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

Is Minimally Invasive Bipolar Technique a Better Alternative to Long Fusion for Adult Neuromuscular Scoliosis?

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

To report the results for an alternative technique based on minimally invasive fusion-less surgery. This approach is original in that it corrects deformities by proximal and distal fixation, with reliable pelvic fixation through the use of iliosacral screws on osteoporotic bones.

METHODS

Adult cerebral palsy patients requiring spinal correction surgery were included prospectively between 2015 and 2019. The technique involved the use of a double-rod construct anchored proximally by four clawed hooks and distally by iliosacral screws, in a minimally invasive approach. Cobb angle and pelvic obliquity were measured before and after initial surgery and at final follow-up. Complications and functional results were reviewed. This group (P) was compared with a second group (R) of patients who underwent surgery between 2005 and 2015, for whom data were collected retrospectively.

RESULTS

Thirty-one patients were included in group P, and 15 in group R. The two groups were comparable for demographic data and deformity. At most recent follow-up (3 years for group P [2-6] and 5 years for group R [2-16]), neither correction nor surgical complications differed between the two groups. However, group P had 50% less blood loss and a lower medical complication rate than group R.

CONCLUSIONS

Our results confirm the effectiveness of this minimally invasive technique for neuromuscular scoliosis in adults. The results were similar to those obtained with the usual techniques, but with fewer medical complications. Confirmation of these results is now required for a longer follow-up period.

Explainable Machine Learning Approach to Prediction of Prolonged Intesive Care Unit Stay in Adult Spinal Deformity Patients: Machine Learning Outperforms Logistic Regression

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Prolonged ICU stay is a driver of higher costs and inferior outcomes in Adult Spinal Deformity (ASD) patients. Machine learning (ML) models have recently been seen as a viable method of predicting pre-operative risk but are often 'black boxes' that do not fully explain the decision-making process. This study aims to demonstrate ML can achieve similar or greater predictive power as traditional statistical methods and follows traditional clinical decision-making processes.

METHODS

Five ML models (Decision Tree, Random Forest, Support Vector Classifier, GradBoost, and a CNN) were trained on data collected from a large urban academic center to predict whether prolonged ICU stay would be required post-operatively. 535 patients who underwent posterior fusion or combined fusion for treatment of ASD were included in each model with a 70-20-10 train-test-validation split. Further analysis was performed using Shapley Additive Explanation (SHAP) values to provide insight into each model's decision-making process.

RESULTS

The model's Area Under the Receiver Operating Curve (AUROC) ranged from 0.67 to 0.83. The Random Forest model achieved the highest score. The model considered length of surgery, complications, and estimated blood loss to be the greatest predictors of prolonged ICU stay based on SHAP values.

CONCLUSIONS

We developed a ML model that was able to predict whether prolonged ICU stay was required in ASD patients. Further SHAP analysis demonstrated our model aligned with traditional clinical thinking. Thus, ML models have strong potential to assist with risk stratification and more effective and cost-efficient care.

Adoption of an Enhanced Recovery after Surgery Protocol for Neuromuscular Scoliosis Shortens Length of Hospital Stay

Introduction

We aimed to implement the enhanced recovery after surgery (ERAS) protocol for pediatric neuromuscular scoliosis (NMS) surgery and to examine the effectiveness of this program in this study.

Methods

Subjects were children with NMS who underwent scoliosis surgery at our department by a surgeon using a single posterior approach. A series of 27 cases before the introduction of ERAS and 27 cases during program stabilization were included in the study. Patient backgrounds did not show significant differences before and after introducing ERAS. Perioperative data, complications, length of hospital stay (LOS), and readmission within 90 days were investigated and statistically analyzed.

Results

When the pre- and post-ERAS induction groups were compared, no significant differences in anesthesia induction time (p=0.979), pelvic fixation (p=0.586), fusion levels (p=0.479), intraoperative hypothermia duration (p=0.154), end-of-surgery body temperature (p=0.197), operative time (p=0.18), postoperative main Cobb angle (p=0.959), main Cobb angle correction rate (p=0.91), postoperative spino-pelvic obliquity (SPO) (p=0.849), and SPO correction rate (p=0.267) were observed. However, significant differences in using V-flap technique (p=0.041), intraoperative blood loss (p=0.001), and LOS (p=0.001) were observed. Intraoperative blood loss was weakly correlated with LOS (p=0.432 and 0.001). No statistically significant difference existed between the V-flap method and LOS (p=0.265). Multiple regression analysis using LOS as the objective variable and ERAS protocols and intraoperative blood loss as explanatory variables revealed that the effect of ERAS on LOS was greater than that of intraoperative blood loss. No statistically significant differences in the readmission rates within 90 days were found.

Conclusions

After the introduction of ERAS, LOS decreased without an increase in complications or readmissions within 90 days.

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

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

Nomogram for predicting postoperative pulmonary complications in spinal tumor patients

OBJECTIVES

Although several independent risk factors for postoperative pulmonary complications (PPCs) after spinal tumor surgery have been studied, a simple and valid predictive model for PPC occurrence after spinal tumor surgery has not been developed.

