Preoperative predictors of prolonged postoperative mechanical ventilation in children following scoliosis repair

Changes in Diaphragm Intrusion and Thoracic Dimensions After Posterior Spinal Fusion in Patients With Neuromuscular Scoliosis

BACKGROUND

Cerebral palsy (CP) can cause scoliosis with large thoracolumbar or lumbar curves. Such curves may impair pulmonary function by causing the abdomen and diaphragm to encroach on the thorax. Our purpose was to investigate changes in diaphragm position and other thoracic radiographic measurements at 2 years after posterior spinal fusion (PSF).

METHODS

Retrospective review of data from 56 pediatric patients (Gross Motor Function Classification System >3) who underwent PSF for CP-related (neuromuscular) scoliosis at one US academic hospital from 2010 to 2018. In this study, we used radiographs taken preoperatively and 2 years after PSF to measure lung volume, diaphragm intrusion index (DII), diaphragm vertebral level (DVL), space available for the lung (SAL), and T1-S1 height.

RESULTS

Lung volume had increased by a mean 902 cm3 (range, -735 to 2697 cm3) at 2-year follow-up. DII improved from a mean (and SD) of 61%±12% to 71%±11% on the left side and 58%±14% to 68%±11% on the right (P<0.001). DVL increased caudally by a mean 1.2 vertebral levels bilaterally, with a mean postoperative position between T8 and T9. Lung space became more symmetrical as the SAL increased from 0.76 to 0.91 (P<0.001). T1-S1 height increased by a mean 7.5±4.3 cm.

CONCLUSIONS

These findings suggest a new way to understand changes in thoracic volume and redistribution of thoracic and lumbar balance when correcting the collapsing spinal deformity in CP. A more caudal postoperative diaphragm position with less diaphragm intrusion into the thorax may reflect an improved length-tension configuration, which could in turn produce greater diaphragmatic strength and endurance.

LEVEL OF EVIDENCE

Level III.

Reoperation, Readmission, and Postoperative Bleeding in Pediatric Cerebral Palsy Patients Undergoing Spinal Arthrodesis

Background Cerebral palsy (CP) is one of the most common neuromuscular disorders in children, and spinal abnormalities are vastly more common in people with CP compared to the general population. Further investigation is needed to improve our understanding of the perioperative factors that place children with CP at greater risk of postoperative complications. This study aims to investigate (1) whether pediatric CP patients have higher rates of postoperative complications after spinal fusion and (2) risk factors for postoperative bleeding, readmission, and reoperation. Methodology The 2019 American College of Surgeons National Surgical Quality Improvement Program Pediatric database was used for this study. Chi-square tests were used to compare patient demographics, frequency of comorbidities, intraoperative factors, and postoperative complications between CP and non-CP patients. Multivariable logistic regression modeling was conducted to determine if CP was an independent risk factor for the composite variable that included postoperative bleeding, readmission, and reoperation. Results A total of 4,445 patients were included in the study, with 606 CP and 3,839 non-CP patients. Several comorbidities were more prevalent in the CP cohort, most notably asthma, gastrointestinal disease, previous cardiac surgery, and hematologic disorders. Multivariable logistic regression modeling revealed that CP, older age, non-Caucasian race, American Society of Anesthesiologists (ASA) class of 3 or higher, posterior surgical approach, previous cardiac surgery, and ostomy were significantly correlated with higher postoperative complications. Conclusions This study demonstrates that CP, older age, non-Caucasian race, ASA class of 3 or higher, posterior approach, previous cardiac surgery, and ostomy are independent risk factors for postoperative complications, including readmission, reoperation, and postoperative bleeding requiring transfusions. Consequently, there is a pressing need for additional research to establish perioperative strategies that reduce postoperative risks for these patients. Spine surgeons should consider the findings of this study when communicating the potential risks of spinal fusion surgery with patients and their families.

Risk Factors of Infectious Complications in Pediatric Patients With Cerebral Palsy After Spinal Arthrodesis

STUDY DESIGN

This was a retrospective study.

OBJECTIVE

The main objective of this study was to investigate (1) whether pediatric patients with cerebral palsy (CP) have higher rates of postoperative infectious complications after spinal fusion and (2) risk factors for postoperative infections.

SUMMARY OF BACKGROUND DATA

Prior studies have shown that patients with CP undergo corrective spine surgery more often than the general population, yet typically have worse postoperative outcomes. Further investigation is needed to improve our understanding of the perioperative factors that place children with CP at greater risk of postoperative infectious complications.

PATIENTS AND METHODS

The 2019 "American College of Surgeons National Surgical Quality Improvement Program" Pediatric database was used for patient data. The univariable analysis compared the prevalence of preoperative comorbidities and perioperative factors between children with and without CP. Multivariable logistic regression modeling was used to ascertain independent risk factors for postoperative infectious complications.

RESULTS

A total of 4445 patients were included in the study; 606 (13.63%) patients had CP and 3839 (86.37%) did not. Patients with CP were more likely to have several notable preoperative comorbidities, and the rate of developing any infectious complication was more than 7 times greater in the CP cohort than in the control cohort (14.36% vs 1.88%; P <0.001). Multivariable analysis revealed CP [odds ratio (OR): 3.55, CI: 2.25-5.60; P <0.001], American Society of Anesthesiologists class 3 or higher (OR: 2.10, CI: 1.29-3.42; P = 0.003), and hematologic disorders (OR: 2.01, CI: 1.06-3.83; P = 0.033) to be independent risk factors for increased postoperative infectious complications.

CONCLUSIONS

CP is an independent risk factor for the development of 30-day postoperative infectious complications in pediatric patients. In addition, the American Society of Anesthesiologists class 3 or higher and hematologic disorders were risk factors for postoperative infections after spinal fusion surgery.

Risk factors for intensive care unit admission following correction surgery for adult spinal deformity

OBJECTIVE

The literature currently available on the characteristics of patients who require intensive care unit (ICU) admission after correction surgery for adult spinal deformity is lacking; this study aimed to identify risk factors for postoperative ICU admission following correction surgery for adult spinal deformity.

METHODS

A retrospective review of patients who underwent primary posterior-based spinal fusion from 2015 to 2023 was performed. According to the ward they returned to, patients were further divided into an ICU group and a non-ICU group. Univariate and multivariate analyses were performed to evaluate preoperative and perioperative parameters to identify independent risk factors for postoperative ICU admission in adult spinal deformity patients.

RESULTS

A total of 274 patients were included, including 115 males (41.97%) and 159 females (58.03%). The mean age of the patients was 32.00 ± 11.16 years (19-77 years). Following adjusted analysis, the preoperative and perioperative factors that were independently associated with ICU admission were age, body mass index ≥ 28 kg/m2, neuromuscular spinal deformity, respiratory disease, grade III-IV American Society of Anesthesiologists (ASA) classification, a scoliosis Cobb angle ≥ 90°, a kyphosis Cobb angle ≥ 90°, and ≥ 12 fused segments. Compared with the non-ICU group, the ICU group had a higher incidence of complications, a longer hospital stay, and higher medical costs (P < 0.05).

