravity traction (HGT) on the c-spine radiographs.

METHODS

Data of 37 pediatric and adult patients who underwent ≥ 12wks pre-op HGT prior to definitive spine surgery from 2013-2015 at a single site in West Africa was reviewed. Radiographic assessment of the c-spine including ADI, SVA and C2-C7 Lordosis were done at pre HGT and at 4 weekly intervals. Paired T-Test was performed to evaluate changes in these parameters during HGT.

RESULTS

37pts, 18/19 (F/M). Average age 18.2yrs. Diagnoses: 22 idiopathic, 6 congenital, 3 Post TB, 2 NM and 4 NF. Average duration of HGT: 125 days. Baseline coronal Cobb:130 deg, corrected 30% in HGT; baseline sagittal Cobb:146 deg, corrected 32% post HGT. Baseline ADI (3.17 ± 0.63 mm) did not change at 4wks (P > 0.05) but reduced at 8wks (2.80 ± 0.56 mm) and 12wks (2.67 ± 0.51 mm) post HGT (P < 0.05). Baseline HGT SVA (20.7 ± 14.98 mm) significantly improved at 4wks (11.55 ± 10.26 mm), 8wks (7.54 ± 6.78 mm) and 12wks (8.88 ± 4.5 mm) (P < 0.05). Baseline C2-C7 lordosis (43 ± 20.1 deg) reduced at 4wks (26 ± 16.37 deg), 8wks (17.8 ± 14.77 deg) and 12wks (16.7 ± 11.33 deg) post HGT (P < 0.05). There was no incidence of atlanto-axial instability on flexion extension radiographs at any interval.

CONCLUSION

Prolonged HGT, while providing partial correction of severe spine deformities, also appeared to have no adverse effect on atlanto-axial stability or cervical alignment. Therefore, HGT can be safely applied for several weeks in the preoperative management of severe spine deformities in pediatric/adult patients.

Predictors of recurrence of chronic subdural haematoma in a cohort study of patients presenting in a sub-Saharan African teaching hospital

Background

Chronic subdural haematoma (CSDH) is a common neurological condition affecting the elderly with decreased quality of life. Recurrence leads to increase in number of hospital admissions and surgical interventions. Several factors contribute to recurrence of chronic subdural haematoma, and determination of these factors will help institute measures to reduce recurrence of CSDH, cost of care and improved quality of life. The aim of this study was to determine the predictors of recurrence of chronic subdural haematoma in a cohort of patients presenting in a Sub-Saharan African Teaching Hospital.

Methods

A prospective hospital-based cohort study of 62 participants who presented with CSDH and underwent burr-hole and drainage at the Neuroscience unit of the Korle-bu Teaching Hospital. The primary outcome of this study was the recurrence of CSDH within 3 months after the surgery. Data was entered into Microsoft Excel 2016 and exported to International Business Machine (IBM) Statistical Package for the Social Sciences (SPSS) version 21.0 for analysis. Predictors of recurrence of CSDH were determined using logistic regression with odds ratio calculated at the 95% confidence level and a p-value less than 0.05 accepted as statistically significant.

Results

There was a male preponderance of 45 (72.6%), over females of 17 (27.4%). The mean age was 63.1 ± 13.6 years. The recurrence rate of CSDH was 21.0% whilst the mortality rate was 4.8%. Facial palsy and dysphasia were associated with the recurrence of CSDH (p = 0.045, 0.029). Hypertension and bilaterality were associated with recurrence of CSDH from a univariate analysis (p = 0.039, OR = 4.865, CI = 0.975–24.285; p = 0.005, OR = 5.979, CI = 1.585–22.557). In a multivariate logistic regression analysis, bilaterality was the only independent predictor of recurrence of CSDH (p = 0.030, AOR = 5.47, CI = 1.18–25.34).