PATIENTS AND METHODS

We collected data from patients who underwent elective spine surgery for a spinal tumor between 2013 and 2020 at a tertiary hospital in China. Data on patient characteristics, comorbidities, preoperative examinations, intraoperative variables, and clinical outcomes were collected. We used univariable and multivariable logistic regression models to assess predictors of PPCs and developed and validated a nomogram for PPCs. We evaluated the performance of the nomogram using the area under the receiver operating characteristic curve (ROC), calibration curves, the Brier Score, and the Hosmer-Lemeshow (H-L) goodness-of-fit test. For clinical use, decision curve analysis (DCA) was conducted to identify the model's performance as a tool for supporting decision-making.

RESULTS

Among the participants, 61 (12.4%) individuals developed PPCs. Clinically significant variables associated with PPCs after spinal tumor surgery included BMI, tumor location, blood transfusion, and the amount of blood lost. The nomogram incorporating these factors showed a concordance index (C-index) of 0.755 (95% CI: 0.688-0.822). On internal validation, bootstrapping with 1000 resamples yielded a bias-corrected area under the receiver operating characteristic curve of 0.733, indicating the satisfactory performance of the nomogram in predicting PPCs. The calibration curve demonstrated accurate predictions of observed values. The decision curve analysis (DCA) indicated a positive net benefit for the nomogram across most predicted threshold probabilities.

CONCLUSIONS

We have developed a new nomogram for predicting PPCs in patients who undergo spinal tumor surgery.

Tranexamic Acid in Hip Reconstructions in Children with Cerebral Palsy: A Double-Blind Randomized Controlled Clinical Trial

Surgical treatment is indicated for hip dislocation in patients with cerebral palsy (CP), but it requires care due to the state of nutrition and associated clinical comorbidities. The use of resources that minimize blood loss and the need for blood transfusions are essential to avoid complications. Tranexamic acid (TXA) has been highlighted for orthopedic surgeries to control intraoperative bleeding; however, there is a lack of large studies for its use in hip surgeries in patients with CP. This study aims to evaluate the efficacy and safety of tranexamic acid to reduce bleeding in pediatric patients with cerebral palsy undergoing surgical treatment for hip instability. A sample of 31 patients with CP who underwent surgical treatment for hip dislocation (hip adductor stretching, varization osteotomy of the proximal femur and acetabuloplasty using the Dega technique) was randomly divided into groups: control (n = 10) and TXA (n = 21). Preoperative and 24 h hemoglobin concentrations, the length of hospital stay (LHS), and intraoperative bleeding (IB) were analyzed. TXA significantly reduced the IB (p = 0.02). The variance in hemoglobin concentration was lower for the TXA group, but without statistical significance (p = 0.06). There was no difference in LHS. Also, no statistical difference was observed for the number of transfusions (p = 0.08). The findings provide evidence of the effectiveness of TXA in decreasing intraoperative bleeding and its safety for use in pediatric patients with cerebral palsy.

Surgical Outcomes of Cerebral Palsy Patients With Scoliosis and Lumbar Hyperlordosis: A Comparative Analysis With 2-year Minimum Follow-up

STUDY DESIGN

Retrospective review of a prospectively collected multicenter database.

OBJECTIVE

To compare outcomes of patients with cerebral palsy (CP) who undergo surgery for scoliosis with normal lordosis (NL) versus hyperlordosis.

SUMMARY OF BACKGROUND DATA

Surgical correction of scoliosis with lumbar hyperlordosis is challenging. Hyperlordosis may confer higher perioperative morbidity, but this is not well understood.

MATERIALS AND METHODS

A multicenter database was queried for CP patients who underwent surgery from 2008 to 2017. The minimum follow-up was 2 years. Two groups were identified: lumbar lordosis <75° (NL) versus ≥ 75° hyperlordosis (HL). Perioperative, radiographic, and clinical outcomes were compared.

RESULTS

Two hundred seventy-five patients were studied: 236 NL and 39 HL (-75 to -125°). The mean age was 14.1 years, and 52.4% were male. Patients with hyperlordosis had less cognitive impairment (76.9% vs. 94.0%, P =0.008) and higher CPCHILD scores (59.4 vs. 51.0, P =0.003). Other demographics were similar between the groups. Patients with hyperlordosis had greater lumbar lordosis (-90.5 vs. -31.5°, P <0.001) and smaller sagittal vertical axis (-4.0 vs. 2.6 cm, P <0.001). Patients with hyperlordosis had greater estimated blood loss (2222.0 vs. 1460.7 mL, P <0.001) but a similar perioperative complication rate (20.5% vs. 22.5%, P =0.787). Significant correction of all radiographic parameters was achieved in both groups. The HL group had postoperative lumbar lordosis of -68.2° and sagittal vertical axis of -1.0 cm. At a 2-year follow-up, patients with hyperlordosis continued to have higher CPCHILD scores and gained the greatest benefit in overall quality of life measures (20.0 vs. 6.1, P =0.008). The reoperation rate was 10.2%: implant failure (3.6%), pseudarthrosis (0.7%), and wound complications (7.3%). There were no differences in the reoperation rate between the groups.

CONCLUSION

Surgical correction of scoliosis with hyperlordosis is associated with greater estimated blood loss but similar radiographic results, perioperative morbidity, and reoperation rate as normal lordosis. Patients with hyperlordosis gained greater overall health benefits. Correction of ≥25% of hyperlordosis seems satisfactory.

LEVEL OF EVIDENCE

3.