CONCLUSION

This study identified independent risk factors associated with postoperative ICU admission in adult spinal deformity patients; and explored relative measures to decrease or avoid the risk of postoperative ICU admission. Surgeons could use these data to develop and plan appropriate perioperative care processes in advance and provide consultation for family members before surgery.

A data-driven model for early prediction of need for invasive mechanical ventilation in pediatric intensive care unit patients

RATIONALE

Acute respiratory failure is a life-threatening clinical outcome in critically ill pediatric patients. In severe cases, patients can require mechanical ventilation (MV) for survival. Early recognition of these patients can potentially help clinicians alter the clinical course and lead to improved outcomes.

OBJECTIVES

To build a data-driven model for early prediction of the need for mechanical ventilation in pediatric intensive care unit (PICU) patients.

METHODS

The study consists of a single-center retrospective observational study on a cohort of 13,651 PICU patients admitted between 1/01/2010 and 5/15/2018 with a prevalence of 8.06% for MV due to respiratory failure. XGBoost (extreme gradient boosting) and a convolutional neural network (CNN) using medication history were used to develop a prediction model that could yield a time-varying "risk-score"-a continuous probability of whether a patient will receive MV-and an ideal global threshold was calculated from the receiver operating characteristics (ROC) curve. The early prediction point (EPP) was the first time the risk-score surpassed the optimal threshold, and the interval between the EPP and the start of the MV was the early warning period (EWT). Spectral clustering identified patient groups based on risk-score trajectories after EPP.

RESULTS

A clinical and medication history-based model achieved a 0.89 area under the ROC curve (AUROC), 0.6 sensitivity, 0.95 specificity, 0.55 positive predictive value (PPV), and 0.95 negative predictive value (NPV). Early warning time (EWT) median [inter-quartile range] of this model was 9.9[4.2-69.2] hours. Clustering risk-score trajectories within a six-hour window after the early prediction point (EPP) established three patient groups, with the highest risk group's PPV being 0.92.

CONCLUSIONS

This study uses a unique method to extract and apply medication history information, such as time-varying variables, to identify patients who may need mechanical ventilation for respiratory failure and provide an early warning period to avert it.

Friends Not Foes: Optimizing Collaboration with Subspecialists

Pediatric orthopedic patients can be complex to manage. As orthopedists plan for possible surgical interventions, consultation with pediatric subspecialists will be necessary. This article discusses the considerations an orthopedist should make when deciding on the timing and the appropriateness of consultation-both preoperatively and perioperatively. Consultation before surgical intervention will especially be useful if the subspecialist will be collaborating in the management of the condition postoperatively (whether inpatient or outpatient). Clear and early consultation in both written and verbal format will facilitate quality and expedite the patient's care.

The influence of viral respiratory season on perioperative outcomes in patients undergoing spinal fusion for neuromuscular scoliosis

PURPOSE

Respiratory complications are common following neuromuscular scoliosis (NMS) spinal fusion. Concern exists regarding the safety to perform complicated procedures in winter months when viral respiratory illness is common. The purpose of this study was to compare perioperative outcomes in children with NMS undergoing spinal fusion during peak (November-March) or non-peak (April-October) viral season.

METHODS

The Health Care and Utilization Project (HCUP) Kids' inpatient database (KID) from 2006 to 2012 was reviewed. Children 20 years or younger who underwent spinal fusion for NMS were included. Patients were grouped by date of surgery during peak or non-peak viral season. Continuous variables were compared using t tests and categorical variables were compared using the Rao-Scott Chi-square test. Weighted logistic regression models were performed.

RESULTS

This study identified 5082 records, including 1711 and 3371 patients who had surgery in peak and non-peak viral seasons, respectively. Patients who had spinal fusion during peak viral season were less likely to experience respiratory failure (p = 0.0008) and did not demonstrate an increased incidence of aspiration pneumonia (p = 0.26), respiratory complication (p = 0.43), or mortality (p = 0.68). Respiratory failure was associated with younger age (p = 0.0031), the presence of a tracheostomy (p < 0.0001), and the number of chronic conditions (p < 0.0001). Higher number of chronic medical conditions (mean of 5.0) was associated with an increased risk of in-hospital mortality (p < 0.0001), aspiration pneumonia (p = 0.0009), and respiratory failure (p < 0.0001).

CONCLUSION

Spinal fusion for NMS during peak viral season has a lower risk of respiratory failure without an increase in mortality or other complications compared to during non-peak viral season.

Post-operative steroids in patients with patients with severe cerebral palsy undergoing posterior spinal fusion

INTRODUCTION

Posterior spinal fusion (PSF) represents a large physiologic challenge for children with neuromuscular scoliosis (NMS). Perioperative complications are numerous with many occurring in the post-operative period due to pain and relative immobilization. This study assessed the impact of steroids on patients undergoing PSF for NMS.

METHODS

A retrospective review of consecutive patients managed at a single center with PSF for NMS was reviewed. Clinical and radiographic analysis was used to evaluate baseline demographics, curve characteristics, and post-operative course.

RESULTS

Eighty-nine patients who underwent PSF for NMS were included. Fifty-seven of these patients did not receive post-operative steroids (NS) while 32 patients were treated with post-operative steroids (dexamethasone, WS) for a median of 3 doses (median 6.0 mg/dose every 8 h after surgery). The demographic variables of the cohorts were similar with no difference in curve magnitude, number of vertebrae fused, number of osteotomies, or EBL between groups. A 70% decrease in the median post-operative morphine equivalents was observed in the steroid cohort (0.50 mg/kg WS vs 1.65 mg/kg NS, p value < 0.001). There was an association between post-operative morphine equivalents and length of stay (Spearman's rho = 0.22, p value = 0.04). There was no difference in wound healing, infection, and pulmonary or gastrointestinal complications between groups. No difference was found in pain at discharge, 30-day ED returns, or 30-day OR returns between groups.

CONCLUSIONS

Post-operative dexamethasone resulted in a 70% decrease in morphine equivalent use after PSF for NMS without any increase in perioperative wound infections.

LEVEL OF EVIDENCE

Level 3: case-control series.

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

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Short-term effect and effect on rate of lung function decline after surgery for neuromuscular or syndromic scoliosis

INTRODUCTION

Understanding the impact of scoliosis surgery on lung function is important for counseling patients about risks and benefits of surgery. We prospectively compared the trends in lung function test (LFT) results before and after scoliosis surgery in children with neuromuscular diseases or dysmorphic syndromes. We hypothesized a stabilization.