Conclusions

Both hypertension and bilaterality showed statistically significant association with recurrence of CSDH. However, only bilaterality proved to be an independent predictor of recurrence of CSDH in patient who underwent burr-hole and drainage.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02857-1.

Surgical outcomes of severe spinal deformities exceeding 100° or treated by vertebral column resection (VCR). Does implant density matter?: an observational study of deformity groupings

STUDY DESIGN

Prospective multicenter international observational study.

OBJECTIVE

To investigate the effect of implant density on clinical outcomes in complex pediatric spine reconstruction. Implant density in spine deformity surgery has been a subject of much debate with some authors advocating higher density for better correction. Few studies have looked at the effect of implant density on severe curves > 100 deg or treated with vertebral column resection (VCR).

METHODS

250/311 pts with 2-year f/u enrolled in the FOX pediatric database from 17 international sites were queried for the impact of implant density and surgical outcomes. Patients were grouped into three implant density categories for comparative analysis Group 1 (density ≤ 1), Group 2 (1 < density < 1.5) and Group 3 (density; 1.5-2).

RESULTS

250 pts: 47 (Grp1)/99 (Grp2) /104 (Grp3); Pre-op age and etiology and curve types were similar in all groups, but body mass index (BMI) was higher in Grp3. Grps 1 and 2 had significantly higher sagittal deformity angular ratio (S-DAR) compared to Grp 3 (p < 0.001). Pre-op Halo Gravity Traction (HGT) was used in 55.3%/44.4%/31.7%, p = 0.017; Grp1/Grp2/Grp3, respectively. Average duration of surgery (min) was higher in Grp3 relative to Grp1 only: 352.5/456.5/515.0, p = 0.0029. Blood loss was similar in all Grps. Rate of VCR, PSO and SPO was similar in all Grps. Pre-op Coronal Cobb avg 96.1/83.6/88.6, p = 0.2342, attained similar correction after HGT (24.6%/27.2%/23.2%, p = 0.4864. Coronal Cobb corrections at 2-year follow-up (FU) were (37.1%/40.3%/53.5%, p = 0.0004). Pre-op sagittal Cobb was (105.4/101.9/75.9, p < 0.01.), achieved similar %correction in HGT (19.1%/22.3%/22.5%, p = 0.6851) and at 2-year FU (39.6%/41.4%/29.8%, p = 0.1916). After adjusting for C-DAR, S-DAR, pre-op coronal and sagittal Cobb, etiology, curve types, age, BMI and number of rods in multivariate analysis, the odds of developing post-operative implant complication was 11 times greater in group 1 compared to group 3 (OR = 11.17,95% CI 2.34-53.32). There was significant improvement in SRS scores in all Grps at 2-year FU.

CONCLUSION

Although higher implant density was observed to be associated with greater curve correction and lower rates of post-operative implant-related complication and revision in heterogeneous case groups, the results may not imply causality of implant density on the outcomes in severe pediatric spine reconstruction.

Postoperative Pulmonary Complications in Complex Pediatric and Adult Spine Deformity: A Retrospective Review of Consecutive Patients Treated at a Single Site in West Africa

STUDY DESIGN

Retrospective review of consecutive series.

OBJECTIVES

This study sought to assess the incidence, risk factors, and outcomes of pulmonary complication following complex spine deformity surgery in a low-resourced setting in West Africa.

METHODS

Data of 276 complex spine deformity patients aged 3 to 25 years who were treated consecutively was retrospectively reviewed. Patients were categorized into 2 groups during data analysis based on pulmonary complication status: group 1: yes versus group 2: no. Comparative descriptive and inferential analysis were performed to compare the 2 groups.