The different applications of Vertebral Body Tethering - Narrative review and clinical experience

Background

Vertebral body tethering (VBT) has been originally developed as a growth modulation technique for the surgical management of skeletally immature patients with adolescent idiopathic scoliosis (AIS). Given the positive results obtained in this setting, the use of VBT is gradually expanding to other patient categories, such as those with no or limited remaining growth or with non-idiopathic scoliosis. Aim of this manuscript is to offer an overview over the current applications of VBT, along with imaging and comments derived from the clinical experience. The work was based on a literature search conducted in January 2023 on Pubmed, Scopus and Web of Science databases. Following keywords were used for the search: vertebral body tethering, adolescent idiopathic scoliosis, early onset scoliosis, neuromuscular scoliosis, syndromic scoliosis.

Results

Three patient categories in which VBT has been applied have been highlighted: VBT for growth modulation in AIS, VBT as anterior scoliosis correction in AIS and VBT for non-idiopathic curves or early-onset scoliosis.

Conclusion

While growth modulation in AIS still represents the most widespread use of VBT, the use of this technique has yielded positive results in different settings as well, such as scoliosis correction in AIS or temporary or definitive curve management in non-AIS curves. While long-term results are lacking, patient selection seems to play a central role to reduce the complication rate and ensure predictable and stable results.

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

Objective

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

Methods

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

Results

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

Conclusions

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

Definitive fusions are better than growing rod procedures for juvenile patients with cerebral palsy and scoliosis: a prospective comparative cohort study

PURPOSE

This study compared the outcomes of juvenile patients with cerebral palsy (CP) and scoliosis who underwent spinal fusion (SF) versus growing rod (GR) surgery.

METHODS

Two prospective multicenter registries were queried for patients 8-10 years old with minimum 2-year follow-up who underwent SF or GR surgery (no MCGR). Demographics, radiographs, complications, and outcome scores were recorded.

RESULTS

There were 35 patients in the SF and 15 in the GR group. The mean age at surgery was 10 and 9.3 years in the SF and GR groups, respectively (p = 0.004). In the SF group preoperatively, the major curve measured 86° and 80° in the GR group (p = 0.40). "Definitive" surgery in the GR group consisted of SF in 10, implant retention in three, and implant removal in two. The SF group had 60.8% and the GR group had 45.0% correction following "definitive" surgery (p = 0.03). In the SF group, 8 patients and in the GR group, 9 patients (SF = 22.9%, GR = 60.0%) had a complication (p = 0.01). In the SF group, two patients (5.7%) had reoperations for infection; eight patients (53.3%) in the GR group had reoperations for infection and implant complications (p < 0.001). In the SF group, 23/30 parents (76.6%) noted that the child's life "improved a lot." In the GR group, 3/6 parents (50.0%) noted they were "neutral" about their child's ability to do things, 2/6 (33.3%) were "very dissatisfied."

CONCLUSIONS

SF treatment for juvenile patients with CP and scoliosis resulted in fewer complications and unplanned reoperations and better radiographic outcomes compared with GR. Quality of life improvements were also better in the SF group.

LEVEL OF EVIDENCE

Level III.

In-hospital complications after cervical fusion in cases with versus without cerebral palsy

Background

Patients with cerebral palsy (CP) are at increased risk for cervical spine pathology. Cervical fusion surgery may be considered in this population, but perioperative outcomes relative to patients without CP remains poorly understood. The purpose of this study was to compare in-hospital complications after cervical fusion in patients with versus without cerebral palsy (CP) using a retrospective cohort design.

Methods

Cervical fusion cases with and without CP were identified in the National Inpatient Sample (NIS) database. In-hospital adverse events were tabulated and grouped into any (AAE), serious (SAE), and minor adverse events (MAE). Length of hospital stay (LOS) and mortality were assessed. Multiple logistic regression models with and without 1:1 propensity matching were used to compare outcomes between cases with and without CP, controlling for demographic and preoperative variables.

Results

After weighting, 1,518,012 cases were included in the study population, of which 4,554 (0.30%) had CP. Those with CP were younger, more often male, suffered more comorbidities, more frequently operated on from a posterior or combined approach, and were more frequently addressed at more than one level. By multiple logistic regression after matching, CP cases had higher odds of AAE (OR 1.72; 95% CI 1.05-2.81; p=0.030) and MAE (OR 2.07; 95% CI 1.20-3.57; p=0.009), but no differences in odds of SAE or in-hospital mortality.

Conclusions

As there is increasing awareness of potentially cervical pathology in the CP population, the current study suggests that surgical intervention for this population can be appropriately considered without severe in-hospital morbidity or mortality.

Surgical Strategies and Perioperative Considerations for Cervical Deformity With Cerebral Palsy: A Comprehensive Review of the Literature

The complex nature of the cervical spine makes surgical intervention challenging when treating cervical deformity in patients with cerebral palsy (CDCP). However, few studies have investigated the unique characteristics of cerebral palsy that create the need for surgery, the most effective surgical strategies, and the possible perioperative complications. The intended benefit and the potential risk of postoperative complications must be considered when deciding to operate for CDCP. Because the approach and correction strategy depend on the type of cervical deformity, as well as the patient's comorbidities and functional status, a customized strategy is needed. Perioperatively, botulinum toxin injections and muscle division techniques can help control excessive involuntary movements and improve the spinal fusion success rate. Surgical intervention for CDCP requires a multidisciplinary approach, and the information presented in this article is intended to help in the perioperative management and surgical treatment of CDCP.