METHODS

We prospectively included children with neuromuscular or syndromic scoliosis able to perform LFTs. We studied (forced) vital capacity ([F]VC), ratio of forced expiratory volume in 1 s (FEV₁ ) and FVC, and peak expiratory flow (PEF). Preoperative LFT results were compared with results 3-4 months after surgery. The mean monthly change in LFT results up to 2 years after surgery was compared with the preoperative natural history using linear mixed-effects models.

RESULTS

We included 43 patients. No significant change was observed in absolute values of (F)VC, FEV₁ /FVC, and PEF before and after surgery. In 23 neuromuscular patients median standardized VC, FVC, and PEF decreased significantly after surgery from 43% to 33%, 42% to 31%, and 51% to 40%, respectively. In 20 syndromic patients, median FVC decreased from 68% to 65%. The monthly rate of change in FVC did not change significantly in both groups with a mean difference of 0.18% (95% CI: -0.27, -0.61) and -0.44% (95% CI: -1.05, 0.16).

CONCLUSION

No stabilization of lung function 3-4 months after scoliosis surgery was observed in children with neuromuscular and syndromic scoliosis with restrictive lung function disease. The effect on the rate of lung function decline remains inconclusive.

Respiratory prehabilitation in pediatric anesthesia in children with muscular and neurologic disease

Children with neuromuscular, chronic neurologic, and chest wall diseases are at increased risk of postoperative respiratory complications including atelectasis, pneumonia, and respiratory failure with the possible need for reintubation or even tracheostomy. These complications negatively impact patient outcomes, including increased healthcare resource utilization and increased surgical mortality. In these children, the existing respiratory reserve is often inadequate to withstand the stresses brought on during anesthesia and surgery. A thorough clinical assessment and objective evaluation of pulmonary function and gas exchange can help identify which children are at particular risk for poor postoperative outcomes and thus merit preoperative interventions. These may include initiation and optimization of non-invasive ventilation and mechanical insufflation-exsufflation. Furthermore, such an evaluation will help identify children who may require a postoperative extubation plan tailored to neuromuscular diseases. Such strategies may include avoidance of pre-extubation lung decruitment by precluding continuous positive airway pressure trials, aggressively weaning to room air and directly extubating to non-invasive ventilation with a high inspiratory to expiratory pressure differential of at least 10 cm H20. Children with cerebral palsy and other neurodegenerative or neurodevelopmental disorders are a more heterogeneous group of children who may share some operative risk factors with children with neuromuscular disease; they may also be at risk of sleep-disordered breathing, may also require non-invasive ventilation or mechanical insufflation-exsufflation, and may have associated chronic lung disease from aspirations that may require perioperative treatment.

Prolonged Postoperative Mechanical Ventilation (PPMV) in children undergoing abdominal operations: An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database

BACKGROUND

Prolonged postoperative mechanical ventilation (PPMV) increases length of stay, hospitalization costs, and postoperative complications. Independent risk factors associated with PPMV are not well-known for children.

METHOD

We identified children (<18 years) in the ACS NSQIP-P database who underwent a general surgical abdominal operation. We excluded children with preoperative ventilator dependence and mortality within 48 h of surgery. PPMV was defined as cumulative postoperative mechanical ventilation exceeding 72 h. A multivariable logistic regression model identified independent predictors of PPMV.

RESULTS

We identified 108,392 children who underwent a general surgical abdominal operation in the ACS NSQIP-P database from 2012 to 2017. We randomly divided the population into a derivation cohort of 75,874(70%) and a validation cohort of 32,518(30%). In the derivation cohort, we identified PPMV in 1,643(2.2%). In the multivariable model, the strongest independent predictor of PPMV was neonatal age (OR:20.66; 95%CI:16.44-25.97). Other independent risk factors for PPMV were preoperative inotropic support (OR:10.56; 95%CI:7.56-14.77), an operative time longer than 150 min (OR:4.30; 95%CI:3.72-4.52), and an American Society of Anesthesiologists classification >3 (OR:12.16; 95%CI:10.75-13.75).

CONCLUSION

Independent preoperative risk factors for PPMV in children undergoing a general surgical operation were neonatal age, preoperative ionotropic support, duration of operation, and ASA classification >3.

Risk factors associated with prolonged intensive care unit stay after posterior spinal fusion for Duchenne muscular dystrophy

BACKGROUND

The perioperative complication rate for spinal fusion in Duchenne muscular dystrophy (DMD) remains high and sometimes prolonged perioperative intensive care is needed. We investigated preoperative and intraoperative risk factors associated with prolonged intensive care unit (ICU) stay after posterior spinal fusion.

METHODS

We reviewed the records of 49 consecutive DMD patients who underwent posterior spinal fusion. Instrumentation was performed from T4 to L5 (46 cases) or to the ilium (3 cases). We recorded the preoperative Cobb angle and perioperative clinical data from patient records. Patients were divided into two groups (ICU stay 0 or 1 day, 2 days or longer). Chi-square and t tests were used for univariate analysis. Factors with p < 0.05 in the univariate analysis were entered into a multilevel logistic regression analysis.

RESULTS

The average age of patients at surgery was 14.2 years (range 11-20 years). Their preoperative Cobb angle was 79.2° (range 40°-154°). Average operative time was 325.3 min (range 225-507 min). The average estimated blood loss (EBL) was 1673.0 ml (range 500-3785 ml). Eight patients stayed in the ICU for 2 days or longer for postoperative monitoring and treatment. Univariate analysis found statistical difference between the two groups in preoperative Cobb angle, Thoracolumbar kyphosis, %VC, operation time, and EBL during surgery. After multiple logistic regression analysis, Cobb angle and EBL was identified as an independent factor. The patients with a larger Cobb angle and greater EBL had a higher rate of prolonged ICU stay in interquartile range-based comparison.

CONCLUSIONS

The present study suggests the preoperative Cobb angle and intraoperative EBL could be predictors for postoperative course in posterior spinal fusion for DMD patients.

Associations between polysomnography measurements and postoperative adverse respiratory events in children with neuromuscular disease

STUDY OBJECTIVES

To determine if polysomnographic cardiorespiratory outcomes are associated with and could have the potential to predict the presence of postoperative adverse respiratory events in children with neuromuscular disease undergoing any surgical procedure.

METHODS

A retrospective cohort study was conducted at a tertiary pediatric institution. The study population included individuals with neuromuscular disease admitted for a surgical intervention under general anesthetic who had undergone a polysomnogram within 1 year before surgical intervention. Polysomnographic indices and postoperative adverse respiratory events were collected through chart review. Multivariable logistic regression was used to model postoperative adverse respiratory events, where PSG results were considered primary predictors.