RESULTS

The incidence of pulmonary complication was 17/276 (6.1%) in group 1. A total of 259 patients had no events (group 2). There were 8 males and 9 females in group 1 versus 100 males and 159 females in group 2. Body mass index was similar in both groups (17.2 vs 18.4 kg/m², P = .15). Average values (group 1 vs group 2, respectively) were as follows: preoperative sagittal Cobb angle (90.6° vs 88.7°, P = .87.), coronal Cobb angle (95° vs 88.5°, P = .43), preoperative forced vital capacity (45.3% vs 62.0%, P = .02), preoperative FEV₁ (forced expiratory volume in 1 second) (41.9% vs 63.1%, P < .001). Estimated blood loss, operating room time, and surgery levels were similar in both groups. Thoracoplasty and spinal osteotomies were performed at similar rates in both groups, except for Smith-Peterson osteotomy. Multivariate logistic regression showed that every unit increase in preoperative FEV₁ (%) decreases the odds of pulmonary complication by 9% (OR = 0.91, 95% CI 0.84-0.98, P = .013).

CONCLUSION

The observed 6.1% incidence of pulmonary complications is comparable to reported series. Preoperative FEV₁ was an independent predictor of pulmonary complications. The observed case fatality rate following pulmonary complications (17%) highlights the complexity of cases in underserved regions and the need for thorough preoperative evaluation to identify high-risk patients.

One-stage multiple posterior column osteotomies and fusion and pre-op halo-gravity traction may result in a comparative and safer correction of complex spine deformity than vertebral column resection

STUDY DESIGN

A retrospective review of prospectively collected from patients recruited at a single center.

PURPOSE

To test whether safe and optimal correction can be obtained with preoperative halo-gravity traction and posterior spinal fusion with adjunctive procedures but without VCR. Posterior vertebral column resection(VCR) is gaining popularity for correction of severe spinal deformity. However, it is a highly technically demanding procedure with potential risk for complications and neurological injury.

METHODS

In total, 72 patients with severe spinal deformity (Cobb angle > 100º) who underwent HGT followed by definitive PSF with PCO, with or without concave rib osteotomy and thoracoplasty. Demographic and surgical data were collected. Conventional coronal and sagittal radiographic measurements were obtained pre-traction, post-traction, post-op and at follow-up to determine the final deformity correction. Postoperative neurological and major complications were reviewed. We used Chi-square to compare proportion between groups and t test to compare groups in quantitative/ordinal variables.

RESULTS

There were 72 patients (35 females, 37 males). The etiology was congenital (21),idiopathic (45), neurofibromatosis (2) and neuromuscular (4). The mean was: age 18 ± 4.6 years; duration of HGT 103 ± 35 days; coronal Cobb angle before traction 131.5 ± 21.4º vs 92. ± 15.9º after HGT (30% correction) and 72.8 ± 12.7º after fusion (47% correction); kyphosis angle before traction 134.7 ± 32.3º vs 97.1 ± 22.4º after HGT and 73.7 ± 21.3º post-fusion. Number of fusion levels 14 ± 1; EBL 1730 ± 744 cc; number of PCOs done 5 ± 2; number of concave rib osteotomies (2 ± 2). There were 16 patients with postoperative complications (22.2%), 10 medical, one wound infection, 2 implant related and 3 post-op neuro-deficits (all of whom recovered at follow-up). There was one death (cardiac arrest).

CONCLUSION

HGT and one-stage posterior fusion with PCO, with or without concave rib resection and thoracoplasty, without VCR, achieved satisfactory correction of rigid complex spine deformity with minimal neurological complications. The results compare favorably with previous reports of similar deformities treated with VCR.

LEVEL OF EVIDENCE

III.

Surgical management of complex post-tuberculous kyphosis among African patients: clinical and radiographic outcomes for a consecutive series treated at a single institution in West Africa

STUDY DESIGN

Retrospective review of consecutive series.

OBJECTIVE

To assess the clinical and radiographic outcomes after surgical management of post-tuberculous kyphosis. Post-tuberculous (TB) kyphosis can lead to progressive pulmonary and neurological deterioration. Surgery is indicated to decompress neural elements and correct the spine deformity. Although posterior vertebral column resection (PVCR) has been established as the treatment of choice for severe TB kyphosis, there is paucity of studies on the clinical outcomes among patients treated in West Africa.

