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

Helping Families Make Difficult Choices: Creation and Implementation of a Decision Aid for Neuromuscular Scoliosis Surgery

BACKGROUND

Decision aids serve to prepare families for a meaningful discussion with their physician during the shared decision-making (SDM) process. Although SDM processes have been used primarily in adult health care settings, we sought to develop a decision aid for use in pediatrics. The treatment of neuromuscular scoliosis was selected due to the complexity of decision making when surgery is considered. Our objective was to determine whether this tool would improve families' knowledge and satisfaction while decreasing decisional conflict.

METHODS

The decision aid was created using a multistep process to provide unbiased evidence-based information about the risks and benefits of the treatment options for neuromuscular scoliosis. The initial draft was written by an orthopaedic surgeon and then formatted by a multidisciplinary group to meet international decision aid standards. The document underwent local, national, and international peer review before prospective implementation by 4 orthopaedic surgeons at a single institution. The decision aid was evaluated and revised for further use.

RESULTS

Eleven children, mean age 12 years (range, 8 to 17 y), were included in the study. Nine of the 11 families opted for surgery. The mean scores on the knowledge test increased from 3.0 (range, 2 to 5) to 4.0 (range, 3 to 5) of a possible 5 points (P=0.067). The mean item score on the SDM satisfaction scale was 3.8 (range, 3.5 to 4.0). The mean score on the SURE test for decisional conflict was 3.7 (range, 3 to 4) of a maximum score of 4. The mean total score on the clinician SDM satisfaction scale was 22.5 (range, 17 to 25).

CONCLUSIONS

The decision aid created for this complex decision resulted in improvements in knowledge gain, satisfaction, and decisional conflict while gaining acceptance of the physicians who utilized it. Consideration should be given to developing additional decision aids within professional societies to maximize efficiency and consensus.

Predicting Short-term Morbidity in Patients Undergoing Posterior Spinal Fusion for Neuromuscular Scoliosis

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The aim of this study was to determine the incidence and risk factors for short-term morbidity following posterior spinal fusion (PSF) for neuromuscular scoliosis (NMS).

SUMMARY OF BACKGROUND DATA

NMS is a challenging spinal deformity for which PSF is often recommended. There is a lack of information on risk factors for short-term adverse outcomes after PSF for NMS.

METHODS

Patients who underwent PSF for NMS during 2012 and 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric database. Patient characteristics were tested for association with adverse events, infectious complications, extended length of stay (LOS), and readmission using multivariate regression.

RESULTS

Of the 940 NMS patients identified, 133 (14.1%) had an adverse event and 99 (10.5%) had a severe adverse event. American Society of Anesthesiologists (ASA) classification ≥3 was found to be the only independent risk factor for any adverse event (relative risk [RR] 2.2, P = 0.012) and severe adverse events (RR 2.5, P = 0.008). Infectious complications were associated with body mass index (BMI)-for-age ≥95th percentile (RR 2.8, P = 0.005), ASA classification ≥3 (RR 5.9, P = 0.003), and instrumentation to the pelvis (RR 1.8, P = 0.039).A total of 254 patients (27%) spent longer than a week in the hospital postoperatively, and ASA classification ≥3 (RR 2.3, P < 0.001), preoperative seizure disorder (RR 1.4, P = 0.002), previous cardiac surgery (RR 1.6, P = 0.004), operative time ≥470 minutes (RR 1.8, P < 0.001), and ≥13 levels instrumented (RR 1.9, P = 0.001) were associated with extended LOS.Seventy-six patients (8.1%) were readmitted, and BMI-for-age ≥95th percentile (RR 1.8, P = 0.033) was the only risk factor found for readmission.

CONCLUSION

The identified factors associated with poor short-term outcomes after PSF for NMS can be used as benchmark data, be useful for optimizing patient care, and can inform future studies in these patients.

LEVEL OF EVIDENCE

3.

Migration of the Anterior Spinal Rod to the Right Thigh, a Rare Complication of Anterior Spinal Instrumentations: A Case Report and a Literature Review

Posterior and anterior fusion procedures with instrumentation are well-known surgical treatments for scoliosis. Rod migration has been described as unusual complication in anterior spinal instrumentations; migration beyond pelvis is a rare complication. A 32-year-old female presented to the consultant with right thigh pain, rod migration was diagnosed, rod extraction by minimal approach was performed, and spinal instrumentation after nonunion diagnosis was underwent. A rod migration case to the right thigh is presented; this uncommon complication of spinal instrumentation should be ruled out as unusual cause of sudden pain without any other suspicions, and long-term follow-up is important to prevent and diagnose this problem.

Neuromuscular scoliosis and pelvic fixation in 2015: Where do we stand?

Neuromuscular scoliosis is a challenging problem to treat in a heterogeneous patient population. When the decision is made for surgery the surgeon must select a technique employed to correct the curve and achieve the goals of surgery, namely a straight spine over a level pelvis. Pre-operatively the surgeon must ask if pelvic fixation is worth the extra complications and infection risk it introduces to an already compromised host. Since the advent of posterior spinal fusion the technology used for instrumentation has changed drastically. However, many of the common problems seen with the unit rod decades ago we are still dealing with today with pedicle screw technology. Screw cut out, pseudoarthrosis, non-union, prominent hardware, wound complications, and infection are all possible complications when extending a spinal fusion construct to the pelvis in a neuromuscular scoliosis patient. Additionally, placing pelvic fixation in a neuromuscular patient results in extra blood loss, greater surgical time, more extensive dissection with creation of a deep dead space, and an incision that extends close to the rectum in patients who are commonly incontinent. Balancing the risk of placing pelvic fixation when the benefit, some may argue, is limited in non-ambulating patients is difficult when the literature is so mottled. Despite frequent advancements in technology issues with neuromuscular scoliosis remain the same and in the next 10 years we must do what we can to make safe neuromuscular spine surgery a reality.

Major perioperative complications after spine surgery in patients with cerebral palsy: assessment of risk factors

PURPOSE

A prospective, longitudinal cohort was studied to determine the incidence, consequences, and risk factors of major perioperative complications in patients with cerebral palsy (CP) treated with spinal fusion. There is a wide variety of data available on the complications of spine surgery; however, little exists on the perioperative complications in patients with CP.

METHODS

A prospective multicenter dataset of consecutive patients with CP treated with spinal fusion was evaluated. All major perioperative complications were identified and stratified into categories: pulmonary, gastrointestinal, other medical, wound infection, neurological, instrumentation related, and unplanned staged surgery. Univariate and multivariate analyses were performed to identify various risk factors for major perioperative complications.

RESULTS

127 patients were identified with a mean age of 14.3 ± 2.6 years. Overall, 39.4% of the patients had a major perioperative complication. Occurrence of a complication [no complication (NC), yes complication (YC)] resulted in significantly increased intensive care unit (ICU) (NC = 3.2 days, YC = 7.8 days, p < 0.05) and hospital stays (NC = 7.7 days, YC = 15.6 days, p < 0.05). Variables associated with greater risk of a complication included: increased estimated blood loss (EBL) (p < 0.001), larger preoperative kyphosis (p = 0.05), staged procedures (p < 0.05), a lack of antifibrinolytic use (p < 0.05), and a trend toward lower body mass index (BMI) (p = 0.08). Multivariate regression analysis revealed an increased EBL as independently associated with a major perioperative complication (p < 0.05).

CONCLUSIONS

In this cohort of patients with CP who underwent spinal fusion, 39.4% experienced a major perioperative complication, with pulmonary being the most common. The occurrence of a major perioperative complication lengthened both ICU and hospital stay. Risk factors for major perioperative complications included greater preoperative kyphosis, staged procedures, a lack of antifibrinolytic use, and increased EBL, with the latter being an independent predictor of a major perioperative complication.

LEVEL OF EVIDENCE

2.

The feasibility and safety of using sublaminar polyester bands in hybrid spinal constructs in children and transitional adults for neuromuscular scoliosis

OBJECT

The authors have previously reported on their early experience with sublaminar polyester bands in spine surgery. In this paper, the authors describe the use of sublaminar polyester bands in long-segment posterior instrumented spinal fusions from the upper thoracic spine to the ilium in 21 children and transitional adults with progressive neuromuscular scoliosis. Transitional adults were patients older than 18 years of age with a spinal disorder of pediatric onset, such as spina bifida. This dedicated study represents the first reported use of polyester bands in spine surgery for neuromuscular scoliosis in this patient population in the US.

METHODS

The authors retrospectively reviewed the demographics and procedural data of patients who underwent posterior instrumented fusion using sublaminar polyester bands for neuromuscular scoliosis.

RESULTS

Twenty-one pediatric and adult transitional patients, ranging in age from 10 to 20 years (mean 14 years), underwent posterior instrumented fusion for progressive neuromuscular scoliosis. The average coronal Cobb angle measured 66° before surgery (range 37°-125°). Immediately after surgery, the mean coronal Cobb angle was 40° (range 13°-85°). At last follow-up, the average coronal Cobb angle was maintained at 42° (range 5°-112°). Regarding sagittal parameters, thoracic kyphosis was restored by 8%, and lumbar lordosis improved by 20% after surgery. Mean follow-up duration was 17 months (range 2-54 months). One patient with an aborted procedure due to loss of intraoperative evoked potentials was excluded from the analysis of radiographic outcomes. Mean surgical time was 7 hours 43 minutes (range 3 hours 59 minutes to 10 hours 23 minutes). All patients received either a 12- or 24-mg dose of recombinant human bone morphogenetic protein-2. Average estimated blood loss was 976 ml (range 300-2700 ml). Complications directly related to the use of sublaminar instrumentation included transient proprioceptive deficit (1 patient) and prolonged paraparesis (1 patient). Other complications noted in this series included disengagement of the rod from an iliac screw (1 patient), proximal junctional kyphosis (1 patient), noninfected wound drainage (2 patients), and perioperative death (1 patient). The lessons learned from these complications are discussed.