RESULTS

Postoperative adverse respiratory events occurred in 25/61 (41%) of individuals and consisted mainly of desaturations requiring intervention 33 (73%), airway obstruction 15 (33%), and atelectasis (22%). Results from the unadjusted and adjusted logistic regression models indicated that saturation nadir and bulbar dysfunction individually were independent risk factors for postoperative adverse respiratory events with the highest areas under the receiver operating characteristic curve. A multivariable prediction model using these 2 risk factors provided an area under the receiver operating characteristic curve of 0.74 (95% confidence interval, 0.65-0.83).

CONCLUSIONS

Knowing that nocturnal oxygen saturation nadir and the presence of bulbar dysfunction are potential predictors of postoperative adverse respiratory events is useful for future counseling of families and surgical planning, in an effort to improve perioperative management and reduce adverse events.

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

STUDY DESIGN

Narrative review.

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Effects of Pulmonary Risk Factors on Hospital Resource Use After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis Correction

OBJECTIVE

The aim of this study was to determine the impact of preoperative pulmonary risk factors (PRFS) on surgical outcomes after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

METHODS

A retrospective cohort study was performed using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database from 2016 to 2018. All pediatric patients with AIS undergoing PSF were identified. Patients were then categorized by whether they had recorded baseline PRF or no-PRF. Patient demographics, comorbidities, intraoperative variables, complications, length of stay, discharge disposition, and readmission rate were assessed.

RESULTS

A total of 4929 patients were identified, of whom 280 (5.7%) had baseline PRF. Compared with the no-PRF cohort, the PRF cohort had higher rates of complications (PRF, 4.3% vs. no-PRF, 2.2%; P = 0.03) and longer hospital stays (PRF, 4.6 ± 4.3 days vs. no-PRF, 3.8 ± 2.3 days; P < 0.001), yet, discharge disposition was similar between cohorts (P = 0.70). Rates of 30-day unplanned readmission were significantly higher in the PRF cohort (PRF, 6.3% vs. no-PRF, 2.7%; P = 0.009), yet, days to readmission (P = 0.76) and rates of 30-day reoperation (P = 0.16) were similar between cohorts. On multivariate analysis, PRF was found to be a significant independent risk factor for longer hospital stays (risk ratio, 0.74; 95% confidence interval, 0.44-1.04; P < 0.001) but not postoperative complication or 30-day unplanned readmission.

CONCLUSIONS

Our study showed that PRF may be a risk factor for slightly longer hospital stays without higher rates of complication or unplanned readmission for patients with AIS undergoing PSF and thus should not preclude surgical management.

Relationship Between Pulmonary Function and Thoracic Morphology in Adolescent Idiopathic Scoliosis: A New Index, the "Apical Vertebra Deviation Ratio", as a Predictive Factor for Pulmonary Function Impairment

STUDY DESIGN

A retrospective study.

OBJECTIVE

The aim of this study was to investigate the relationship between thoracic morphology (TM) and pulmonary function (PF) in patients with adolescent idiopathic scoliosis (AIS) and the feasibility of the "apical vertebra deviation ratio (AVDR)" as a predictor of PF impairment.

SUMMARY OF BACKGROUND

The PF of AIS is one of the key focuses of clinicians' attention. Early identification of AIS patients who are at risk of developing impaired PF is important for improving patient management.

METHODS

Preoperative PF and radiographic examination data of 108 patients with thoracic AIS were collected. The following TM data were collected: the costophrenic angle distance (CAD), distance between T1 and mean diaphragm height (T1-diaphragm), T1-T12 height, and AVDR. The correlation coefficient between PF and TM measurements was analyzed, and univariable and multivariable linear regressions were used to determine whether the TM measurements could predict PF.

RESULTS

The CAD, T1-diaphragm, and T1-T12 height were significantly positively correlated with forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), vital capacity, and total lung capacity (r = 0.54-0.74, P < 0.01). A linear equation between CAD and pulmonary volume could be established: FVC (L) = -3.46 + CAD (cm) × 0.27 (R2 = 0.54). If T1-T12 height is included, the correlation is further enhanced (R2 = 0.68). There was a significant negative correlation between the AVDR and predicted values of forced vital capacity (FVC%), FEV1%, predicted values of vital capacity, and predicted values of total lung capacity (r = -0.46 to -0.52, P < 0.01). The AVDR could predict the value of each of these variables. One of the linear equations is as follows: FVC% = 110.70-99.73 × AVDR (R2 = 0.272).

CONCLUSION

The two novel, two-dimensional TM measurements, CAD and AVDR, can be used as moderate to strong predictors of PF outcome in statistical terms. An AVDR >0.2 suggests that the patient may suffer from moderate or severe PF damage.Level of Evidence: 4.

Risk factors for postoperative pulmonary complications in children with severely compromised pulmonary function secondary to severe scoliosis

OBJECTIVES

After corrective surgery for scoliosis, postoperative pulmonary complications lead to increases in morbidity, length of hospital stay (LOS) and mortality. This study aimed to identify associations with such respiratory complications, and to assess the utility of noninvasive ventilation (NIV) in children with severe scoliosis METHODS: This retrospective cohort study included all children aged ≤17 years who underwent spinal surgery for scoliosis between January 2009 and January 2012 at a quaternary pediatric hospital. Data were collated regarding polysomnography (PSG) and NIV use, before and after corrective surgery. Factors associated with severely compromised pulmonary function (SCPF) were established and correlations with the occurrence of postoperative pulmonary complications and LOS were identified.

RESULTS

Altogether, 133 children had corrective surgery for scoliosis, aged 12.7 (range: 2-17) years at operation. Scoliosis causes were identified as: idiopathic (39.8%), neuromuscular disease (32.2%), syndrome (15.7%), and congenital (12%). Correlates with SCPF (forced vital capacity [FVC] <40% predicted, n = 10) included markers of sleep hypoventilation, including serum bicarbonate ≥29 mmol/L, morning pCO₂  > 50mm Hg (P = .003), and overnight, episodic CO₂ retention of >7 mm Hg. Using these parameters an additional eight children with SCPF were identified making a total of 18 out of 133 (13.5%) of the patients. Postoperative pulmonary complications were seen in 24 children (18%) and their occurrence correlated with higher Cobb angle (>90°), lower pulmonary function (FVC), higher serum bicarbonate and underlying neuromuscular disease. Amongst the 18 children with SCPF, regular use of NIV preoperatively was associated with reduced rate of postoperative pulmonary complications (P = .02) and reduced LOS by 6.4 days (P = .01).

CONCLUSION

Nocturnal hypoventilation on PSG identifies children with SCPF. Use of NIV in children with SCPF was linked to fewer postoperative pulmonary complications and reduced duration of hospital stay.