METHODS

Clinical and radiographic data of 57 patients (pts) who underwent surgical correction of post-TB kyphosis at a single site in West Africa between 2013 and 2018 (≥ 2-year follow-up in 36 pts, ≥ 1-year FU in 21 pts). Pre- and post-op SRS scores and radiographic outcomes were compared using Paired t test.

RESULTS

57 patients, 36M:21F. Mean age 19 (11-57 years). 22/57 pts (39.3%) underwent pre-op halo gravity traction (HGT) for an average duration of 86 days (8-144 days). HGT pts had a higher baseline regional kyphosis (125.1 ± 20.9) compared to non-HGT pts (64.6 ± 31.8, p < 0.001). Post-HGT regional kyphosis corrected to 101.2 ± 23 (24° correction). 53 pts (92.9%) underwent posterior-only surgery and 4 (7.0%) combined anterior-posterior surgery. 39 (68.4%) had PVCR, 11 (19.3%) PSO, and 16 (28.1%) thoracoplasty. Intraoperative neuromonitoring (IOM) signal changes occurred in 23/57 pts (≈ 40%), dural tear in 5 pts (8.8%), pleural tear in 3 pts (5.3%), ureteric injury in 1 pt (1.7%), and vascular injury in 1 pt (1.7%). Post-op complications included four (7.0%) infection, three (5.3%) implant related, two (3.5%) radiographic (one PJK and one DJK), one (1.7%) neurologic, one (1.7%) wound problem, and two (3.5%) sacral ulcers. IOM changes were similar in the VCR (48.7%) and non-VCR (23.5%) pts, p > 0.05. Complication rates were similar among HGT and non-HGT groups. Significant improvements from baseline were seen in the average SRS Total and domains scores and radiographic measurements for patients who attained 2-year follow-up.

CONCLUSION

PVCR ± HGT can provide safe and optimal correction in cases of severe post-TB kyphosis with good clinical and radiographic outcomes in underserved regions.

The efficacy and safety of intraoperative acute normovolaemic haemodilution in complex spine surgery in a private surgical facility in Ghana

Objectives

To assess the safety and clinical benefits of intraoperative acute normovolaemic haemodilution (ANH) in complex spine surgery.

Design

Prospective comparative cohort study.

Setting

A private orthopaedic hospital in Ghana.

Patients

Seventy-six patients who underwent complex spine deformity surgery.

Interventions

Patients were randomly assigned to two groups. 45 patients to the acute normovolaemic haemodilution (ANH) or Group 1 and 31patients to the non-ANH or Group 2. Following anesthetic administration and before incision, autologous blood was collected from patients in Group1 and was reinfused during/shortly after surgery while patients in Group2 were transfused with compatible allogeneic blood intraoperatively.

Main Outcome Measures

Changes in haemodynamic parameters and incidence of allogeneic transfusions and related complications.

Results

The mean age (years), gender ratio, deformity size and aetiology, fusion levels, and operative times were similar in both groups. Blood loss (ml) of patients in groups 1 and 2 were 1583ml± 830.48 vs 1623ml ± 681.34, p=0.82, respectively. The rate of allogeneic blood transfusion in groups 1 and 2 were 71% vs 80.65%, p=0.88, respectively. Haemoglobin levels (g/dL) in groups 1 and 2 were comparable in both groups at Post-operative Day (POD) 0 and POD 1. Incidence of minor allogeneic transfusion reaction was 1/45 vs 1/31, p=0.80, group-1 and group-2, respectively.

Conclusion

Acute normovolaemic haemodilution can be safely performed in complex spine surgery in underserved regions. However, its use does not obviate allogeneic transfusion in patients with complex spine deformities in whom large volumes of blood loss is expected.

Funding

None declared.