Does Routine Subspecialty Consultation Before High-Risk Pediatric Spine Surgery Decrease the Incidence of Complications?

BACKGROUND

Children with neuromuscular disorders and syndromic scoliosis who require operative treatment for scoliosis are at increased risk for postoperative complications. Complications may include surgical site infection and pulmonary system problems including respiratory failure, gastrointestinal system disorders, and others. The purpose of our study was to determine the effect of a standardized perioperative pathway specifically designed for management of high-risk pediatric patients undergoing surgery for scoliosis.

METHODS

The High-Risk Protocol (HRP) at our institution is a multidisciplinary process with subspecialty consultations before scoliosis surgery. This was a retrospective chart and radiographic review at a single institution. Inclusion criteria were high-risk subjects, age 8 to 18 years old, who underwent surgery between January, 2009 and April, 2009 with a minimum 2-year follow-up. Diagnoses included neuromuscular scoliosis or Syndromic scoliosis.

RESULTS

Seventy one subjects were analyzed. The mean age was 13 (±2 SD) years. Follow-up was 63 (±24 SD) months. The study group consisted of 35 subjects who had fully completed the HRP and the control group consisted of 36 subjects who did not. Nine of the 35 (26%) subjects in the HRP had surgery delayed while interventions were performed. Compared with controls, the study group had larger preoperative and postoperative curve magnitudes: 90 versus 73 degrees ( P =0.002) and 35 versus 22 degrees ( P =0.001). Pulmonary disease was more common in the HRP, 60 versus 31% ( P =0.013). The overall incidence of complications in the study group was 29% (10 of 35 subjects) and for controls 28% (10 of 36). There were no differences between groups for types of complications or Clavien-Dindo grades. Three subjects in the study group and 1 in the controls developed surgical site infection. Eleven subjects required unplanned reoperations during the study period.

CONCLUSIONS

The findings of our study suggest a structured pathway requiring routine evaluations by pediatric subspecialists may not reduce complications for all high-risk pediatric spine patients. Selective use of consultants may be more appropriate.

LEVEL OF EVIDENCE

Level III, Retrospective Cohort study.

Barriers to Discharge After Hip Reconstruction Surgery in Non-ambulatory Children With Neurological Complex Chronic Conditions

BACKGROUND

Hip reconstruction surgery in patients with neurological complex chronic conditions (CCC) is associated with prolonged hospitalization and extensive resource utilization. This population is vulnerable to cognitive, developmental, and medical comorbidities which can increase length of stay (LOS). The aims of this study were to characterize barriers to discharge for a cohort of children with neurological CCC undergoing hip reconstruction surgery and to identify patient risk factors for prolonged hospitalization and delayed discharge.

METHODS

Retrospective chart review of nonambulatory patients with neurological CCC undergoing hip reconstruction surgery between 2007-2016 was conducted. Hospitalization ≥1 day past medical clearance was characterized as delayed discharge. Barriers were defined as unresolved issues at the time of medical clearance and categorized as pertaining to the caregiver and patient education, durable medical equipment, postdischarge transportation/placement, and patient care needs.

RESULTS

The cohort of 116 patients was 53% male, 16% non-English speaking, and 49% Gross Motor Function Classification System (GMFCS) V with the mean age at surgery of 9.1±3.64 years. Median time from admission to medical clearance was 5 days with median LOS of 6 days. Approximately three-quarters of patients experienced delayed discharge (73%) with barriers identified for 74% of delays. Most prevalent barriers involved education (30%) and durable medical equipment (29%). Postdischarge transportation and placement accounted for 26% of barriers and 3.5 times longer delays ( P <0.001). Factors associated with delayed discharge included increased medical comorbidities ( P <0.05) and GMFCS V ( P <0.001). Longer LOS and medical clearance times were found for female ( P =0.005), older age ( P <0.001), bilateral surgery ( P =0.009), GMFCS V ( P =0.003), and non-English-speaking patients ( P <0.001).

CONCLUSIONS

Patients with neurological CCC frequently encounter postoperative barriers contributing to increased LOS and delayed discharge. Patients that may be at higher risk for prolonged hospitalization and greater resource utilization include those who are female sex, adolescent, GMFCS V, non-English speaking, have additional comorbidities, and are undergoing bilateral surgery. Standardized preoperative assessment of educational needs, perioperative equipment requirements, and posthospital transportation may decrease the LOS, reduce caregiver and patient burden/distress, cost, and ultimately reduce variation in care delivery.

LEVEL OF EVIDENCE

Level III, Retrospective Case Series.

Predictors of postoperative systemic inflammatory response syndrome after scoliosis surgery in adolescents with cerebral palsy: A retrospective analysis

Background

Systemic inflammatory response syndrome (SIRS) is known to complicate postsurgical intensive care patients. We noticed that roughly half children with cerebral palsy who undergo posterior spinal fusion (PSF) for neuromuscular scoliosis developed SIRS in the intensive care unit. There is a paucity of literature detailing the impact of intraoperative causes of postoperative SIRS and downstream consequences in these patients. Study purpose was to understand the factors associated with SIRS in children who undergo PSF for neuromuscular scoliosis.

Methods

This retrospective, case control study included children who underwent PSF for neuromuscular scoliosis. Patients with idiopathic scoliosis, osteogenesis imperfecta, and tracheotomy were excluded. Subjects were divided into two study groups based on the diagnosis of SIRS in the intensive care unit. Descriptive statistical analysis was used to identify factors associated with SIRS; a regression analysis was used to further evaluate the independent and significant influence of these factors.