CONCLUSIONS

Pedicle screws, laminar/pedicle/transverse process hooks, and sublaminar metal wires have been incorporated into posterior spinal constructs and widely reported and used in the thoracic and lumbar spines and sacrum with varying success. This report demonstrates the satisfactory radiological outcomes of hybrid posterior spinal constructs in pediatric and adult neuromuscular scoliosis that include sublaminar polyester bands that promise the technical ease of passing sublaminar instrumentation with the immediate biomechanical rigidity of pedicle screws and hooks. However, the high neurological complication rate associated with this technique (2/21, or 10%) tempers the acceptable radiographic outcomes.

Outcomes of infection following pediatric spinal fusion

BACKGROUND

Removal of instrumentation is often recommended as part of treatment for spinal infections, but studies have reported eradication of infection even with instrumentation retention by using serial débridements and adjuvant antibiotic pharmacotherapy. We sought to determine the effect of instrumentation retention or removal on outcomes in children with spinal infections.

METHODS

We retrospectively reviewed the cases of patients who experienced early (< 3 mo) or late (≥ 3 mo) infected spinal fusions. Patients were evaluated at least 2 years after eradication of the infection using the following protocol outcomes: follow-up Cobb angle, curve progression and nonunion rates.

RESULTS

Our sample included 35 patients. The mean age at surgery was 15.1 ± 6.0 years, 65.7% were girls, and mean follow-up was 41.7 ± 26.9 months. The mean Cobb angle was 63.6° ± 14.5° preoperatively, 29.4° ± 16.5° immediately after surgery and 37.2° ± 19.6° at follow-up. Patients in the implant removal group (n = 21) were more likely than those in the implant retention group (n = 14) to have a lower ASA score (71.4% v. 28.6%, p = 0.03), fewer comorbidities (66.7% v. 21.4%, p = 0.03), late infections (81.0% v. 14.3%, p = 0.01) and deep infections (95.2% v. 64.3%, p = 0.03). Implants were retained in 12 of 16 (75.0%) patients with early infections and 2 of 19 (10.5%) with late infections. Patients with implant removal had a higher pseudarthrosis rate (38.1% v. 0%, p = 0.02) and a faster curve progression rate (5.8 ± 9.8° per year v. 0.2 ± 4.7° per year, p = 0.04).

CONCLUSION

Implant retention should be considered, irrespective of the timing or depth of the infection.

Incidence and risk factors for post-operative complications after scoliosis surgery in patients with Duchenne muscular dystrophy : a comparison with other neuromuscular conditions

We report the incidence of and risk factors for complications after scoliosis surgery in patients with Duchenne muscular dystrophy (DMD) and compare them with those of other neuromuscular conditions. We identified 110 (64 males, 46 females) consecutive patients with a neuromuscular disorder who underwent correction of the scoliosis at a mean age of 14 years (7 to 19) and had a minimum two-year follow-up. We recorded demographic and peri-operative data, including complications and re-operations. There were 60 patients with cerebral palsy (54.5%) and 26 with DMD (23.6%). The overall complication rate was 22% (24 patients), the most common of which were deep wound infection (9, 8.1%), gastrointestinal complications (5, 4.5%) and hepatotoxicity (4, 3.6%). The complication rate was higher in patients with DMD (10/26, 38.5%) than in those with other neuromuscular conditions (14/84, 16.7% (p = 0.019). All hepatotoxicity occurred in patients with DMD (p = 0.003), who also had an increased rate of deep wound infection (19% vs 5%) (p = 0.033). In the DMD group, no peri-operative factors were significantly associated with the rate of overall complications or deep wound infection. Increased intra-operative blood loss was associated with hepatotoxicity (p = 0.036). In our series, correction of a neuromuscular scoliosis had an acceptable rate of complications: patients with DMD had an increased overall rate compared with those with other neuromuscular conditions. These included deep wound infection and hepatotoxicity. Hepatotoxicity was unique to DMD patients, and we recommend peri-operative vigilance after correction of a scoliosis in this group.

A standardized protocol to reduce pediatric spine surgery infection: a quality improvement initiative

OBJECT

Quality improvement methods are being implemented in various areas of medicine. In an effort to reduce the complex (instrumented) spine infection rate in pediatric patients, a standardized protocol was developed and implemented at an institution with a high case volume of instrumented spine fusion procedures in the pediatric age group.

METHODS

Members of the Texas Children's Hospital Spine Study Group developed the protocol incrementally by using the current literature and prior institutional experience until consensus was obtained. The protocol was prospectively applied to all children undergoing complex spine surgery starting August 21, 2012. Acute infections were defined as positive wound cultures within 12 weeks of surgery, defined in alignment with current hospital infection control criteria. Procedures and infections were measured before and after protocol implementation. This protocol received full review and approval of the Baylor College of Medicine institutional review board.

RESULTS

Nine spine surgeons performed 267 procedures between August 21, 2012, and September 30, 2013. The minimum follow-up was 12 weeks. The annual institutional infection rate prior to the protocol (2007-2011) ranged from 3.4% to 8.9%, with an average of 5.8%. After introducing the protocol, the infection rate decreased to 2.2% (6 infections of 267 cases) (p = 0.0362; absolute risk reduction 3.6%; relative risk 0.41 [95% CI 0.18-0.94]). Overall compliance with data form completion was 63.7%. In 4 of the 6 cases of infection, noncompliance with completion of the data collection form was documented; moreover, 2 of the 4 spine surgeons whose patients experienced infections had the lowest compliance rates in the study group.

CONCLUSIONS

The standardized protocol for complex spine surgery significantly reduced surgical site infection at the authors' institution. The overall compliance with entry into the protocol was good. Identification of factors associated with post-spine surgery wound infection will allow further protocol refinement in the future.

The incidence and risk factors for short-term morbidity and mortality in pediatric deformity spinal surgery: an analysis of the NSQIP pediatric database

STUDY DESIGN

Retrospective review of a prospective cohort.

OBJECTIVE

To determine the incidence and risk factors for 30-day morbidity and mortality after pediatric deformity spinal surgery.

SUMMARY OF BACKGROUND DATA

Pediatric deformity spinal surgery is generally considered a safe and effective treatment option. The rising costs associated with spinal surgery and related perioperative complications have received national attention. Few studies with standardized definitions and data collection methods exist.

METHODS

A large, multicenter clinical registry specifically designed to collect pediatric surgical outcomes was queried for all patients undergoing spinal deformity surgery in 2012. Current Procedural Terminology codes were used to select patients undergoing anterior, posterior, and combined fusions. Detailed patient and case characteristics were analyzed. Thirty-day morbidity and mortality rates were calculated. Univariate and multivariate logistic regression analyses were used to identify patient characteristics, comorbidities, and operative variables predictive of complication.

RESULTS

In total, 2005 pediatric patients undergoing deformity spinal fusion were included. The rate of 30-day complications was 10.0%; with a mortality rate of 0.15% (3 patients), a morbidity rate of 8.4%, reoperation rate of 3.74%, and readmission rate of 3.94%. The morbidity rate was highest in the neuromuscular group (13.09%) and lowest in the idiopathic cohort (5.69%), P < 0.01). Compared with posterior fusions, anterior fusions and those extending to the pelvis were associated with higher complication rates (P < 0.01). Risk factors for complication included hepatobiliary disease (P = 0.03), cognitive impairment (P = 0.02), elevated American Society of Anesthesiologists class (P < 0.01), and prolonged operative time (P < 0.01).

CONCLUSION

The overall rate of 30-day morbidity after pediatric spinal deformity surgery was 10%. Multiple patient comorbidities and surgical duration and invasiveness were associated with an increased complication risk. These data may aid in the informed consent process, facilitate patient risk assessment, and allow quality comparisons between surgeons and institutions.

LEVEL OF EVIDENCE

2.

Correction of severe pelvic obliquity using maximum-width segmental sacropelvic screw fixation: an analysis of 20 neuromuscular scoliosis patients

STUDY DESIGN

The present study was a retrospective analysis.

OBJECTIVE

The purpose of the study was to evaluate the safety and efficacy of the maximum-width (M-W) segmental sacropelvic fixation technique, comprising iliac screws and/or iliosacral pedicle screws, to correct severe pelvic obliquity. Classic spinal fixation using the Luque-Galveston procedure for the correction of neuromuscular scoliosis may be inadequate to manage severe pelvic obliquities.

METHODS

A series of 20 consecutive patients with severe neuromuscular spinopelvic deformities was reviewed by an independent observer. Coronal and sagittal Cobb angle, frontal pelvic obliquity, and trunk shift were measured preoperatively, immediately postoperatively and at final follow-up.

RESULTS

All 20 patients underwent spinal fusion with instrumentation extending to the pelvis. Fourteen cases had primary operations, and six patients had undergone previous spinal fusion above the pelvis, requiring extension to the pelvis. The mean age of the patients at surgery was 13 years, and the mean duration of the follow-up period was 36 months. The mean preoperative Cobb angle was 84° (range 56°-135°), which was corrected to a mean of 41° (range 8°-75°) postoperatively. At the final follow-up, the mean spinal curve remained at 42° (range 10°-75°). The mean preoperative pelvic obliquity was 42° (range 15°-105°), which was corrected by 78 % to 9° (range 0°-49°) postoperatively, with a pelvic obliquity of 10° (range 2°-49°) at final follow-up. Comparing the results of the present study with results in the literature describing the Luque-Galveston or unit rod techniques, despite patients in the present study having a greater mean pelvic obliquity (42° compared with 21° in the literature), a 78 % correction was still achieved, which is similar and, in certain instances, superior to the results of other published case series (78 % compared with 53 %).

CONCLUSIONS

Maximum-width (M-W) segmental sacropelvic fixation, comprising iliosacral screws and/or iliac screws, enables a superior correction of severe pelvic obliquity in patients with neuromuscular scoliosis.