New neurologic deficit and recovery rates in the treatment of complex pediatric spine deformities exceeding 100 degrees or treated by vertebral column resection (VCR)

STUDY DESIGN

Prospective multicenter international observational study.

OBJECTIVE

To investigate incidence of new neurologic deficit (NND) and the long-term recovery patterns following complex pediatric spine deformity surgery. The SRS M&M reports identify pediatric patients as having higher rate of new neurologic deficit compared with adults, while congenital and neuromuscular deformities are associated with higher new neurologic risks. Very few studies have had the large numbers of pediatric patients with curves exceeding 100 deg to ascertain the new neurologic deficit (NND) rates and recovery patterns as it relates to curve laterality and diagnosis.

METHOD

The FOX pediatric database from 17 international sites was queried for New Neurologic Deficit (NND) as characterized by change in American Spinal Injury Association (ASIA) Lower or Upper Extremity Motor Score. Recovery rates at specific intervals were recorded and related to the curve type and etiology.

RESULTS

Data of 286 consecutive patients with normal pre-operative neurologic exams were reviewed. There were 160 females vs 125 males with an average age of 14.6 years. NND occurred in 27 patients (9.4%) in the immediate post-operative period. Diagnostic categories included idiopathic scoliosis (3 patients); idiopathic kyphoscoliosis(5 patients); congenital scoliosis (7 patients); congenital kyphoscoliosis (4 patients); congenital kyphosis (6 patients), other kyphosis (1 patient) and syndromic (1 patient). 1 patient was lost to follow-up (f/u) after discharge; 1 had chronic deficits at the first post-operative erect visit (from discharge to 9 months f/u) and was subsequently lost to follow-up; 2 patients were improving at 1-year f/u but lost to subsequent f/u. 16 patients had normal neurologic function by the time of the first post-operative erect visit, 21 patients at 1-year f/u and 21 patients at the 2-year f/u. 2 patients (0.69%) had improved NND at 2-year mark.

CONCLUSION

A significant proportion of patients with complex spine deformity experience NND. However, significant improvement in neurologic function can be expected over time as seen in this study without additional surgical intervention in most cases. Congenital deformities accounted for 63% of the patients experiencing NND.

Characterization of complex vertebral transposition (gamma deformity) > 180 degrees: clinical and radiographic outcomes of halo gravity traction and vertebral column resection (VCR)

STUDY DESIGN

Prospective case series OBJECTIVE: Results of surgical treatment of complex vertebral transposition "Gamma Deformity" > 180 degrees with halo gravity traction (HGT) and vertebral column resection (VCR). We recently published a novel classification system for complex spine deformities of which complex vertebral transposition > 180 degrees (Gamma; type 3) was described. Halo gravity traction (HGT) has been shown to mitigate surgical risk in complex spine deformity correction and in some cases obviates the need for three-column osteotomy. However, we are not aware of report of its utilization in treating Gamma deformities with or without vertebral column resection (VCR).

METHODS

A consecutive series of 13 patients with Gamma deformity (GD) were prospectively enrolled at a single site in West Africa. Standard radiographs and 3D computerized tomography (CT) were done to assess coronal and sagittal vertebral transposition (CVT and SVT). The HGT with 50% of body weight was applied over several weeks followed by VCR. Demographics, operative data, radiographic parameters, and complications data were collected.

RESULTS

13 pts with GD underwent HGT for an avg of 110 days prior to definitive surgery. Etiologies were Congenital-11 pts and Neurofibromatosis-2 pts. Average age: 17.8 years; Pts were reviewed at 3 months post-op and at minimum 2-year follow-up. Preop myelopathy was present in five patients. Pre-op CVT avg 75% and was corrected in all cases post-op. SVT avg 211 deg and improved with HGT by 36% and corrected to 53 deg (74% correction) post-op. Thoracic kyphosis avg -42 deg and averaged 48 deg post-op. Intra-op spinal cord monitoring (SCM) alerts occurred in 8 pts (61%). Post-operative LEM deficits occurred in 5 pts: 2 fully recovered by 3 months and 2 year follow-up, while the remaining 3 improved but had residual motor deficits at final follow-up. There was one post-operative mortality.