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

BACKGROUND

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

QUESTIONS/PURPOSES

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical Issues for Pediatric Pulmonologists Managing Children With Thoracic Insufficiency Syndrome

Thoracic insufficiency Syndrome (TIS) is a recently coined phrase to describe children with spine and chest wall deformities, inherited and acquired, who have respiratory impairment, and are skeletally immature. This population has both restrictive and less often obstructive lung disease due to changes in spine and rib configuration which reduce lung volume, stiffen the chest wall, and reduce respiratory muscle strength. Although the population is heterogeneous with regard to age of onset, etiology, severity of deformity, and rate of progression of the deformity, there are common issues that arise which can be addressed by pediatric pulmonologists. These are illustrated in this review by using Early Onset Scoliosis as a common form of TIS. The pulmonary issues pertaining to TIS require collaboration with multi-disciplinary teams, particularly spine surgeons, in order to make decisions about non-surgical and surgical strategies, timing of surgery and medical supportive care over time. Pulmonary input about respiratory function should be used in conjunction with structural features of each deformity in order to determine the impact of the deformity and the response to various treatment options. In those patients with residual lung function impairment as young adults, pediatric pulmonologists must also ensure successful transition to adult care.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III, therapeutic.

Risk factors for pulmonary complications after posterior spinal instrumentation and fusion in the treatment of congenital scoliosis: a case-control study

BACKGROUND

Although surgery prevents the progression of deformity and maintains the overall balance of the spine in congenital scoliosis (CS) patients, it is associated with a high risk of perioperative complications. Pulmonary complication is one of the most common complications. This retrospective study aimed to investigate the risk factors for pulmonary complications in CS patients after posterior spinal instrumentation and fusion.

METHODS

Analysis of consecutive patients who underwent posterior spinal instrumentation and fusion for congenital scoliosis was performed. Preoperative clinical data, intraoperative variables, and perioperative radiographic parameters were collected to analyze the risk factors for pulmonary complications. Patients were separated into groups with and without postoperative pulmonary complications. Potential risk factors were identified by univariate testing. Multivariate logistic regression was used to evaluate independent predictors of pulmonary complications.

RESULTS

Three hundred and twenty-three CS patients were included. Forty-five (13.9%) patients developed postoperative pulmonary complications, which included pleural effusion in 34 (75.6%) cases, pneumonia in 24 (53.3%) cases, pneumothorax in 3 (6.7%) cases, atelectasis in 4 (8.9%) cases, pulmonary edema in 2 (4.4%) cases, respiratory failure in 2 (4.4%) cases, and prolonged mechanical ventilation in 4 (8.9%) cases. The independent risk factors for development of pulmonary complications included age (Odds ratio (OR) = 1.088, P = 0.038), reoperation (OR = 5.150, P = 0.012), preoperative pulmonary disease (OR = 10.504, P = 0.004), correction rate (OR = 1.088, P = 0.001), middle thoracic screw-setting (OR = 12.690, P = 0.043), and thoracoplasty (OR = 5.802, P = 0.001). The area under the receiver operating characteristic (ROC) curve based on predicted probability of the logistic regression was 0.903.

CONCLUSIONS

Age, reoperation, preoperative pulmonary disease, correction rate, middle thoracic screw-setting, and thoracoplasty were independent risk factors for pulmonary complications after posterior spinal instrumentation and fusion in CS patients.

Postoperative pulmonary complications following posterior spinal instrumentation and fusion for congenital scoliosis

Background

Congenital scoliosis (CS) may lead to more serious pulmonary complications compared with idiopathic scoliosis after spinal fusion surgery. However, little has been reported about postoperative pulmonary complication events in patients with CS after spinal fusion surgery.

Objective

To investigate the incidence of and predictive factors of postoperative pulmonary complications following posterior spinal instrumentation and fusion surgery for the treatment of CS.

Methods

We retrospectively reviewed the records of 174 patients with CS (128 females and 46 males, mean age 16.4 years) treated with posterior spinal instrumentation and fusion surgery between January 2012 and April 2017. We extracted demographic, medical history, and clinical data, and investigated the major predictive factors for postoperative pulmonary complications by logistic regression and receiver-operating characteristic curves analyses.

Results

A total of 26 (14.9%) patients developed postoperative pulmonary complications, consisting of pleural effusion (10.9%), pneumonia (6.9%), pneumothorax (1.1%), atelectasis (2.3%), hypoxemia (6.3%), and respiratory failure (1.1%). Logistic regression analysis revealed that the predictive factors for postoperative pulmonary complications were age > 18.1 years (P = 0.039), a Cobb angle of > 77° (P = 0.011), operation time of > 430 min (P = 0.032), and blood transfusion volume > 1500 ml (P = 0.015).

Conclusions

Postoperative pulmonary complications are among the main complications following posterior spinal instrumentation and fusion surgery in patients with CS. Such patients aged >18.1 years, with Cobb angles > 77°, operation times > 430 min, and/or blood transfusion volume of > 1500 ml may be more likely to develop postoperative pulmonary complications.

Predictors of Postoperative Ventilation in Scoliosis Surgery: A Retrospective Analysis

Background:

Patients undergoing corrective surgery for scoliosis may require postoperative ventilation for various reasons.

Aim:

The aim was to study the correlation of preoperative (pulmonary function test [PFT], etiology, and Cobb's angle) and intraoperative factors (type of surgery, number of spinal segments involved, blood transfusion, and temperature at the end of surgery) on postoperative ventilation following scoliosis surgery.

Settings and Design:

patients' medical records of scoliosis surgery at a tertiary care center during 2010–2016 were retrospectively analyzed.

Materials and Methods:

We studied retrospectively 108 scoliosis surgeries done in our institute during this period by the same group of anesthetists using standardized anesthesia technique. We analyzed preoperative (etiology, preoperative PFT, and Cobb's angle) and intraoperative factors (type of surgery, number of spinal segments involved, blood transfusion, and temperature) influencing postoperative ventilation.

Statistical Analysis:

For all the continuous variables, the results are either given in mean ± standard deviation, and for categorical variables as a percentage. To obtain the association of categorical variables, Chi-square test was applied.

Results:

Patients with Cobb's angle above 76° and spinal segment involvement of 11 ± 3 required postoperative ventilation. Forced expiratory volume in 1 s (FEV1%) <38 and forced vital capacity (FVC%) <38.23 of the predicted could not be extubated. Increased blood transfusion and hypothermia were found to affect postoperative ventilation.

Conclusion:

Preoperative factors such as etiology of scoliosis, Cobb's angle, spirometric values FEV1% and FVC% of predicted and intraoperative factors like number of spinal segments involved, affect postoperative ventilation following scoliosis surgery. Increased blood transfusion and hypothermia are the preventable factors leading to ventilation.

Incidence, Risk Factors, and Mortality of Reintubation in Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective study of an administrative database.