Results

There was no significant difference in the demographic and other preoperative variables. However, total blood products (ml/kg) administered was significantly higher among the SIRS group compared with the non-SIRS group (54.4±41.0 vs 34.1±21.5 P <0.034). Percent of patients remaining intubated was greater in the SIRS group compared with the non-SIRS group (44.1% vs 7.0%, P < 0.001). The regression model revealed that the odds to develop SIRS in patients who were not extubated were 7.467-fold higher (CI: 1.534-36.347) compared with those who were extubated (p=0.013).

Conclusions

The incidence of SIRS is significantly higher among the patients who were not extubated at the end of PSF surgery. Further prospective studies are needed to look at the factors that impede the ability to extubate these patients at the end of surgery.

Spinal Fusion in Pediatric Patients With Low Bone Density: Defining the Value of DXA

BACKGROUND

Children with medical complexity are at increased risk of low bone mineral density (BMD) and complications after spinal fusion compared with idiopathic scoliosis patients. Our aim was to compare treatments and outcomes of children with medical complexity undergoing spinal fusion in those who had dual-energy x-ray absorptiometry (DXA) scans versus those who did not in an effort to standardize the workup of these patients before undergoing spinal surgery.

METHODS

We conducted a retrospective review of patients with low BMD who underwent spinal fusion at a tertiary care pediatric hospital between 2004 and 2016. We consulted with a pediatric endocrinologist to create standard definitions for low BMD to classify each subject. Regardless of DXA status, all patients were given a clinical diagnosis of osteoporosis [at least 2 long bone or 1 vertebral pathologic fracture(s)], osteopenia (stated on radiograph or by the physician), or clinically low bone density belonging to neither category. The last classification was used for patients whose clinicians had documented low bone density not meeting the criteria for osteoporosis or osteopenia. Fifty-nine patients met the criteria, and 314 were excluded for insufficient follow-up and/or not meeting a diagnosis definition. BMD Z -scores compare bone density ascertained by DXA to an age-matched and sex-matched average. Patients who had a DXA scan were also given a DXA diagnosis of low bone density (≤-2 SD), slightly low bone density (-1.0 to -1.9 SD), or neither (>-1.0 SD) based on the lowest BMD Z -score recorded.

RESULTS

Fifty-nine patients were analyzed. Fifty-four percent had at least 1 DXA scan preoperatively. Eighty-one percent of DXA patients received some form of treatment compared with 52% of non-DXA patients ( P =0.03).

CONCLUSIONS

Patients referred for DXA scans were more likely to be treated for low BMD, although there is no standardized system in place to determine which patients should get scans. Our research highlights the need to implement clinical protocols to optimize bone health preoperatively.

LEVEL OF EVIDENCE

Level II-retrospective prognostic study.

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.

Transition of Caregiver Perceptions after Pediatric Neuromuscular Scoliosis Surgery

Introduction

Spinal fusion for children with neuromuscular scoliosis has been known to improve sitting balance and quality of life as well as for high caregiver satisfaction. However, most studies performed were single surveys, and it remains unclear whether high satisfaction levels are maintained. Thus, in this article, we report the short- and medium-term improvements in caregiver standing assessment after neuromuscular scoliosis surgery in children with Gross Motor Function Classification System (GMFCS) level IV or V.

Methods

In total, 18 patients with GMFCS levels IV and V were included in this study. The underlying diseases were typical cerebral palsy in 12 cases, chromosomal abnormalities in 5 cases, and congenital myopathy in 1 case. The median age at the time of surgery was 14.5 years. The medians for the first and second follow-up surveys were after 1.4 and 5.9 years, respectively. All the patients had undergone posterior spinal fusion, whereas 12 had undergone pelvic fixation. These patients were assessed using a caregiver questionnaire, in addition to patient demographic data and radiographic assessments.

Results

The median BMI was 15.4 kg/m² preoperatively, 16.6 kg/m² at the first survey, and 17.1 kg/m² at the second survey. The main Cobb angles were 97.5°, 36.5°, and 37.0° and the spino-pelvic obliquity angles were 22.5°, 6.0°, and 6.5° preoperatively, at the first survey and at the second survey, respectively. In the questionnaire, most domains were rated similarly in the first and second surveys, but the ratings for the “children's QOL” and “digestion and defecation” domains were noted to increase, while that for the “transfer” and “satisfaction with treatment” domains have decreased.

Conclusions

Neuromuscular scoliosis surgery in children has been associated with extremely high treatment satisfaction in the early postoperative period. However, some caregivers showed a decline in the “transfer” and “treatment satisfaction” domains over time.