CONCLUSION

The management of complex vertebral transposition (Gamma deformity) > 180 degrees with HGT prior to VCR is not only effective in some patients, but also associated with high SCM alerts and neurologic injury rates. Myelopathic patients with thoracic deformities are at higher risk of developing permanent neurologic deficits. Surgeons should be aware of this rare and unusual deformity and consider HGT and VCR bearing in mind the technical challenges and high complication rate.

A novel radiographic classification of severe spinal curvatures exceeding 100°: the Omega (Ω), gamma (γ) and alpha (α) deformities

PURPOSE

For spine curvatures with Cobb angles > 100°, curve classification and characterization become more difficult with conventional radiographs. 3-D computerized axial tomography scans add relevant information to categorize and describe a new classification to aid preoperative assessment in communication and patient evaluation. The purpose of this study is to describe a radiographic classification system of curves exceeding 100°.

METHODS

A consecutive series of patients with curves exceeding 100° underwent a full spine radiographic review using conventional radiographs and 3-D CT. A descriptive analysis was performed to categorize curves into 4 main types (1, 2, 3 and 4) and 6 subtypes (1C, 1S, 1CS, 2P, 2D and 2PD) based on the location of the Cobb angle of the major scoliotic and kyphotic deformity as well as the location of the upper/lower end vertebra relative to the apical vertebra.

RESULTS

A total of 98 patients met the inclusion criteria. There were 51 males and 47 females with an average age of 17.8 ± 4.5 years. The diagnosis included idiopathic (48); congenital (24); neuromuscular (4); and neurofibromatosis (2). The mean major coronal and sagittal Cobb (kyphosis) were 131.2° ± 23.4° and 154 ± 45.6, respectively. The classification scheme yielded 4 main types (1, 2, 3 and 4) and 6 subtypes under types 1 and 2 (1C, 1S, 1CS, 2P, 2D and 2PD).

CONCLUSIONS

Our study describes a novel method of classifying severe spinal curvatures exceeding 100° using erect AP/lateral radiographs and 3-D CT reconstructive images. We hope that the descriptive analysis and classification will expand our understanding of these complex deformities. These slides can be retrieved under Electronic Supplementary Material.

Incidence and Risk Factors for Major Surgical Complications in Patients With Complex Spinal Deformity: A Report From an SRS GOP Site

STUDY DESIGN

Retrospective analysis of a prospectively collected single-center database.

OBJECTIVES

To report the incidence of and identify risk factors for perioperative complications in surgically treated pediatric and adult patients with complex spine deformities in an underserved region and Scoliosis Research Society Global Outreach Program site.

SUMMARY OF BACKGROUND DATA

Surgical treatment for complex spinal deformity is challenging and requires a multidisciplinary approach for optimal management. The incidence and risk factors for major perioperative complications in outreach sites with limited resources are unknown.

METHODS

A total of 427 consecutive patients who underwent instrumented spinal fusion for complex spinal deformities were reviewed. Clinical, radiographic, and demographic data were reviewed at preoperative and postoperative time points, and potential risk factors for perioperative complications were assessed. The authors performed multivariate logistic regression analysis (LRA) to determine independent risk factors for postoperative complications and neurological deficits.

RESULTS

Major complications were seen in 85 cases, which consisted of neurologic deficits (n = 27; 17 transient and 10 permanent), wound infections (n = 17), implant-related problems (n = 35), progressive deformity (n = 13), and death (n = 6). Among the possible risk factors, univariate LRA indicated 3-column osteotomies as a risk factor for postoperative major complications and multivariate LRA indicated 3-column osteotomies as an independent risk factor for neurological deficit. Curves 100° and above were at higher risk for complications.