OBJECTIVE

The objective was to investigate the incidence, risk factors, and mortality rate of reintubation after adult spinal deformity (ASD) surgery.

BACKGROUND DATA

There are limited data regarding the occurrence of reintubation after ASD surgery.

MATERIALS AND METHODS

The Nationwide Inpatient Sample database from 2002 to 2011 was used to identify adult patients who underwent elective surgery for scoliosis. Patients who required reintubation were identified and compared with controls (no reintubation). A multivariable logistic regression analysis was performed to identify independent factors associated with reintubation.

RESULTS

A total of 9734 patients who underwent surgery for ASD were identified, and 182 required reintubation [1.8%; 95% confidence interval (CI), 1.6%-2.1%] on average 2 days after surgery (range, 0-28 d). After multivariable analysis, the strongest independent risk factors associated with reintubation included postoperative acute respiratory failure [odds ratio (OR), 12.0; 95% CI, 8.6-16.6], sepsis (OR, 6.9; 95% CI, 3.5-13.6), and deep vein thrombosis (OR, 5.7; 95% CI, 3.0-10.9); history of chronic lung disease (OR, 1.6; 95% CI, 1.1-2.3) and fusion of 8 or more segments (OR, 1.5; 95% CI, 1.1-2.2) were also independent risk factors. Mortality rates were significantly higher in reintubated patients (7.3%) compared with that in nonreintubated patients (0.2%, P<0.001). More importantly, reintubation was an independent risk factor for inpatient mortality (OR, 9.8; 95% CI, 4.1-23.5; P<0.001).

CONCLUSIONS

The reintubation rate after ASD surgery is approximately 1.8%. Patients with a history of chronic lung disease and patients undergoing fusion of 8 or more segments may be at an increased risk for reintubation; other associated factors included acute respiratory failure, sepsis, and deep vein thrombosis. Patients who required postoperative airway management after ASD surgery were 9.8 times more likely to die during their hospital stay compared with controls.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Improving perioperative care for adolescent idiopathic scoliosis patients: the impact of a multidisciplinary care approach

The complex nature of the surgical treatment of adolescent idiopathic scoliosis (AIS) requires a wide variety of health care providers. A well-coordinated, multidisciplinary team approach to the care of these patients is essential for providing high-quality care. This review offers an up-to-date overview of the numerous interventions and safety measures for improving outcomes after AIS surgery throughout the perioperative phases of care. Reducing the risk of potentially devastating and costly complications after AIS surgery is the responsibility of every single member of the health care team. Specifically, this review will focus on the perioperative measures for preventing surgical site infections, reducing the risk of neurologic injury, minimizing surgical blood loss, and preventing postoperative complications. Also, the review will highlight the postoperative protocols that emphasize early mobilization and accelerated discharge.

Clinical Features and Outcomes of Respiratory Complications in Patients with Thoracic Hyperkyphosis

INTRODUCTION

There are few data about thoracic hyperkyphosis which focused on respiratory events and prognoses. We investigated the clinical features and outcomes of respiratory complications requiring hospitalization in patients with thoracic hyperkyphosis.

METHODS

Following a retrospective review of the medical records between 2002 and 2011, we included 51 patients with thoracic hyperkyphosis who had visited the respiratory department due to respiratory symptoms.

RESULTS

Of total 51 patients, 35 patients were hospitalized due to respiratory events. Among 56 total hospitalized events, acute respiratory failure (ARF) (n = 18) and exacerbation of a chronic airway disorder (n = 18) were the most common causes. Respiratory events related mortality was 13.7 % (7/51). The median value of the thoracic kyphosis angle was 89.0°. The ratio of the measured kyphosis angle to the normal value according to age and sex showed the median value of 2.38 (interquartile range 1.61-2.87). This ratio was negatively correlated with both predicted forced vital capacity (γ = -0.647, p < 0.0001) and predicted forced expiratory volume for 1 s (γ = -0.518, p = 0.008). After adjustments for age and sex, hyperkyphosis (angle ≥90°) was not found to influence the development of ARF (hazard ratio 3.2; 95 % confidence interval, 0.86-12.14; p = 0.082).

CONCLUSIONS

Patients with thoracic hyperkyphosis presenting to a respiratory department with respiratory issues commonly experienced respiratory events requiring hospitalization and had a poor prognosis. In addition, the severity of the kyphosis angle was correlated with respiratory insufficiency although it was not a risk factor for the development of ARF.

Non-neurologic complications following surgery for scoliosis

BACKGROUND

The purpose of this study was to determine the prevalence of non-neurologic complications following surgery for scoliosis and to identify factors that can increase this risk.

METHODS

The demographic data, medical and surgical histories, and prevalence of non-neurologic complications were reviewed in a retrospective cohort of 602 patients, who had undergone corrective surgery for scoliosis between January 2001 and June 2011.

RESULTS

There were 450 patients under 20 years old (U20) and 152 of patients above 20 years old (A20) enrolled in this study. Forty-nine patients in U20 (10.9%) and 18 patients in A20 (11.8%) had post-operative complications. Respiratory complications were most common in U20 (4%) and gastrointestinal complications were most common in A20 (7%). There was no significant difference between the 2 groups in the prevalence of complications. Logistic regression revealed that factors that correlated with an increased odds for complications were Cobb angle (P = 0.001/P = 0.013, respectively), length of operation time (P = 0.003/P = 0.006, respectively), duration of anesthesia (P < 0.001/P = 0.005, respectively) and transfusion (P = 0.003/P = 0.015, respectively) in U20 and A20. Also, comorbidities (P = 0.021) in U20, and decreased body mass index (P = 0.030), pre-operative forced vital capacity (P = 0.001), forced expired volume in 1s (P = 0.001), increased numbers of vertebrae fused (P = 0.004), blood loss (P = 0.001) in A20 were associated with increased odds for complications.

CONCLUSIONS

There was no difference in the prevalence of complication in scoliosis patients by age. The prevalence of complication was dependent on Cobb angle, length of operation time, duration of anesthesia and transfusion of PRBC. Deterioration of preoperative pulmonary function significantly increased risk of post-operative complications in adult patients.

The preoperative and intraoperative risk factors for early postoperative mechanical ventilation after scoliosis surgery: A retrospective study

BACKGROUND

Patients undergoing corrective surgery for scoliosis of spine are commonly ventilated in our institute after the operation. Postoperative mechanical ventilation (PMV) and subsequent prolongation of intensive care unit stay are associated with increase in medical expenditure and complications such as ventilator-associated pneumonia. Identification of factors which may contribute to PMV and their modification may help in allocation of resources effectively. The present study was performed to identify preoperative and intraoperative factors associated with early PMV after scoliosis surgery.