Complications in pediatric scoliosis surgery

BACKGROUND

Scoliosis surgery in childhood is associated with a range of postoperative complications that may require admission to the pediatric intensive care unit (PICU) or high-dependency unit (HDU).

AIM

The aim of this study was to identify preoperative factors associated with PICU and HDU admissions after corrective surgery and devise a scoring system that could be used by clinicians to predict the level of dependency required postoperatively.

METHODS

A retrospective case note review was carried out in 90 patients who underwent corrective scoliosis surgery at Sheffield Children's Hospital (SCH) between January 2008 and October 2010. Predictors of PICU and HDU requirement postoperatively were identified and a simple scoring system created using multiple logistic regression and receiver operator characteristic (ROC).

RESULTS

There was a statistically significant difference in the preoperative parameters (pulmonary function, Cobb angle, and number of vertebrae fused) of those patients who required PICU or HDU care compared with those who did not. The area under the receiver operator characteristic curve for the final scoring system was 0.95 for PICU admission and 0.87 for HDU admission at the optimal cut-off point, demonstrating good diagnostic accuracy.

CONCLUSIONS

The authors have identified a significant relationship between preoperative variables and the levels of dependency required postoperatively and have proposed a scoring system which can be used to aid decision-making involving bed planning for patients after corrective scoliosis surgery. However, this work is based on the clinical course of a single set of patients who had surgery in a single tertiary center and has not been tested on patients from other centers.

Surgical Treatment of Scoliosis in Non-Ambulatory Spastic Quadriplegic Cerebral Palsy Patients: A Matched Cohort Comparison of Unit Rod Technique and All-Pedicle Screw Constructs

STUDY DESIGN

Matched cohort.

OBJECTIVE

To compare the unit rod instrumentation (UR) technique with all-pedicle screw (PS) constructs in the surgical care of scoliosis in Gross Motor Function Classification System IV/V non-ambulatory spastic quadriplegic cerebral palsy patients.

SUMMARY OF BACKGROUND DATA

Over the past 20 years, there has been a transition from the UR technique to the use of pedicle screws and iliac screws in neuromuscular scoliosis. To date, no head-to-head comparative analysis has been reported between the UR technique and PS constructs for posterior segmental spinal instrumentation and fusion in cerebral palsy patients.

METHODS

A matched cohort study was performed between 2 tertiary-care pediatric centers: 1 using UR technique and the other PS constructs. Minimum follow-up was 2 years postoperatively (PS 2.5 years, UR 4.6 years, not significant). Fourteen patients were matched from each center based on age (mean age: PS 15.4 years, UR 15.5 years), preoperative pelvic obliquity (mean: PS 33.8°, UR 29.1°) and major coronal Cobb angle (mean: PS 100.9°, UR 100.1°).

RESULTS

There was posterior-only surgery in 14 of 14 PS and 11 of 14 UR surgeries. The final follow-up Cobb angle was lower in the PS group (13.5° vs. 34.3°, p < .05), with 86.5% correction in the PS group and 65.7% in the UR group. Final follow-up pelvic obliquity was similar (PS 8.5° vs. UR 3.3°; not significant). There were no major complications in the PS group. In the UR group, there was 1 deep infection and 1 reoperation for removal of a prominent sublaminar wire.

CONCLUSIONS

This is the first study to directly compare UR with PS constructs using matched patient cohorts in this patient population. All-pedicle screw constructs had better correction of coronal Cobb angle, lower blood loss, and shorter hospital stays. There was no difference in the correction of pelvic obliquity, complications, or reoperations.

Correction of pelvic obliquity in neuromuscular spinal deformities using the "T construct": results and complications in a prospective series of 60 patients

BACKGROUND

We present the results of a prospective series of 60 patients treated for neuromuscular spinal deformities with an original spinopelvic construct using two sacral screws and two iliac screws. Clinical and radiological results obtained with this new surgical technique were studied and discussed according to the epidemiological data and relevant literature.

METHODS

From January 2008 to June 2010, the clinical data of every patient who underwent spinopelvic fixation for treatment of a neuromuscular spinal deformity were recorded prospectively.

RESULTS

Sixty patients were operated on during the study period. Spinal correction and fusion was performed by posterior approach. In six patients with a residual spinopelvic imbalance more than 15° on lateral preoperative bending films, an anterior release of the thoracolumbar junction was performed on the same day, before posterior correction. Preoperative pelvic obliquity (PO) ranged from 4° to 44° (mean 21.6°). Postoperative pelvic obliquity ranged from 0° to 14 (mean 4.6°). No significant loss of correction was noted at the last follow-up. One patient died 3 months after the initial procedure due to respiratory compromise. 11 patients had early postoperative infections of the posterior approach.

CONCLUSIONS

Despite a high rate of infectious complications, optimal correction of pelvic obliquity requires extension of spinal instrumentation to the pelvis. Spinopelvic fixation remains a difficult challenge in neurological patients with hypotrophy. We think that pelvic fixation with the "T construct" did provide effective and improved spinal stabilization in these patients, while reducing the need for a postoperative cast or brace. As a result, patients had a favourable postoperative course with early mobilization and return to a comfortable sitting position.

Pediatric scoliosis surgery--is postoperative intensive care unit admission really necessary?

BACKGROUND

It is common practice for patients to be admitted to the intensive care unit following scoliosis surgery, because of the prolonged anesthesia, the need for efficient pain control and the known immediate postoperative complications. However, this may be unnecessary in many patients.

PURPOSE

We aimed to establish possible associations between pre- and perioperative parameters and early postoperative complication rates, in particular the need for prolonged mechanical ventilation (>1 day), and the presence of major complications in children undergoing primary spinal fusion by thoracolumbar spine instrumentation.

METHODS

We conducted a retrospective review of children undergoing primary scoliosis surgery at a university-affiliated general hospital from 1998 to 2008.

RESULTS

Surgical approaches were as follows: anterior spinal fusion, posterior spinal fusion, and combined anterior and posterior fusion. Prior to mid-2005, anesthesia included morphine; thereafter, remifentanil was used. Major complications correlated significantly with neuromuscular scoliosis (NMS) (OR, 4.94; 95% CI, 1.02-24.05), comorbidity conditions (OR, 3.47; 95% CI, 1.16-10.42), and anterior or combined fusion (OR, 7.81; 95% CI, 2.12-28.57). Late extubation correlated significantly with NMS (OR, 31.25; 95% CI, 1.06-100.00) and morphine use during anesthesia (OR, 17.91; 95% CI, 1.44-222.9).

CONCLUSIONS

Relatively young, healthy idiopathic scoliosis children receiving intraoperative remifentanil sedation and undergoing posterior fusion can be successfully managed in regular wards in the immediate postoperative period. However, intensive care unit admission should be considered in NMS patients, patients with comorbidity conditions, those undergoing anterior or combined spinal fusion, and patients whose anesthesia involves long-acting opioids.

Quality of life after surgery for neuromuscular scoliosis

Surgery in patients with neuromuscular scoliosis is associated with a higher rate of complications. It is still controversially discussed whether the patients truly benefit from deformity correction. The purpose of this study is to investigate if the quality of life has been improved and if the patients and their caregivers are satisfied with the results of surgery. This is a retrospective clinical outcome study of 46 patients with neuromuscular scoliosis which were treated with primary stable posterior pedicle screw instrumentation and correction. To achieve fusion only autologous bone was used. Follow up was minimum 2 years and maximum 5 years with an average of 36 months. The patients and/or their caregivers received a questionnaire based on the PEDI (pediatric disability inventory) and the GMFS (gross motor function score). The patients (and their caregivers) were also asked if the quality of life has improved after surgery. Only 32 of 46 patients answered the questionnaire. The answers showed a high approval-rate regarding the patients satisfaction with the surgery and the improvement of quality of life. The questionnaire could be answered from 1 (I do not agree) to 4 (I completely agree). The average agreement to the following statements was: i) the quality of life has improved: 3.35; ii) I am satisfied with surgery: 3.95; iii) the operation has fulfilled my expectations: 3.76. The average age at surgery was 12.7 years. The mean pre-operative cobb-angle of the main curve was 83.1° with a correction post-operatively to a mean of 36.9° and 42.6° at final follow-up. That is an average correction of 56.9%. Although spinal fusion in neuromuscular scoliosis is associated with a higher rate of complications our results show that the patients and their caregivers are satisfied with the operation and the quality of life has improved after surgery.

Growing rods for the treatment of scoliosis in children with cerebral palsy: a critical assessment

STUDY DESIGN

Retrospective analysis.

OBJECTIVE

To evaluate, in children with cerebral palsy, the following aspects of growing rod (GR) treatment for scoliosis: structural effectiveness, effect of pelvic fixation, hospital stay duration, and complications.

SUMMARY OF BACKGROUND DATA

Children with cerebral palsy frequently develop severe spinal deformity and pelvic obliquity (PO). Growth-preserving strategies are attractive, but comorbidities raise the risk/benefit ratio. To our knowledge, no previous studies have focused on growth-preserving spine surgery in these children.

METHODS

From our multicenter patient group, we identified 27 children with cerebral palsy treated with GRs (single rod in 4; dual rods in 23 [15 extending to the pelvis]). We collected radiographical, surgical, hospital stay, and major complication data. We compared Cobb angle and PO improvement between patients with and without pelvic instrumentation via the Student t test (significance, P = 0.05). No patient required anterior spinal fusion.

RESULTS

Average improvements for all patients (preoperative to latest follow-up) were: Cobb angle, 35° ± 23°; PO, 14° ± 19°; T1-S1 length, 7.9 ± 4.4 cm; and space available for lung ratio, 0.17 ± 0.21. For the 8 patients who underwent fusion, average improvements (preoperative to postfusion) were: Cobb angle, 43° ± 28°; PO, 2° ± 21°; T1-S1 length, 9.5 ± 6.0 cm; and space available for lung ratio, 0.26 ± 0.28. Pelvic GR fixation produced better PO correction (P < 0.001) but similar Cobb angle correction (P = 0.556). Hospital stays averaged 8.7 ± 12.1 days after initial surgery, 1.4 ± 2.5 days after lengthening (45% were outpatient procedures), and 13.4 ± 6.2 days after fusion. The most common complication was deep wound infection (30%).