CLINICAL OUTCOMES OF PATIENTS UNDERGOING CORRECTION OF NEUROMUSCULAR SCOLIOSIS WITH A CONTROLLED HOSPITAL PROTOCOL – PRELIMINAR OUTCOMES

ABSTRACT Objectives: To identify the main hospital outcomes of patients undergoing surgical correction of neuromuscular scoliosis and to assess complication rates and achievement of mobility goals after the use of a managed protocol. Methods: This is a longitudinal, retrospective study, with data obtained six months after the application of a protocol in 103 patients of both sexes submitted to surgical correction of neuromuscular scoliosis, at a tertiary level hospital in São Paulo, between June and December 2018 (pre-protocol) and between May and September 2019 (post-protocol). Data from patients who had previously undergone other orthopedic spine surgeries were excluded. In addition to the data for epidemiological characterization of the underlying diseases, the clinical characteristics and complications were analyzed. Results: Of the 103 patients evaluated, there was a predominance of females (53.4%) and a mean age of 14.9 years. The most frequent diagnosis was cerebral palsy, the mean angle of curvature was 75°, and the most frequently observed comorbidities were lung diseases (25%). The protocol was partially adhered to by professionals and after its implementation, there was a significant decrease in pain and the systemic inflammatory response syndrome (SIRS), prevention of immobility and a low rate of infection. Conclusions: The use of a protocol focused on patients undergoing correction of neuromuscular scoliosis led to reduced complications of SIRS and reduced pain; kept the surgical site infection rate low, and prevented short-term immobility. Level of evidence III; Retrospective study.

Comparative cost-utility analysis of postoperative discharge pathways following posterior spinal fusion for scoliosis in non-ambulatory cerebral palsy patients

PURPOSE

Accelerated postoperative discharge (AD) pathways have demonstrated numerous benefits for patients with adolescent idiopathic scoliosis undergoing PSF. Although early evidence supports the application of AD pathways over more traditional discharge (TD) approaches for patients with neuromuscular scoliosis, the economic impact of these pathways has not been investigated.

METHODS

A decision-analysis model was constructed using a hypothetical 15-year-old male with non-ambulatory CP with a 65-degree thoracolumbar scoliosis and pelvic obliquity undergoing operative treatment with PSF from T2-pelvis with pedicle screw fixation. The literature was reviewed to estimate costs, probabilities, and quality-adjusted life years (QALYs)) for identified complication profiles for discharge pathways. QALYs were constructed using age-matched values for US population average, applying a CP diagnosis corrective value. A probabilistic sensitivity analysis was performed using a second-order Monte Carlo simulations. Incremental cost-utility ratio and incremental net monetary benefit (NMB) were calculated. One-way sensitivity analyses were performed by selective variable variation.

RESULTS

AD pathway resulted in an average cost and effectiveness of $67,069 and 15.4 QALYs compared with $81,312 and 15.4 QALYs for TD. AD resulted in a 2.1% greater NMB with a cost-effectiveness ratio of $4361/QALY compared with $5290/QALY in the TD. The cost-effectiveness of TD was inversely sensitive to implant cost variation while the AD maintained effectiveness despite cost variations.

CONCLUSION

This cost-utility analysis demonstrated that the implementation of an AD pathway following PSF for non-ambulatory CP scoliosis is economically more effective, providing a 17.5% cost reduction with enhanced value of care evidenced by a 2.1% greater NMB over a TD pathway. The cost-effectiveness of the AD was maintained despite implant cost variations.

Factors Affecting Postoperative Complications and Outcomes of Cervical Spondylotic Myelopathy with Cerebral Palsy : A Retrospective Analysis

Objective

Cervical surgery in patients with cervical spondylotic myelopathy (CSM) and cerebral palsy (CP) is challenging owing to the complexities of the deformity. We assessed factors affecting postoperative complications and outcomes after CSM surgery in patients with CP.

Methods

Thirty-five consecutive patients with CP and CSM who underwent cervical operations between January 2006 and January 2014 were matched to 35 non-cerebral palsy (NCP) control patients. Postoperative complications and radiologic outcomes were compared between the groups. In the CP group, the Japanese Orthopaedic Association score; Oswestry neck disability index; modified Barthel index; and values for the grip and pinch, Box and Block, and Jebsen-Taylor hand function tests were obtained preand postoperatively and compared between those with and without postoperative complications.

Results

Sixteen patients (16/35%) in the CP group and seven (7/35%) in the NCP group (p=0.021) had postoperative complications. Adjacent segment degeneration (p=0.021), postoperative motor weakness (p=0.037), and revisions (p=0.003) were significantly more frequent in the CP group than in the NCP group; however, instrument-related complications were not significantly higher in the CP group (7/35 vs. 5/35, p=0.280). The number of preoperative fixed cervical deformities were significantly higher in CP with postoperative complications (5/16 vs. 1/19, p=0.037). In the CP group, clinical outcomes were almost similar between those with and without postoperative complications.

Conclusion

The occurrence of complications during the follow-up period was high in patients with CP. However, postoperative complications did not significantly affect clinical outcomes.

Complication rate after scoliosis surgery in children with cerebral palsy

Scoliosis is an important problem in children with cerebral palsy (CP). However, the choice for a spinal fusion has to be weighed against the risks of major surgery in this vulnerable population. Paediatricians are frequently consulted preoperatively to assess the (respiratory) risk involved, but data on this question specific for CP are rare. Therefore, we investigated the complication rate after scoliosis surgery in children with CP, compared to idiopathic scoliosis (IS), and we searched for risk factors for the most common complications. In a retrospective monocenter study we analyzed the medical records from all children with CP and IS undergoing scoliosis surgery from 2010 until 2014. Duration of hospitalization and postoperative complications were compared within a 6-month follow-up. Univariate and multivariate logistic regression models were used to identify risk factors. The study included 44 patients with CP (mean age 15y0mo) and 78 patients with IS (mean age 14y6mo). Children with CP experience a higher rate of complications : respiratory and cardiovascular, as well as wound infections and decubitus ulcers (p<0.05). Postoperative pneumonia was the most frequent complication in both patient groups (43% and 18% in CP and IS respectively), with epilepsy being a significant risk factor (OR 3.85, p= 0.037) in children with CP. Intensive care unit and total hospital stay were longer in the CP group (p<0.001). These results may add information on perioperative care and surgical decision making.