METHODS

One hundred and two consecutive patients who underwent operation for scoliosis correction between January 2006 to July 2011 were reviewed retrospectively. Patients requiring PMV included patients who were not extubated in the operating room and were continued on mechanical ventilation. Preoperative and intraoperative factors which were analysed included age, gender, weight, cardiorespiratory function, presence of kyphosis, number and level of vertebrae involved, surgical approach, whether thoracoplasty was done, duration of surgery, blood loss, fluids and blood transfused, hypothermia and use of antifibrinolytics.

RESULTS

The average age of the patients was 14.31±3.78 years with female preponderance (57.8%). Univariate analysis found that longer fusions of vertebrae (more than 8), blood loss, amount of crystalloids infused, blood transfused and hypothermia were significantly associated with PMV (P<0.05). Independent risk factors for PMV were longer fusion (Odds Ratio (OR), 1.290; 95% confidence interval (CI), 1.038-1.604) and hypothermia (OR, 0.096; 95% CI, 0.036-0.254; P<0.05).

CONCLUSION

The authors identified that longer fusions and hypothermia were independent risk factors for early PMV. Implementation of measures to prevent hypothermia may result in decrease in PMV.

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.

Neuromuscular disease and the pulmonologist

PURPOSE OF REVIEW

The heterogeneous nature of neuromuscular disorders (NMDs) continues to promote slow but steady advances in diagnosis, classification, and treatment. This review focuses on the updates in the general management and treatment of NMDs, with emphasis on key updates in muscular dystrophy, myotonic dystrophy, mitochondrial myopathy, spinal muscular atrophy, and hereditary neuropathies.

RECENT FINDINGS

Current research shows that improvements in morbidity and mortality in various NMDs may be possible. Key components include advances in identification and classification of individual NMDs; attention to anesthetic and surgical risks; aggressive pulmonary care; and implementations of a proactive, multidisciplinary, standard-of-care approach. Innovative molecular and pharmaceutical therapeutic options are being investigated in many of these disorders, but unfortunately no new intervention has borne out.

SUMMARY

Important advances were made in the last year in the field of neuromuscular disease. However, because of their heterogeneous nature and rarity, diagnosis and treatment of these disorders either as a single disorder or as a group continue to be both a clinical and a research challenge. It is of utmost importance that clinicians and researchers be aware of these disorders to aid in identification and treatment.

Characterization of pediatric patients receiving prolonged mechanical ventilation

OBJECTIVE

To describe the characteristics and risk factors of pediatric patients who receive prolonged mechanical ventilation, defined as ventilatory support for >21 days.

DESIGN

Prospective cohort.

SETTING

Four medical-surgical pediatric intensive care units in four university-affiliated hospitals in Argentina.

PATIENTS

All consecutive patients from 1 month to 15 yrs old admitted to participating pediatric intensive care units from June 1, 2007, to August 31, 2007, who received mechanical ventilation (invasive or noninvasive) for >12 hrs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographic and physiologic data on admission to the pediatric intensive care units, drugs and events during the study period, and outcomes were prospectively recorded. A total of 256 patients were included. Of these, 23 (9%) required mechanical ventilation for >21 days and were assigned to the prolonged mechanical ventilation group. Patients requiring prolonged mechanical ventilation had higher mortality (43% vs. 21%, p < .05) and longer pediatric intensive care unit stay: 35 days [28-64 days] vs. 10 days [6-14]). There was no difference between the groups in age and gender distribution, reasons for admission, incidence of immunodeficiencies, or Paediatric Index of Mortality 2 score. The only difference at admission was a higher rate of genetic diseases in prolonged mechanical ventilation patients (26% vs. 9%, p < .05). There was a higher incidence of septic shock (87% vs. 34%, p < .01), acute respiratory distress syndrome (43% vs. 20%, p < .01), and ventilator-associated pneumonia (35% vs. 8%, p < .01) and higher utilization of dopamine (78% vs. 42%, p < .01), norepinephrine (61% vs. 15%, p < .01), multiple antibiotics (83% vs. 20%, p < .01), and blood transfusions (52% vs. 14%, p < .01). The proportion of extubation failure was higher in the prolonged mechanical ventilation group with similar rates of unplanned extubations in both groups. Variables remaining significantly associated with prolonged mechanical ventilation after multivariate analysis were treatment with multiple antibiotics, septic shock, ventilator-associated pneumonia, and use of norepinephrine.

CONCLUSIONS

Patients with prolonged mechanical ventilation have more complications and require more pediatric intensive care unit resources. Mortality in these patients duplicates that from those requiring shorter support.

Value of preoperative pulmonary function test in flaccid neuromuscular scoliosis surgery

STUDY DESIGN

Retrospective study.

OBJECTIVE

To evaluate the prognostic value of preoperative pulmonary function test (PFT) for postoperative pulmonary complications and to identify the operability associated with severely decreased forced vital capacity (FVC) (<30%) status in flaccid neuromuscular scoliosis.

SUMMARY OF BACKGROUND DATA

The preoperative PFT, especially more than 30% FVC, is known as a critical factor for the operability of flaccid neuromuscular scoliosis. But only one study reported that patients with pre-existing respiratory failure on nocturnal noninvasive ventilation can undergo an operation for deformity correction without mortality and severe complications.

METHODS

A total of 74 patients (45 male and 29 female) presented with flaccid neuromuscular scoliosis. For all patients, preoperative PFTs were evaluated and subdivided into three groups (<30% FVC, 30%-50% FVC, and >50% FVC). Then postoperative pulmonary complications, pneumothorax, pneumonia, atelectasis, prolonged ventilator care in the intensive care unit (more than 72 hours), and postoperative tracheostomy were evaluated.

RESULTS

Among these patients, 59 had muscular dystrophy; 5, spinal muscular atrophy; 2, cerebral palsy; and 8, others. The mean age at surgery was 16.8 years (range, 5-32 years). The mean preoperative Cobb angle was 54.6° (16°-135°). The overall postoperative pulmonary complication rate was 31% (23 complications in 74 patients). The less than 30% FVC group had 6 complications among 18 patients; the 30% to 50% FVC group had 7 complications among 18 patients; and the more than 50% FVC group had 10 complications among 38 patients. There were no deaths during the perioperative period. There is no statistical difference between the three groups (P = 0.6195).

CONCLUSION

Patients with flaccid neuromuscular scoliosis can undergo an operation for deformity correction regardless of the severely decreased pulmonary function.

Risk factors for major complications after surgery for neuromuscular scoliosis

STUDY DESIGN

Retrospective, case series.

OBJECTIVE

To determine the prevalence of major complications and to identify factors that increase the risk of complications in patients undergoing surgery for neuromuscular scoliosis.

SUMMARY OF BACKGROUND DATA

Complications after surgery for neuromuscular scoliosis are more prevalent than in idiopathic scoliosis. However, the associated risk factors have not been statistically significant.