CONCLUSION

GRs via a posterior-only approach are effective. Constructs extending to the pelvis control PO more effectively. However, 30% of patients experienced deep wound infection.

Prevalence of complications in neuromuscular scoliosis surgery: a literature meta-analysis from the past 15 years

PURPOSE

Our objectives were primarily to review the published literature on complications in neuromuscular scoliosis (NMS) surgery and secondarily, by means of a meta-analysis, to determine the overall pooled rates (PR) of various complications associated with NMS surgery.

METHODS

PubMed and Embase databases were searched for studies reporting the outcomes and complications of NMS surgery, published from 1997 to May 2011. We focused on NMS as defined by the Scoliosis Research Society's classification. We measured the pooled estimate of the overall complication rates (PR) using a random effects meta-analytic model. This model considers both intra- and inter-study variation in calculating PR.

RESULTS

Systematic review and meta-analysis were performed for 68 cohort and case-control studies with a total of 15,218 NMS patients. Pulmonary complications were the most reported (PR = 22.71 %) followed by implant complications (PR = 12.51 %), infections (PR = 10.91 %), neurological complications (PR = 3.01 %) and pseudoarthrosis (PR = 1.88 %). Revision, removal and extension of implant had highest PR (7.87 %) followed by malplacement of the pedicle screws (4.81 %). Rates of individual studies have moderate to high variability. The studies were heterogeneous in methodology and outcome types, which are plausible explanations for the variability; sensitivity analysis with respect to age at surgery, sample size, publication year and diagnosis could also partly explain this variability. In regard to surgical complications affiliated with various surgical techniques in NMS, the level of evidence of published literature ranges between 2+ to 2-; the subsequent recommendations are level C.

CONCLUSION

NMS patients have diverse and high complication rates after scoliosis surgery. High PRs of complications warrant more attention from the surgical community. Although the PR of all complications are affected by heterogeneity, they nevertheless provide valuable insights into the impact of methodological settings (sample size), patient characteristics (age at surgery), and continual advances in patient care on complication rates.

Pelvic fixation for neuromuscular scoliosis deformity correction

Pelvic fixation is most frequently indicated in the pediatric population for the treatment of neuromuscular scoliosis with significant pelvic obliquity. Neuromuscular scoliosis surgery is associated with a high risk of complications, and this is further increased by extension of fusion to the sacrum. Numerous techniques have been described for pelvic fixation associated with a long spine fusion each with its own set of specific benefits and risks. This article reviews the contemporary surgical techniques of pelvic fixation used to extend a spine fusion to the sacrum and pelvis focusing on the management of neuromuscular scoliosis, including their biomechanical rationale, results, and complications.

Does patient diagnosis predict blood loss during posterior spinal fusion in children?

STUDY DESIGN

A retrospective review.

OBJECTIVE

To assess the relationship between diagnosis and blood loss in children undergoing posterior spinal fusion surgery for deformity correction.

SUMMARY OF BACKGROUND DATA

To our knowledge, this relationship is not well established. It has important implications for understanding the mechanisms for blood loss and planning for surgery.

METHODS

Clinical records were reviewed for all patients 10 to 18 years of age who underwent spinal fusion surgery (at least 5 levels) by the senior author from 2001 through 2011. Patients were excluded for antifibrinolytic use, vertebral column resections, history of spinal surgery, nonpedicle screw instrumentation, cervical spine fusion, or anterior approaches. The 617 patients (with 37 diagnoses) were categorized into 5 groups: idiopathic scoliosis (IS), Scheuermann kyphosis (SK), cerebral palsy, other neuromuscular disorders, and genetic and syndromic disorders. Analysis of covariance was used to assess differences in blood loss across the diagnostic groups. Normalized blood loss (NBL) was calculated by dividing blood loss by number of levels fused and by patient's weight; NBL differences between groups were analyzed using Bonferroni correction method. Significance was set at P < 0.05.

RESULTS

Blood loss differed significantly by diagnostic group, adjusting for extent of fusion and patient weight (P < 0.001). Patients with cerebral palsy had a significantly higher NBL than patients with IS (P < 0.001), SK (P < 0.001), other neuromuscular disorders (P = 0.049), or genetic and syndromic disorders (P = 0.006). Patients with other neuromuscular disorders had a significantly higher NBL than patients with IS (P < 0.001) or SK (P < 0.001). Patients with genetic and syndromic disorders also had a significantly higher NBL than patients with IS (P < 0.001) or SK (P < 0.001).

CONCLUSION

There is a significant relationship between patient diagnosis and blood loss during posterior spinal fusion surgery in children.

Surgical site infection after pediatric spinal deformity surgery

The incidence of surgical site infection (SSI) after spinal deformity surgery for adolescent idiopathic scoliosis ranges from 0.5-6.7%. The risk of infection following spinal fusion in patients with neuromuscular scoliosis is greater, with reported rates of 6.1-15.2% for cerebral palsy and 8-41.7% for myelodysplasia. SSIs result in increased patient morbidity, multiple operations, prolonged hospital stays, and significant financial costs. Recent literature has focused on elucidating the most common organisms involved in SSIs, as well as identifying modifiable risk factors and prevention strategies that may decrease the rates of infection. These include malnutrition, positive urine cultures, antibiotic prophylaxis, surgical site antisepsis, antibiotic-loaded allograft, local application of antibiotics, and irrigation solutions. Acute and delayed SSIs are managed differently. Removal of instrumentation is required for effective treatment of delayed SSIs. This review article examines the current literature on the prevention and management of SSIs after pediatric spinal deformity surgery.

Subsequent, unplanned spine surgery and life survival of patients operated for neuropathic spine deformity

STUDY DESIGN

Retrospective study of a prospectively assembled cohort.

OBJECTIVE

To characterize the survival from subsequent spine surgery and the life survival of patients treated surgically for severe spinal deformity due to neuropathic diseases.

SUMMARY OF BACKGROUND DATA

Survivorship analysis is widely used to study the natural history of disease processes and of treatments provided, but has very seldom been used to study patients' course after surgery for spinal deformity associated with neuropathic diseases.

METHODS

Patients with neuropathic spinal deformity treated with primary posterior instrumentation and arthrodesis from 1989 through 2002 were identified and studied by review of charts and radiographs, and by mail survey. Subsequent spine surgery and death events, and the time interval from surgery were identified. Fifteen variables possibly influencing survivorship were studied.

RESULTS

There were no perioperative deaths, spinal cord injuries, or acute wound infections in the 117 eligible patients. Reoperation and life survival statuses were available for 110 patients (94%) at an average follow-up of 11.89 years (±5.3; range: 2-20.9 yr). Twelve patients (11%) had subsequent spine surgery. Survival from subsequent spine surgery was 91% at 5 years, 90% at 10 and 15 years, and 72% at 20 years. Proximal fixation problems occurred in 4 patients. Twenty-two patients (20%) had died from 4 to 20 years postoperative. Life survival was 98% at 5 years, 89% at 10 years, 81% at 15 years, and 56% at 20 years. The only variable associated with life survival was the occurrence of one or more perioperative complications, P = 0.0032. The younger half of the series at operation (<13.75 yr) was significantly more likely to have one or more perioperative complications, P = 0.0068. Spinal deformity type and magnitude were similar for the younger and older halves of the patients. Life survival of the patients with cerebral-palsy and not-cerebral-palsy upper motor neuron disease was not different. One-hundred-two of 105 were at least satisfied or would have the surgery again for the same condition.

CONCLUSION

Survival from subsequent spine operation was similar to adolescent idiopathic scoliosis series studied in the same manner. Life survival decline began at 4 years postoperative and was significantly associated with the occurrence of one or more perioperative complications. Even after successful spine deformity surgery, this population's health status is often precarious.

Infections after spinal correction and fusion for spinal deformities in childhood and adolescence

BACKGROUND

Infection after spinal fusion for scoliosis is a commonly reported complication. Although techniques in paediatric spinal fusion have improved with regard to infection prophylaxis, postoperative infection rates range from 0.4% to 8.7%.

INFECTION RATES AND CAUSATIVE FACTORS

The rate of infection in surgery for adolescent idiopathic scoliosis (AIS) has ranged from 0.9% to 3%. The rate of infection in spinal surgery for deformity related to myelomeningocele has been reported to be from 8% to 24%. The rate of infection in spinal surgery for deformity related to cerebral palsy has been reported to be from 6.1% to 8.7%. Infection after spinal fusion for scoliosis related to a muscular dystrophy is generally less frequent. Despite a large number of cases and studies, the literature did not provide documentation of several factors that may be related to the occurrence of wound infection. The rate of wound infection after spine surgery is dependent on many factors, including the complexity of the procedure, health status of the patient, and potentially the experience and technique of the operating surgeon.

TREATMENT ALGORITHM

The general algorithm for treatment depends on a variety of factors, including the delay from the index procedure, the infecting organism, the location and extent of the infection, the gross appearance of the fusion mass, and the surgical strategy used to correct the initial deformity. For infections that develop within the first 90 days after the index procedure all attempts to retain the instrumentation should be made. In late infections, the fusion mass must be carefully inspected before instrumentation removal is considered. Although fusion may appear to be solid both radiographically and intra-operatively, there still may be the possibility of loss of correction at last follow-up.

CONCLUSION

Deep wound infection after instrumented fusion of the spine remains a difficult and challenging clinical problem and entails substantial morbidity, cost, and recovery time for the patient. An aggressive approach to deep wound infection emphasising early irrigation and debridement allowed preservation of instrumentation and successful fusion in most cases. At the conclusion of treatment, patients can expect a medium-term clinical outcome similar to patients in whom infectious complication did not occur.

Safety and accuracy of pedicle screws and constructs placed in infantile and juvenile patients

STUDY DESIGN

Retrospective review.