Growth-friendly surgery results in more growth but a higher complication rate and unplanned returns to the operating room compared to single fusion in neuromuscular early-onset scoliosis: a multicenter retrospective cohort study

PURPOSE

Compare radiographic outcomes, complications, and QoL in neuromuscular early-onset scoliosis (EOS) patients treated with single posterior spinal fusion (PSF) versus growth-friendly surgery and definitive fusion (GFDF).

METHODS

In a retrospective cohort study, children with neuromuscular EOS, age 8-11 years at index surgery with PSF or GF devices, with minimum 2-year follow-up after final fusion were identified from a multicenter database.

RESULTS

16 PSF and 43 GFDF patients were analyzed. Demographics were similar except PSF patients were older at index surgery and had shorter follow-up. PSF patients had greater percentage major curve correction (62% vs 38%, p = 0.001) and smaller major curve at final follow-up (23° vs 40°, p = 0.005). The GFDF group underwent over five times more surgeries (8.7 vs 1.6, p = 0.0001). Four PSF patients (25%) experienced ten complications, resulting in five unplanned returns to the operating room (UPROR) in three patients (19%). 36 GFDF patients (84%) experienced 83 complications, resulting in 45 UPRORs in 24 patients (56%). Poisson regression adjusted for age showed that the GFDF group had more complications (p = 0.001) and UPRORs (p = 0.01). Although the GFDF patients had smaller preoperative T1-T12 and T1-S1 lengths, these were similar to the PSF patients at final follow-up, indicating that the GFDF patients had greater spinal growth. PSF patients had better postoperative EOSQ-24 Financial Impact and Family Burden scores.

CONCLUSION

While there was a difference in age at index surgery, PSF may be more effective than GFDF at controlling neuromuscular EOS. GFDF patients achieved more spinal growth but eight times more complications and nine times more UPRORs.

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

DESIGN

Prospective cerebral palsy (CP) registry review.

OBJECTIVES

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Therapeutic-level III.

How Do Complications Within the First 30 days after Spinal Deformity Surgery in Children with Cerebral Palsy Affect Length of Stay?

BACKGROUND

Surgery for spinal deformity in patients with cerebral palsy is reported to have high perioperative complication rates. However, minor complications are not generally reported and the influence of the varied severity of complications on length of stay is not known. Understanding the risk factors for both minor and major perioperative complications and their effect on length of stay is important information for clinicians who seek to improve care for this group of children.

QUESTIONS/PURPOSES

(1) What is the prevalence of postoperative complications in the first 30 days after surgery for spinal deformity in a New Zealand national cohort of children with cerebral palsy using the Clavien-Dindo classification? (2) What are the patient and operative predictive risk factors for minor and major perioperative complications? (3) What is the effect of year of operation on risk of minor and major perioperative complications? (4) What is the effect of perioperative complications on length of stay?

METHODS

We conducted a retrospective cohort study, identifying all children in New Zealand with a confirmed diagnosis of cerebral palsy who had surgery for a spinal deformity from January 1997 to January 2018. Two hundred-three patients with cerebral palsy (102 boys) were surgically treated for a spinal deformity, at a mean age of 14 ± 3 years, at one of three centers in New Zealand. Six children had Gross Motor Function Classification System Level II or III, 66 had Gross Motor Function Classification System Level IV, and 131 had Gross Motor Function Classification System Level V. Thirty-day perioperative complications were extracted from the patients' health records and classified according to the Clavien-Dindo system. Univariate and multivariate analyses were performed to identify patient and operative risk factors for complications, and the effect on length of stay.

RESULTS

In all, 85% of patients experienced at least one perioperative complication. There were 300 Clavien-Dindo Grade I complications in 141 patients, 156 Clavien-Dindo Grade II complications in 102 patients, 25 Clavien-Dindo Grade III complications in 22 patients, 29 Clavien-Dindo Grade IV complications in 28 patients, and one Clavien-Dindo Grade V complication (death; 0.5%). Univariate analysis showed that multiple independent factors, Gross Motor Function Classification System Level V ability (odds ratio 2.13 [95% confidence interval 1.15 to 3.95]; p = 0.02), seizure disorder (OR 2.27 [95% CI 1.20 to 4.32]; p < 0.01), preoperative Cobb angle of greater than 70° (OR 2.40 [95% CI 1.20 to 4.78]; p < 0.01), and anterior approach to surgery (OR 3.29 [95% CI 1.21 to 8.90]; p = 0.02), were associated with Grade I complications but, of these factors, only the presence of a seizure disorder (OR 2.27 [95% CI 1.20 to 4.32]; p < 0.01) was associated with Grade I complications on multivariate analysis. Previous recurrent respiratory infections predicted an increased risk of Clavien-Dindo Grade II complications (OR 3.6 [95% CI 1.81 to 7.0]; p = 0.03). The presence of a feeding gastrostomy was associated with an increased risk of Clavien-Dindo Grade IV complications (OR 2.6 [95% CI 1.19 to 5.87]; p = 0.02). The year of operation did not influence the frequency of any grade of complication, but the presence of any complication led to an increased length of stay.