METHODS

Our computerized Pediatric Orthopedic Spine Database identified 131 consecutive patients with neuromuscular scoliosis, excluding those with myelodysplasia, who underwent surgery and had a minimum of 2 years of follow-up. Preoperative, intraoperative, and postoperative factors were analyzed for any association with major complications and length of stay using stepwise logistic and multiple regression analyses. Odds ratios were calculated for significant dichotomous variables, and receiver operator characteristic curves were created for significant continuous variables.

RESULTS

There were 81 male and 50 female patients with a mean age at surgery of 13.4 years (range, 6-21 years). The majority of patients (n = 75) had cerebral palsy. Eighty-eight patients (67%) underwent posterior spinal fusion and segmental spinal instrumentation (only), whereas 43 patients (33%) underwent an anterior spinal fusion followed by a posterior spinal fusion with segmental spinal instrumentation. Seventy-seven patients (59%) were fused to the pelvis using the Galveston technique. The mean follow-up was 3.9 years (range, 2-16.9 years). There were 46 major complications in 37 patients (28% prevalence), including 2 deaths.Nonambulatory status (P < 0.05) and preoperative curve magnitude (P < 0.01) were associated with an increased prevalence of major complications. Nonambulatory patients (n = 94) were almost 4 times more likely to have a major complication (odds ratio of 3.8, P < 0.05) in comparison with ambulatory patients. A preoperative major curve magnitude of ≥ 60° (P < 0.01) was the most accurate indicator for an increased risk for a major complication.

CONCLUSION

Nonambulatory status and a preoperative curve magnitude (≥ 60°) are directly associated with an increased risk for major complications and indirectly associated with increased length of stay. As such, we recommend operative intervention in neuromuscular scoliosis before curve progression to ≥ 60°. Level of Evidence. Level III.

Preoperative predictors of postoperative pulmonary complications in neuromuscular scoliosis

BACKGROUND

Neuromuscular scoliosis (NMS) is associated with progressive restrictive lung disease and an increased risk of prolonged ventilation following surgery. This study reports the experiences of a single institution and evaluates whether preoperative pulmonary function tests (PFT) can predict the development of postoperative pulmonary complications.

METHODS

Correlations between preoperative PFT (forced expired volume in 1 s, FEV(1); forced vital capacity, FVC) findings and postoperative pulmonary complications were searched for among 74 NMS patients who underwent surgical correction at our medical center from 2002 to 2008.

RESULTS

Thirty-seven patients (50%) developed a pulmonary complication. The independent factors found to contribute to the development of a pulmonary complication were: FEV(1) <40% of the predicted value (P = 0.007), FVC <39.5% of the predicted value (P = 0.005), a larger Cobb angle (>69°) (P = 0.002), and older age (>16.5 years) (P = 0.027). Of these 37 patients, 6 needed postoperative ventilation. PFT findings found to be independently associated with the need for postoperative ventilation were: FEV(1) <40% of the predicted value (P = 0.017) and FVC <39.5% of the predicted value (P = 0.015).

CONCLUSIONS

NMS patients with a preoperative FVC of <39.5% of the predicted value, an FEV(1) <40% of the predicted value, a Cobb angle of >69°, or age >16.5 years were found to be more likely to develop a postoperative pulmonary complication.

Evaluation of high-risk patients undergoing spinal surgery: a matched case series

BACKGROUND

Neuromuscular (NM) spinal deformities necessitating surgical intervention present a difficult challenge to the medical community. Underlying comorbidities lead to extended hospital stays, significant complications, and social challenges in the extensive perioperative period. In response to this problem, a therapeutic algorithm, the Care Pathway for Spinal Surgery (CAPSS) has been developed at our institution to address this complex medical issue.

METHODS

In 1999, a multidisciplinary team developed a treatment protocol, CAPSS, that emphasized perioperative work up and operative scheduling under the direction of a dedicated care coordinator. A case series analysis was conducted to compare the surgical outcomes from before and after CAPSS implementation. Statistical analyses were performed on a carefully paired subset of NM patients (N=9). Outcome measures were hospital length of stay (LOS), pediatric intensive care unit LOS, number of days intubated, surgical estimated blood loss, postoperative curve magnitude, percent curve correction, and perioperative complications.

RESULTS

Statistical analyses indicated that the use of CAPSS provided significant reduction in overall LOS, pediatric intensive care unit LOS, and perioperative complication rate within this patient group.

CONCLUSIONS

CAPSS is an effective method to improve perisurgical care within the NM patients with spinal deformity necessitating operative stabilization.

LEVEL OF EVIDENCE

III-Retrospective comparative study.

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.

New strategies and decision making in the management of neuromuscular scoliosis

The outcome of spinal fusion in neuromuscular scoliosis demonstrates a consistently high satisfaction rate among parents and caretakers. It is somewhat more difficult to determine the functional benefits in individual patients, especially in those with the most severe involvement. Even in those children, a predicted 70% survival rate at 11 years has been documented following surgery. Scoliosis is common in children with neuromuscular diseases, especially cerebral palsy. Most of these children need stabilization to enhance their quality of life by improving sitting ability. Studies continue to show a high family satisfaction and caregiver satisfaction following spine reconstructive surgery for neuromuscular scoliosis and other spine deformities.

Spinal fusion surgery in children with non-idiopathic scoliosis: is there a need for routine postoperative ventilation?

BACKGROUND

The perioperative management of children with non-idiopathic scoliosis undergoing spinal deformity surgery has not been standardized and the current practice is to routinely ventilate these patients in the postoperative period. This study reports the experience from a single institution and evaluates the need and reasons for postoperative ventilation. Details of ventilated patients are presented.

METHODS

All patients undergoing spinal fusion surgery for non-idiopathic scoliosis were recorded prospectively (2003-4). Patients were anaesthetized according to a standardized technique. Physical characteristics, cardiopulmonary function, intraoperative blood loss and fluid requirement, postoperative need for ventilation and all perioperative adverse events were recorded on a computer database.

RESULTS

A total of 76.2% of patients were safely extubated at the end of surgery without any further complications or need for re-ventilation; 23.8% of patients required postoperative ventilation with half of the cases being planned before operation and 40% of all patients with Duchenne muscular dystrophy (DMD) required postoperative ventilation. There were no specific factors that could predict the need for postoperative ventilation, although an increased tendency for children with DMD and those with a preoperative forced vital capacity <30% towards requiring postoperative ventilation was observed.

CONCLUSIONS

Early extubation can be safely performed after spinal deformity surgery for non-idiopathic scoliosis. The use of short-acting anaesthetics, drugs to reduce blood loss, experienced spinal anaesthetists and the availability of intensive care support are all essential for a good outcome in patients with neuromuscular disease and cardiopulmonary co-morbidity.