OBJECTIVE

To determine the safety of pedicle screws placed in infantile and juvenile patients younger than 10 years of age, and to evaluate the accuracy and the incidence of short and long-term (>2-year follow-up) complications for the screws and construct utilized.

SUMMARY OF BACKGROUND DATA

Although much has been written regarding the use of pedicle screws for the treatment of adult and adolescent spinal deformities, few studies have examined complication rates with regard to pedicle screws placed for pediatric spinal deformities in patients younger than 10 years of age.

METHODS

Eighty-eight patients treated with 948 pedicle screws placed for a variety of pediatric spinal deformities were performed at a single institution. We evaluated the accuracy of pedicle screw placement via radiographic review by two spinal surgeons not involved in the surgical treatment.

RESULTS

The average age at surgery was 6.8 year (range, 1 + 11 to 9 + 11 year). Five hundred ninety-four pedicle screws were placed in the thoracic spine and 354 screws in the lumbar spine. Three screws (0.32%) violated the lateral wall of the pedicle, two screws (0.21%) violated the inferior wall, and three screws (0.32%) were suspected of medial wall violation for a total of eight screws (0.84%) malpositioned. Although short-term complications occurred in nine patients (10.2%) (four-wound infection, two-foot drop, two-respiratory problems, first-sixth cranial nerve palsy), there were no insertion or short-term complications specifically related to the use of pedicle screws. Long-term complications occurred in nine patients (10.2%) (three-deformity progression, four-growing rod breakage), whereas two patients required revision surgery because of pullout and prominence of proximal thoracic pedicle screws (n = 4) placed in growing rod constructs (2.3% of patients, 0.4% of screws).

CONCLUSION

There were no intraoperative or short-term pedicle screw insertion-related complications and a very low long-term complication rate (2.3% of patients, 0.4% of screws) specifically related to the use of pedicle screws in infantile and juvenile spinal deformity patients. More than 99% of screws were accurately placed.

Hyperbaric oxygen in the treatment of postoperative infections in paediatric patients with neuromuscular spine deformity

The aim of this study is to evaluate possible benefits of hyperbaric oxygen (HBO) therapy in the treatment of deep postoperative infections in six high risk paediatric patients with neuromuscular spine deformity. The study involved review of medical records including radiology, office visits, and telephone contacts for six patients, referred for postoperative HBO therapy in 2003-2005. Infection control and healing without removal of implants or major revision surgery with a minimum of 2-year follow-up after index surgery were considered to represent success. All infections were resolved. Median time for wound healing, normalisation of blood tests and antibiotic weaning were 3 months. Radiological bony fusion, intact implants without any signs of radiolucent zones were seen in all cases at a mean follow-up of 54 months (37-72). Side effects of HBO treatment were minor. HBO is a safe and potentially useful adjuvance in the treatment of early deep postoperative infections in complex situations with spinal implants in high risk paediatric patients.

Cotrel-Dubousset instrumentation in neuromuscular scoliosis

The study design is retrospective. The aim is to describe our experience about the treatment of patients with neuromuscular scoliosis (NMS) using Cotrel-Dubousset instrumentation. Neuromuscular scoliosis are difficult deformities to treat. A careful assessment and an understanding of the primary disease and its prognosis are essential for planning treatment which is aimed at maximizing function. These patients may have pelvic obliquity, dislocation of the hip, limited balance or ability to sit, back pain, and, in some cases, a serious decrease in pulmonary function. Spinal deformity is difficult to control with a brace, and it may progress even after skeletal maturity has been reached. Surgery is the main stay of treatment for selected patients. The goals of surgery are to correct the deformity producing a balanced spine with a level pelvis and a solid spinal fusion to prevent or delay secondary respiratory complications. The instrumented spinal fusion (ISF) with second-generation instrumentation (e.g., Luque-Galveston and unit rod constructs), are until 1990s considered the gold standard surgical technique for neuromuscular scoliosis (NMS). Still in 2008 Tsirikos et al. said that "the Unit rod instrumentation is a common standard technique and the primary instrumentation system for the treatment of pediatric patients with cerebral palsy and neuromuscular scoliosis because it is simple to use, it is considerably less expensive than most other systems, and can achieve good deformity correction with a low loss of correction, as well as a low prevalence of associated complications and a low reoperation rate." In spite of the Cotrel-Dubousset (CD) surgical technique, used since the beginning of the mid 1980s, being already considered the highest level achieved in correction of scoliosis by a posterior approach, Teli et al., in 2006, said that reports are lacking on the results of third-generation instrumentation for the treatment of NMS. Patients with neuromuscular disease and spinal deformity treated between 1984 and 2008 consecutively by the senior author (G.D.G.) with Cotrel-Dubousset instrumentation and minimum 36 months follow-up were reviewed, evaluating correction of coronal deformity, sagittal balance and pelvic obliquity, and rate of complications. 24 patients (Friedreich's ataxia, 1; cerebral palsy, 14; muscular dystrophy, 2; polio, 2; syringomyelia, 3; spinal atrophy, 2) were included. According the evidence that the study period is too long (1984-2008) and that in more than 20 years many things changed in surgical strategy and techniques, all patients were divided in two groups: only hooks (8 patients) or hybrid construct (16 patients). Mean age was 18.1 years at surgery (range 11 years 7 months-max 31 years; in 17 cases the age at surgery time was between 10 and 20 years old; in 6 cases it was between 20 and 30 and only in 1 case was over 30 years old). Mean follow-up was 142 months (range 36-279). The most frequent patterns of scoliosis were thoracic (10 cases) and thoracolumbar (9 cases). In 8 cases we had hypokyphosis, in 6 normal kyphosis and in 9 hyperkyphosis. In 8 cases we had a normal lordosis, in 11 a hypolordosis and in 4 a hyperlordosis. In 1 case we had global T4-L4 kyphosis. In 8 cases there were also a thoracolumbar kyphosis (mean value 24°, min 20°-max 35°). The mean fusion area included 13 vertebrae (range 6-19); in 17 cases the upper end vertebra was over T4 and in 11 cases the lower end vertebra was over L4 or L5. In 7 cases the lower end vertebra was S1 to correct the pelvic obliquity. In 5 cases the severity of the deformity (mean Cobb's angle 84.2°) imposed a preoperative halo traction treatment. There were 5 anteroposterior and 19 posterior-only procedures. In 10 cases, with low bone quality, the arthrodesis was performed using iliac grafting technique while in the other (14 cases) using autologous bone graft obtained in situ from vertebral arches and spinous processes (in all 7 cases with fusion extended until S1, it was augmented with calcium phosphate). The mean correction of coronal deformity and pelvic obliquity averaged, respectively, 57.2% (min 31.8%; max 84.8%) and 58.9% (mean value preoperative, 18.43°; mean value postoperative, 7.57°; mean value at last follow-up, 7.57°). The sagittal balance was always restored, reducing hypo or hyperkyphosis and hypo or hyperlordosis. Also in presence of a global kyphosis, we observed a very good restoration (preoperatory, 65°; postoperatory, 18° kyphosis and 30° lordosis, unmodified at last f.u.). The thoracolumbar kyphosis, when present (33.3% of our group) was always corrected to physiological values (mean 2°, min 0°-max 5°). The mean intraoperative blood lost were 2,100 cc (min 1,400, max 5,350). Major complications affected 8.3% of patients, and included 1 postoperative death and 1 deep infection. Minor complications affected none of patients. CD technique provides lasting correction of spinal deformity in patients with neuromuscular scoliosis, with a lower complications rate compared to reports on second-generation instrumented spinal fusion.

Surgical management of spinal deformities in cerebral palsy. A review

Cerebral palsy (CP) spinal deformities encompass a spectrum of deformities that are often initially treated nonoperatively, only to result in progression of scoliotic curves and further morbidity. Various surgical interventions have been devised to address the progressive curvature of the spine. This endeavor cannot be taken lightly and at times can be encumbered by prior treatments such as the use of baclofen pumps or dorsal rhizotomies. Care of these patients requires a multidisciplinary approach and comprehensive preoperative and postoperative management, including nutritional status, orthopedic assessment of functional level with specific emphasis on the hips and pelvic obliquity, and wheelchair modifications. The surgical techniques in CP scoliosis have progressively evolved from the classic Luque-Galveston fixation methods, the use of unit rods, and lately the use of pedicle screws, to modern sacropelvic fixation. With the latter method, the spinal deformity in patients with CP can usually be almost completely corrected.

Epidemiologia da infecção pós-operatória em pacientes com mielomeningocele, tratados para correção de deformidades da coluna vertebral

OBJETIVO: As cirurgias de coluna realizadas em pacientes com mielomeningocele, apresentam maior risco de infecção pós-operatória. Fizemos um levantamento epidemiológico dessas infecções e fatores possivelmente associados para estabelecer fatores de risco. MÉTODOS: Levantamento retrospectivo de dados de cirurgias de coluna realizadas em pacientes com mielomeningocele, na Associação de Assistência à Criança Deficiente - AACD/Hospital Abreu Sodré. A comparação para possíveis fatores de risco avaliados foi feita através do teste exato de Fisher. Foram considerados significativos os resultados com p < 0,05. RESULTADOS: Avaliamos 27 procedimentos cirúrgicos com um total de sete casos de infecção pós-operatória do sítio cirúrgico (25,92%). Cinco destes pacientes com infecção do sítio cirúrgico apresentaram infecção concomitante do trato urinário (ITU), com p = 0,004. Não encontramos significância estatística para os demais fatores avaliados: via de acesso, tipo de procedimento e linfócitos séricos totais. CONCLUSÃO: a ITU está relacionada à infecção do sítio cirúrgico, mas é necessário um estudo prospectivo com maior número de casos para elucidar esse fator de risco com um possível fator de confusão: estado nutricional e imunológico.