CONCLUSIONS

Postoperative complications were seen in 20% of surgically treated patients with complex spine deformities at a Scoliosis Research Society SRS Global Outreach Program site. Three-column osteotomies were identified as an independent risk factor of both postoperative complications and neurological deficits. The significant observed correlation of 3-column osteotomies and postoperative neurological deficits should serve as a guide for surgeons in the preoperative planning and management of severe spinal deformities, especially in locations with limited resources. Patients undergoing correction of large curves may also have a higher complication rate.

Surgical Risk Stratification Based on Preoperative Risk Factors in Severe Pediatric Spinal Deformity Surgery

STUDY DESIGN

Retrospective review.

OBJECTIVE

The purpose of this study is to review the postoperative complications in pediatric patients undergoing spine surgery and to establish a preoperative classification that stratifies surgical risk and case difficulty.

SUMMARY OF BACKGROUND DATA

Pediatric spinal deformity (PSD) surgery can be challenging technically as well as economically. Often, a multidisciplinary approach to managing these patients is necessary. In an environment where resources are limited, such as in global outreach efforts, a method for stratifying PSD surgical cases can be useful for allocating appropriate resources and assigning appropriate skill sets in order to optimize patient outcomes and to streamline efforts.

MATERIALS AND METHODS

A total of 145 consecutive PSD patients who underwent instrumented spinal fusion were reviewed. Radiographic measurements and demographic data were reviewed. A classification was established based on the curve magnitude, etiology, ASA grade, number of levels fused, the preoperative neurologic status, body mass index and type of osteotomies. Multiple regression analysis (MRA) and logistic regression analysis (LRA) were applied to indicate risk factors for complications.

RESULTS

The average age was 14.3 years (10-20 years). The etiology was idiopathic scoliosis (n = 71), congenital scoliosis (n = 38), infectious (n = 11), and others. 23 patients had neurologic deficits preoperatively. Twenty-three patients had a posterior vertebral column resection. Patients were classified as Level 1 (n = 5), Level 2 (n = 19), Level 3 (n = 24), Level 4 (n = 58), and Level 5 (n = 39). Intraoperative neuro-monitoring changes were observed in 46 cases. Major complications were seen in 45 cases. A major complication consisted of implant related (n = 13), deep wound infection (n = 8), neurologic deficit (n = 7), death (n = 2), and others (n = 9). MRA demonstrated a significant correlation between classified level and %EBL/TBV, operative time, and complication rate. The risk level predicted the occurrence of general (odds ratio [OR] = 1.54; 95% confidence interval [CI] = 1.08-2.21; p = .019) and neurologic (OR = 3.34; 95% CI = 1.06-17.70; p = .036) complications. Osteotomy and resection procedures were independent predictors for postoperative neurologic complications (OR = 1.7, 95% CI = 1.11-2.85; p = .015).

CONCLUSION

Corrective spine surgery for complex pediatric deformity is challenging and carries a substantial risk. No single parameter appears to independently predict postoperative complications. However, when all risk factors are considered, there is a trend toward increased intraoperative electromonitoring change and postoperative neurologic risk with the higher level score in our classification. The newly established surgical risk stratification based on patient-specific clinical and radiographic factors can guide surgeons in their preoperative planning and surgical management of severe spine deformity in order to achieve optimal outcomes.

Ileal stricture following strangulated inguinal hernia

Small intestinal stenosis due to ischaemia following strangulated hernia is uncommon as patients with external hernias have ready access to elective herniorrhaphy. Small intestinal stenosis secondary to ischaemia may lead to acute small bowel obstruction, acute-on-chronic obstruction or chronic small bowel obstruction. It may also give rise to the blind loop syndrome. Preoperative diagnosis of this condition is difficult. We report four cases of small intestinal stenosis who presented to one surgical unit at the Korle-Bu Teaching Hospital with acute intestinal obstruction over a period of 15 months.