Tratamento da escoliose em crianças com paralisia cerebral utilizando a prótese vertical expansível de titânio para costela (VEPTR)

OBJETIVO: Avaliar o uso da prótese vertical expansível de titânio (VEPTR) como opção de tratamento inicial da escoliose em crianças de baixa idade portadoras de paralisia cerebral. MÉTODOS: Foram avaliados 10 pacientes portadores de paralisia cerebral (PC) tratados com VEPTR pelo grupo de escoliose da AACD de São Paulo. Caracterizavam-se por imaturidade esquelética e escoliose progressiva; sem deformidade grave no plano sagital. Realizamos avaliação da curva pelo método de Cobb no pré e pós-operatório e após dois anos de seguimento. RESULTADOS: A correção obtida com o uso do VEPTR no pós-operatório imediato foi em média de 41,4% nas radiografias iniciais sem tração (p = 0,005) e 9,1% (p = 0,055) nas radiografias com tração. Após quatro meses de pós-operatório mantiveram-se ganhos de 27,2% com relação ao início. Houve correção da obliquidade pélvica de 10,2º no pré-operatório para 5,4º em média (p = 0,007). As complicações ocorreram em seis pacientes (60%) e em apenas um paciente foi necessária a retirada do VEPTR. CONCLUSÃO: O VEPTR é um método que obteve correção significativa no tratamento provisório das escolioses na PC, apesar de frequentes complicações de baixa morbidade.

One-stage major spine deformity correction surgery: comparison between groups with and without additional neurosurgical intervention, with more than 24 months of follow-up

Object

Early-onset, nonidiopathic spine deformities are frequently caused by intraspinal anomalies necessitating both neurosurgical and orthopedic intervention. The clinical tradition at most treatment units is to perform neurosurgical and orthopedic procedures separately. Sometimes the deformity correction surgery is also done in stages, which leads to several periods of hospitalization, increased use of health care resources, and a long rehabilitation time for the patient. The purpose of this project was to perform an outcome survey for major spine surgery in high-risk patients, and to analyze whether an additional neurosurgical intervention during the same session increased the risk of complications.

Methods

A consecutive series of 81 patients with major rigid spine deformities treated by the same orthopedic surgeon was analyzed. In 24 of 81 cases there were additional intraspinal pathological entities indicating a neurosurgical procedure. All cases were divided into 2 groups: one with anterior-posterior surgery and also neurosurgery, and the other with anterior-posterior surgery but without neurosurgery. The result variables for the group comparisons were as follows: clinical and radiographic outcome, operating time, length of intensive care and hospital stay, relative blood loss, and occurrence of complications or adverse events. Groups were similar in terms of sex, size of spinal curve, and surgical procedures, but different in terms of diagnosis (there were more patients with myelomeningocele in the group treated with both anterior-posterior surgery and neurosurgery) and patient age (the group with both anterior-posterior surgery and neurosurgery was younger).

Results

An additional neurosurgical procedure combined with fusion surgery did not increase the complication rate or use of resources compared with fusion surgery alone, except in the length of operating time. The mean correction of the spinal curve was 56.7%, and the mean correction of the pelvic obliquity was 74.7%. The loss of correction was 3° on average. A more than 10° progression was seen in 9 cases. There were no deaths, and there were no neurological complications or surgery-related deterioration of ambulatory function. There were 10 complications that altered the planned postoperative course, including 5 infections.

Conclusions

One-stage major spine surgery, even when neurosurgery is included, is safe and does not increase the risk of complications. The increase in hospital and ICU stays is marginal.

Complications of the Luque-Galveston scoliosis correction technique in paediatric cerebral palsy

PURPOSE OF THE STUDY

Severe scoliosis is a very frequent condition in cerebral palsy children (CP). It is surgically managed, with unit rod instrumentation being the gold standard in English-speaking countries. The purpose of this work was to report on a small, homogeneous series of non-ambulatory, quadriplegic, spastic patients treated by the Luque-Galveston technique in Strasbourg, France. We present the radiographic outcome of the technique along with a full description of any post-operative complications encountered.

MATERIALS AND METHODS

Twenty-eight children were operated on according to the Luque-Galveston technique between January 1997 and January 2006. This instrumentation, with fusion, included the whole spine from the sacrum to level T2. All procedures were performed as a one-stage posterior arthrodesis. The spinal deformities were single thoraco-lumbar curvatures, except in one patient. Both curve magnitude and pelvic obliquity were measured by X-ray pre-operatively, post-operatively and after longest follow-up (over 24 months). Our study focused on the rate of complications of this treatment. Only 16 patients out of 28 were tracked since the remaining 12 were lost to follow-up.

RESULTS

Mean curve magnitude was corrected from 80 degrees to 34.8 degrees (mean correction, 56.5%), and pelvic obliquity, from 20.9 degrees to 4.2 degrees (mean correction, 79.6%). Loss of correction at average 3.46-year follow-up was 3.9 degrees of curve magnitude and 2.7 degrees of pelvic obliquity. Mean operating time was 301.5 minutes, and average blood loss was 861.9 ml. Patients were discharged from hospital after an average 19.5-day stay, including mean 8.4-day intensive care unit stay. A single major complication, monocular blindness, occurred during the procedure, probably resulting from air embolism. Post-operative complications (totaling 57.1% of our 28 patients) were: one death, three pneumothoraxes, six segmental atelectasias, seven pneumonias and one superficial wound infection. Late-onset complications (totaling 56.2% of our 16 patients at latest follow-up) were: seven broken sublaminar wires, one iliac perforation by the rod, one skin irritation from extreme malnutrition needing hardware removal, and three superficial sacral decubitus ulcers.

DISCUSSION

Our correction rate in children affected by CP and manifesting severe scoliosis is similar to that reported in the literature by different surgical teams. Moreover, we did not observe any deep wound infection, haematoma, septicaemia, neurological and digestive complications. Late-onset complications mainly involved asymptomatic sublaminar wire breakage at the two uppermost levels, but no major complication was due to hardware failure, and vertebral fracture did not occur. There was no need for re-intervention because of the hardware, except for one case in which extreme malnutrition provoked skin conflict with the rod. We encountered 10 "windshield wiper" effects in the iliac bone, but we believe they cannot be considered as complications since they seemed to disappear after fusion was fully obtained. Last but not least, unit rod instrumentation is not very expensive compared to more modern techniques.

CONCLUSION

Correction of scoliosis and pelvic obliquity, attributed to CP in non-ambulatory children, by the Luque-Galveston technique is both an effective and safe choice in such an indication. Moreover, it is far less expensive than most other techniques, an aspect which should be taken into consideration.

LEVEL OF EVIDENCE

Level IV retrospective therapeutic study.

Infection after spinal fusion for pediatric spinal deformity: thirty years of experience at a single institution

STUDY DESIGN

A retrospective, consecutive case study of 1571 pediatric patients who underwent spinal deformity surgery and had minimum 2-year follow-up.

OBJECTIVE

To identify (1) the rate of infection after pediatric spinal deformity surgery; (2) the number of surgeries required to treat a postoperative infection after a pediatric spinal deformity surgery; (3) the percentage of patients with a postoperative infection after pediatric spinal deformity surgery who require implant removal to quantify the effect of removal on the deformity; and (4) the microbiology of postoperative infections after pediatric spinal deformity surgery.

SUMMARY OF BACKGROUND DATA

Several previous reports have discussed the rates of infection after spinal surgery for pediatric spinal deformity. No previous reports have quantified the rate and magnitude of deformity progression after infection in pediatric spinal deformity surgery.

METHODS

A retrospective review was performed of the medical records and radiographs of all children undergoing surgery for spinal deformity at the Shriners Hospital for Children in Chicago from January 1, 1975, to June 1, 2005.

RESULTS

The rate of infection varied based on underlying diagnosis: idiopathic scoliosis 0.5%, myelomeningocele 19.2%, myopathies 4.3%, and cerebral palsy 11.2%. On average, 2 surgeries were required to eradicate the infection. Approximately half of the patients required removal of the instrumentation to treat their infection. Forty-four percent of patients who developed an infection had significant progression of their deformity, with an average increase in deformity magnitude of 27 degrees. Implant removal predisposed patients to progression of deformity. The 3 most common organisms in order were Staphylococcus aureus, S. epidermidis, and Pseudomonas aeruginosa.

CONCLUSION

Infection after spinal deformity in idiopathic scoliosis is rare but is relatively common in neuromuscular conditions. Eradication of infection can be expected, but implant removal is often required. Should implants be totally removed, significant progression of the deformity is possible.

Spinal fusion for spastic neuromuscular scoliosis: is anterior releasing necessary when intraoperative halo-femoral traction is used?

STUDY DESIGN

Retrospective radiographic and clinical study.

OBJECTIVE

To compare the complications and radiographic outcomes of 2 types of surgical treatments, posterior-only fusion and circumferential fusion, in patients with nonambulatory quadriplegic cerebral palsy treated with adjunctive intraoperative halo-femoral traction.

SUMMARY OF BACKGROUND DATA

Circumferential anterior-posterior spinal fusion (A/PSF) has been used to improve deformity correction and rate of fusion in patients with neuromuscular scoliosis (NMS) but is associated with increased morbidity. Anterior procedures may increase operative time (OR time) and estimated blood loss (EBL) as well as compromise pulmonary function. Posterior-only spinal fusion (PSF-only) may be sufficient, thereby forgoing the need for the anterior approach without sacrificing deformity correction or outcome.

METHODS

Twenty-six patients (age <21 years) who underwent PSF-only for spastic NMS (quadriplegic cerebral palsy) were matched with a comparison cohort of 26 patients who underwent A/PSF (11 staged, 15 same day). All posterior fusions extended from the proximal thoracic spine (T2/T3) to the pelvis. Anterior fusions used a thoracoabdominal approach. All 52 patients underwent intraoperative halo-femoral traction. Mean follow-up for PSF-only was 2.9 years and A/PSF 3.3 years.

RESULTS

There were no significant differences between the 2 groups in demographic data or preoperative radiographic measures. The PSF-only group had statistically significant shorter OR time (6.1 vs. 10.3 hours), lower EBL (873 vs. 1361 mL), lower frequency of postoperative intubation (38% vs. 81%), shorter length of postoperative intubation (2 vs. 6.5 days), and lower frequency of postoperative pulmonary complications (7.7% vs. 26.9%). There were no statistically significant differences at the final follow-up for thoracolumbar/lumbar curve Cobb, % correction of thoracolumbar/lumbar Cobb, pelvic obliquity, C7 plumb line and the center sacral vertical line, sagittal T5-T12, sagittal T10-L2, and sagittal T12-S1 Cobb measurements. There were no halo-femoral traction-related complications.

CONCLUSIONS

When intraoperative halo-femoral traction is used, PSF-only surgery for NMS can provide excellent curve correction and spinal balance. In this study, the PSF-only group had shorter OR time, lower EBL, lower frequency of postoperative intubation, and fewer cases of pneumonias when compared with A/PSF with similar radiographic outcomes at 2-year follow-up.

Can the caudal extent of fusion in the surgical treatment of scoliosis in Duchenne muscular dystrophy be stopped at lumbar 5?

Instrumentation and fusion to the sacrum/pelvis has been a mainstay in the surgical treatment of scoliosis in Duchenne muscular dystrophy (DMD) and is recommended to correct pelvic obliquity. The caudal extent of instrumentation and fusion in the surgical treatment of scoliosis in DMD has remained a matter of considerable debate, and there have been few studies on the use of segmental pedicle screw instrumentation for this pathology. From 2004 to 2007, a total of 28 patients with DMD underwent segmental pedicle screw instrumentation and fusion only to L5. Assessment was performed clinically and with radiologic measurements. All patients had a curve with the apex at L2 or higher preoperatively. Preoperative coronal curve averaged 74 degrees, with a postoperative mean of 14 degrees, and 17 degrees at the last follow-up. The pelvic obliquity improved from 17 degrees preoperatively to 6 degrees postoperatively, and 6 degrees at the last follow-up. Good sagittal plane alignment was recreated after surgery and maintained long term. In 23 patients with a preoperative L5 tilt of less than 15 degrees, the pelvic obliquity was effectively corrected to less than 10 degrees and maintained by adequately addressing spinal deformity, while five patients with a preoperative L5 tilt of more than 15 degrees had a postoperative pelvic obliquity of more than 15 degrees. Segmental pedicle screw instrumentation and fusion to L5 was effective and safe in patients with DMD scoliosis with a minimal L5 tilt (<15 degrees) and a curve with the apex at L2 or higher, both initially and long term, obviating the need for fixation to the sacrum/pelvis. Segmental pedicle screw instrumentation and fusion to L5 was safe and effective in patients with DMD scoliosis with stable L5/S1 articulation as evidenced by a minimal L5 tilt of less than 15 degrees, even though pelvic obliquity was significant. There was no major complication. With rigid segmental pedicle screw instrumentation, the caudal extent of fusion in the treatment of DMD scoliosis should be determined by the degree of L5 tilt. This method in appropriate patients can be a viable alternative to instrumentation and fusion to the sacrum/pelvis in the surgical treatment of DMD scoliosis.

Two-year results for scoliosis secondary to Duchenne muscular dystrophy fused to lumbar 5 with segmental pedicle screw instrumentation

BACKGROUND

Instrumentation and fusion to the sacrum/pelvis has been a mainstay in the surgical treatment of scoliosis in patients with Duchenne muscular dystrophy since the development of the intrailiac post. It is recommended for correcting pelvic obliquity. However, caudal extent of instrumentation and fusion has remained a matter of considerable debate. This study was performed to determine the efficacy and safety of stopping segmental pedicle screw constructs at L5 during surgical treatment of scoliosis associated with Duchenne muscular dystrophy (DMD).

METHODS

From May 2005 to June 2007, a total of 20 consecutive patients underwent posterior spinal fusion and segmental pedicle screw instrumentation only to L5 for scoliosis secondary to DMD. All patients had progressive scoliosis, difficulty sitting, and back pain before surgery. A minimum 2-year follow-up was required for inclusion in this study. Assessment was performed clinically and with radiological measurements. The Cobb angles of the curves and spinal pelvic obliquity were measured on the coronal plane. Thoracic kyphosis and lumbar lordosis were measured on the sagittal plane. These radiographic assessments were performed before surgery, immediately after surgery, and at a 3-month interval thereafter. The operating time, blood loss, and complications were evaluated. Patients were questioned about whether they had difficulty sitting and felt back pain before surgery and at 6 weeks, 1 year, and 2 years after surgery.

RESULTS

A total of 20 patients, aged 11-17 years, were enrolled. The average follow-up period was 37 months. Preoperative coronal curves averaged 70 degrees (range 51 degrees -85 degrees ), with a postoperative mean of 15 degrees (range 8 degrees -25 degrees ) and a mean of 17 degrees (range 9 degrees -27 degrees ) at the last follow-up. Pelvic obliquity improved from 13 degrees (range 7 degrees -15 degrees ) preoperatively to 5 degrees degrees (range 3 degrees -8 degrees ) postoperatively and 6 degrees (range 3 degrees -9 degrees ) at the last follow-up. Good sagittal plane alignment was recreated and maintained. Only a small loss of correction of scoliosis and pelvic obliquity was noted. The mean operating time was 271 min (range 232-308 min). The mean intraoperative blood loss was 890 ml (range 660-1260 ml). The mean total blood loss was 2100 ml (range 1250-2880 ml). There was no major complication. All patients reported that difficulty sitting and back pain were alleviated after surgery.

CONCLUSION

Segmental pedicle screw instrumentation and fusion only to L5 is safe and effective in patients with DMD scoliosis of <85 degrees and pelvic obliquity of <15 degrees . Good sagittal plane alignment was achieved and maintained. All patients benefited from surgery in terms of improved quality of life. There was no major complication.

Is spine deformity surgery in patients with spastic cerebral palsy truly beneficial?: a patient/parent evaluation

STUDY DESIGN

Retrospective clinical outcome study.

OBJECTIVE

To evaluate the clinical outcomes and satisfaction associated with the surgical treatment of neuromuscular spinal deformity secondary to cerebral palsy.

SUMMARY OF BACKGROUND DATA

Controversy still exists regarding whether spinal deformity surgery is truly a beneficial surgery for patients with cerebral palsy (CP) since there is limited functional benefit and higher perioperative complications rates in this patient population.

METHODS

Neuromuscular patient evaluation questionnaires were answered retrospectively by 84 patients/families of spastic CP patients undergoing spinal fusion. The average follow-up was 6.2 years (range: 2-16). The questionnaires were designed to assess expectation, cosmesis, function, patient care, quality of life, pulmonary function, pain, health status, self-image, and satisfaction. Questionnaire results, complications, and radiographic data were divided into "satisfied group" and "less satisfied group" and we analyzed reasons of satisfaction and dissatisfaction.

RESULTS

The overall satisfaction rate was 92%. Ninety-three percent reported improvement with sitting balance, 94% with cosmesis, and 71% in patient's quality of life. Functional improvements seemed limited, but 8% to 40% of the patients still perceived the surgical results as improvement. The postoperative complication rate was 27%. The mean preoperative Cobb angle of the major curve was 88 degrees (range: 53 degrees-141 degrees), which corrected to 39 degrees (range: 5 degrees-88 degrees) after surgery. The less satisfied group had a significantly higher late complication rate, less correction of the major curve, greater residual major curve, and hyperlordosis of the lumbar spine after surgery.

CONCLUSION

Despite the perioperative difficulties seen with CP patients, the majority of the patient/parents were satisfied with the results of the spinal deformity surgery. Functional improvements were limited but 8% to 40% of the patients still perceived the results as improved. The reason for less than optimal satisfaction appears to be due to less correction of the major curve, greater residual major Cobb angle, hyperlordosis of the lumbar spine after surgery, and late postoperative complications.

A national perspective of surgery in children with cerebral palsy

PURPOSE

Children with cerebral palsy (CP) often require surgery, but may be at higher risk for surgical complications and poorer outcomes than children without CP. This study provides a national perspective of the children, hospitals and hospital course associated with the five most commonly performed surgeries in children with CP and compares this perspective to that of children without CP undergoing the same procedures.

METHODS

Analysis of the 1997 Healthcare Cost and Utilization Project Kids' Inpatient Database.

RESULTS

The most common surgeries performed in children with CP (n = 37 000) were gastrostomy tube placements (n = 1743), soft tissue musculoskeletal procedures (n = 1393), fundoplications (n = 1062), spinal fusions with instrumentation (n = 765) and bony hip surgeries (n = 651). Together, the five procedures accounted for nearly 50 000 hospital days and over 150 million dollars in hospital charges in 1997. The largest difference in outcomes between children with and without CP was seen in those undergoing surgery for scoliosis.

CONCLUSIONS

Surgical procedures are frequent in children with CP. Their costs and impact on the US health care system are substantial. The findings provide a strong incentive to carefully study the benefits of the procedures and to develop interventions to improve outcomes, particularly in the case of scoliosis surgery.

Surgical correction and fusion using posterior-only pedicle screw construct for neuropathic scoliosis in patients with cerebral palsy: a three-year follow-up study

STUDY DESIGN

It is a retrospective study of 52 neuromuscular scoliosis patients with cerebral palsy (CP).

OBJECTIVE

To determine the effectiveness and amount of correction using posterior-only pedicle screw construct.

SUMMARY OF BACKGROUND DATA

Although there have been many reports in literature supporting the use of pedicle screw-only constructs for the correction of adolescent idiopathic scoliosis, similar studies have not been reported in patients with CP.

METHODS

We retrospectively evaluated outcomes of 52 neuropathic scoliosis patients (28 males and 24 females) with CP over minimum 2 years of follow-up. All patients underwent pedicle screw fixation without any anterior procedure for the correction. Pelvic fixation was done in 10 patients who had pelvis obliquity more than 15 degrees . All coronal and sagittal parameters were noted after surgery and at final follow-up. Patient's functional outcome was measured using modified Rancho Los Amigos Hospital system criteria. Complications were recorded from record sheets and any change in the ambulatory status was also recorded.

RESULTS

Mean age was 22 years at the time of operation and average follow-up was 36.1 month. Cobb's angle was improved to 62.9% (P < 0.0001) from 76.8 degrees to 30.1 degrees after surgery and 31.5 degrees at final follow-up. This correction of scoliosis (41% approximately 92%) was found to be statistically significant (P < 0.0001). Overall correction in pelvic obliquity was 56.2% from 9.2 degrees before surgery to 4.0 degrees after surgery which was 43.1% at final follow-up to 5.2 degrees. Twenty-one patients (42%) improved their functional ability by grade 1 with 2 patients by grade 2. After the operation parent or caretakers of patients exhibited better sitting balance and nursing care. There were 32% complications in the series major being pulmonary. There were 2 perioperative deaths and 1 patient developed neurologic deficit due to screw impingement in canal, which was resolved after removal.

CONCLUSION

We reported satisfactory coronal and sagittal correction with posterior-only pedicle screw fixation without higher complication rate in CP patients. Further long-term study is recommended to evaluate the success of pedicle screw in this population.

Surgical complications in neuromuscular scoliosis operated with posterior- only approach using pedicle screw fixation

Background

There are no reports describing complications with posterior spinal fusion (PSF) with segmental spinal instrumentation (SSI) using pedicle screw fixation in patients with neuromuscular scoliosis.

Methods

Fifty neuromuscular patients (18 cerebral palsy, 18 Duchenne muscular dystrophy, 8 spinal muscular atrophy and 6 others) were divided in two groups according to severity of curves; group I (< 90°) and group II (> 90°). All underwent PSF and SSI with pedicle screw fixation. There were no anterior procedures. Perioperative (within three months of surgery) and postoperative (after three months of surgery) complications were retrospectively reviewed.

Results

There were fifty (37 perioperative, 13 postoperative) complications. Hemo/pneumothorax, pleural effusion, pulmonary edema requiring ICU care, complete spinal cord injury, deep wound infection and death were major complications; while atelectesis, pneumonia, mild pleural effusion, UTI, ileus, vomiting, gastritis, tingling sensation or radiating pain in lower limb, superficial infection and wound dehiscence were minor complications. Regarding perioperative complications, 34(68%) patients had at least one major or one minor complication. There were 16 patients with pulmonary, 14 with abdominal, 3 with wound related, 2 with neurological and 1 cardiovascular complications, respectively. There were two deaths, one due to cardiac arrest and other due to hypovolemic shock. Regarding postoperative complications 7 patients had coccygodynia, 3 had screw head prominence, 2 had bed sore and 1 had implant loosening, respectively. There was a significant relationship between age and increased intraoperative blood loss (p = 0.024). However it did not increased complications or need for ICU care. Similarly intraoperative blood loss > 3500 ml, severity of curve or need of pelvic fixation did not increase the complication rate or need for ICU. DMD patients had higher chances of coccygodynia postoperatively.

Conclusion

Although posterior-only approach using pedicle screw fixation had good correction rate, complications were similar to previous reports. There were few unusual complications like coccygodynia.

Surgical management of severe scoliosis with high-risk pulmonary dysfunction in Duchenne muscular dystrophy

Between 2005 and 2007, 14 patients who had severe scoliosis in Duchenne muscular dystrophy (DMD) and a poor forced vital capacity (FVC) of <30% at admission underwent scoliosis surgery. FVC on admission was 21.6% (range, 16-27%). The patients were given respiratory muscle training using a pulmonary trainer (Threshold IMT, Philips Respironics, Inc.) for six weeks before operation. FVC increased to 26.2% (range, 22-31%) the day before operation. The mean preoperative scoliosis was 98 degrees (range, 81 degrees-130 degrees). All patients underwent posterior fusion and all-screw construction and were extubated on the operative day. No patients developed any respiratory complications. The postoperative scoliosis was 34 degrees (range, 20 degrees-40 degrees) (65%). FVC remained stable at six weeks after operation. FVC decreased to 19.8% (range, 16-25%) and the mean scoliosis was 35 degrees (range, 23 degrees-40 degrees) (64%) at two years after operation. DMD patients with severe scoliosis and FVC considered too low to permit reasonable surgical risk could undergo surgery and could benefit from surgery.

A Dutch guideline for the treatment of scoliosis in neuromuscular disorders

Background

Children with neuromuscular disorders with a progressive muscle weakness such as Duchenne Muscular Dystrophy and Spinal Muscular Atrophy frequently develop a progressive scoliosis. A severe scoliosis compromises respiratory function and makes sitting more difficult. Spinal surgery is considered the primary treatment option for correcting severe scoliosis in neuromuscular disorders. Surgery in this population requires a multidisciplinary approach, careful planning, dedicated surgical procedures, and specialized after care.

Methods

The guideline is based on scientific evidence and expert opinions. A multidisciplinary working group representing experts from all relevant specialties performed the research. A literature search was conducted to collect scientific evidence in answer to specific questions posed by the working group. Literature was classified according to the level of evidence.

Results

For most aspects of the treatment scientific evidence is scarce and only low level cohort studies were found. Nevertheless, a high degree of consensus was reached about the management of patients with scoliosis in neuromuscular disorders. This was translated into a set of recommendations, which are now officially accepted as a general guideline in the Netherlands.

Conclusion

In order to optimize the treatment for scoliosis in neuromuscular disorders a Dutch guideline has been composed. This evidence-based, multidisciplinary guideline addresses conservative treatment, the preoperative, perioperative, and postoperative care of scoliosis in neuromuscular disorders.

Rate of complications in scoliosis surgery - a systematic review of the Pub Med literature

Background

Spinal fusion surgery is currently recommended when curve magnitude exceeds 40–45 degrees. Early attempts at spinal fusion surgery which were aimed to leave the patients with a mild residual deformity, failed to meet such expectations. These aims have since been revised to the more modest goals of preventing progression, restoring 'acceptability' of the clinical deformity and reducing curvature.

In view of the fact that there is no evidence that health related signs and symptoms of scoliosis can be altered by spinal fusion in the long-term, a clear medical indication for this treatment cannot be derived. Knowledge concerning the rate of complications of scoliosis surgery may enable us to establish a cost/benefit relation of this intervention and to improve the standard of the information and advice given to patients. It is also hoped that this study will help to answer questions in relation to the limiting choice between the risks of surgery and the "wait and see – observation only until surgery might be recommended", strategy widely used. The purpose of this review is to present the actual data available on the rate of complications in scoliosis surgery.

Materials and methods

Search strategy for identification of studies; Pub Med and the SOSORT scoliosis library, limited to English language and bibliographies of all reviewed articles. The search strategy included the terms; 'scoliosis'; 'rate of complications'; 'spine surgery'; 'scoliosis surgery'; 'spondylodesis'; 'spinal instrumentation' and 'spine fusion'.

Results

The electronic search carried out on the 1^st February 2008 with the key words "scoliosis", "surgery", "complications" revealed 2590 titles, which not necessarily attributed to our quest for the term "rate of complications". 287 titles were found when the term "rate of complications" was used as a key word. Rates of complication varied between 0 and 89% depending on the aetiology of the entity investigated. Long-term rates of complications have not yet been reported upon.

Conclusion

Scoliosis surgery has a varying but high rate of complications. A medical indication for this treatment cannot be established in view of the lack of evidence. The rate of complications may even be higher than reported. Long-term risks of scoliosis surgery have not yet been reported upon in research. Mandatory reporting for all spinal implants in a standardized way using a spreadsheet list of all recognised complications to reveal a 2-year, 5-year, 10-year and 20-year rate of complications should be established. Trials with untreated control groups in the field of scoliosis raise ethical issues, as the control group could be exposed to the risks of undergoing such surgery.

Incidence and risk factors of prolonged mechanical ventilation in neuromuscular scoliosis surgery

Patients with neuromuscular scoliosis (NMS) are frequently considered at high risk for postoperative complications based on their underlying disease and comorbidities. Postoperative complications include prolonged mechanical ventilation (MV), defined longer than 72 h, at the paediatric intensive care unit. The objectives of this retrospective study were to assess the incidence of prolonged MV in patients with NMS following scoliosis surgery and to identify predictive risk factors. A total of 46 consecutive patients underwent surgical spinal fusion and instrumentation for progressive NMS. Prolonged MV was required in seven of 46 patients (15%). The only risk factor for prolonged MV was a decreased preoperative pulmonary function. Forced expired volume in 1 s and vital capacity were significantly decreased in patients with MV >72 h compared with patients with MV <72 h. Routine preoperative pulmonary function testing may reveal important information with regard to restrictive lung disease in the preoperative assessment of patients with NMS and predict the early postoperative clinical course.

Cervical kyphosis and thoracic lordoscoliosis in a patient with cerebral palsy

The management of cerebral palsy and spinal deformity can be challenging for spine surgeons. Scoliosis is the most common spinal deformity associated with cerebral palsy; however, the development of thoracic lordoscoliosis is rare. Cervical kyphosis in cerebral palsy patients is associated primarily with athetoid cerebral palsy. This article presents a case of progressive myelopathy and concurrent cervical kyphosis and thoracic lordoscoliosis in a 17-year-old spastic quadriplegic cerebral palsy patient who underwent 2-stage treatment. In the first stage, the cervical spine was managed with a 2-level cervical corpectomy of C5 and C6, with multilevel laminectomies, lateral mass plating, and wire fixation. In the second stage 3 months later, the thoracic deformity was corrected through a combined anterior spinal release of the thoracic spine with posterior spinal segmental instrumentation and sublaminar wiring. Postoperatively, the patient successfully returned to independent ambulation.