CONCLUSION

Overall, 85% of patients with cerebral palsy had at least one complication after spinal deformity surgery and 25% had major complications (Grades III, IV, and V), with proportionate increases in the postoperative length of stay. Patient-specific factors aid in the identification of complication risk.

LEVEL OF EVIDENCE

Level II, prognostic study.

Do seizures compromise correction maintenance after spinal fusion in cerebral palsy scoliosis?

Seizure disorder in cerebral palsy (CP) has been described as a risk factor for postoperative complications after posterior spinal fusion. However, the effect of seizures on the maintenance of curve correction has not been reported. The aim of this study is to investigate associations between seizure history and maintenance of curve correction after posterior spinal fusion in children with CP. We analyzed records of 201 children with CP who underwent posterior spinal fusion with two-year follow-up. Patients were classified as having no seizures (31%); controlled seizures (54%); or poorly controlled seizures (PCS, 15%). Perioperative data, radiographic measurements, and complications were compared between groups. Groups were similar in operative time, estimated blood loss, and rates of deep wound infection and implant-related complications. The PCS group had a higher rate of respiratory complications (27%) than the no seizures (10%; P = 0.03) and controlled seizures (12%; P = 0.04) groups. Controlled seizures and PCS groups had longer ICU stays than the no seizures group (P= 0.02 and P= 0.04). Major coronal curve and pelvic obliquity were corrected significantly in all groups, and correction was maintained at 2 years. Loss of correction during follow-up was similar between groups. Although seizures were associated with longer ICU stays and more respiratory complications, there was no association between seizure history and loss of curve correction at two years of follow-up after CP scoliosis surgery.

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.

Analysis of orthopedic surgical procedures in children with cerebral palsy

BACKGROUND

Orthopedic surgery in children with cerebral palsy (CP) aims to improve function and prevent deformities. Each child’s condition in CP is unique and many co-variables influence surgical decision-making including a patient's age and their functional level. Little is known about the frequency of different types of orthopedic surgery in children with CP who have varied functional levels, particularly in countries from Latin America.

AIM

To assess the type of orthopedic surgical procedures in relation to age and gross motor function in children with CP.

METHODS

This retrospective study included all children with CP (n = 245) treated with elective orthopedic surgery at a Uruguayan university hospital between October 2010 and May 2016 identified from a surgical database. Eighteen children (7%) were lost to follow-up due to missing medical charts. Demographics, gross motor function classification (GMFCS), and orthopedic surgeries were obtained from the medical records of 227 children. Chi-squared tests and analysis of variance were used to assess the frequency of surgery, accounting for GMFCS levels. Mean age for soft tissue vs bone surgery was compared with the independent samples t-test.

RESULTS

A total of 711 surgical procedures were performed between 1998 and 2016. On average, children had 3.1 surgical procedures and the mean age at first surgery was 8.0 years. There were no significant differences in age at first surgery among GMFCS levels (P = 0.47). The most common procedures were lower leg soft tissue surgery (n = 189, 27%), hip tenotomy (n = 135, 19%), and hamstring tenotomy (n = 104, 14%). For children with GMFCS level I, the mean number of surgeries per child [1.8 (range 1-9)] differed significantly at P < 0.05 in children with GMFCS levels II [3.2 (1-12)], III [3.2 (1-8)], IV [3.3 (1-13)], and V [3.6 (1-11)]. Within II, III, IV, and V, there was no significant difference in mean number of surgeries per child when comparing across the groups. The proportion of soft tissue surgery vs bone surgery was higher in GMFCS levels I-III (80%-85%) compared to levels IV (68%) and V (55%) (P < 0.05).

CONCLUSION

The frequency of surgical procedures per child did not increase with higher GMFCS level after level I. However, the proportion of bone surgery was higher in GMFCS levels IV-V compared to I-III.

Major complications following surgical correction of spine deformity in 257 patients with cerebral palsy

STUDY DESIGN

Observational.

OBJECTIVES

To report on the rate of major complications following spinal fusion and instrumentation to treat spinal deformity in patients with cerebral palsy (CP). Understanding the risk of major complications following the surgical treatment of spine deformities in patients with CP is critical.

METHODS

A prospectively collected, multicenter database of patients with CP who had surgical correction of their spinal deformity (scoliosis or kyphosis) was reviewed for all major complications. Patients with ≥ 2 year follow-up or who died ≤ 2 years of surgery were included. A complication was defined as major if it resulted in reoperation, re-admission to the hospital, prolongation of the hospital stay, was considered life-threatening, or resulted in residual disability. Overall complication and revision rates were calculated for the perioperative (Peri-op; occurring ≤ 90 days postoperative) and delayed postoperative (Delayed; > 90 days) time periods.

RESULTS

Two hundred and fifty-seven patients met inclusion. Seventy-eight (30%) patients had a major complication, 18 (7%) had > 1. There were 92 (36%) major complications; 64 (24.9%) occurred Peri-op. The most common Peri-op complications were wound (n = 16, 6.2%) and pulmonary issues (n = 28, 10.9%), specifically deep infections (n = 12, 4.7%) and prolonged ventilator support (n = 21, 8.2%). Delayed complications (n = 28, 10.9%) were primarily deep infections (n = 8, 3.1%) and instrumentation-related (n = 6, 2.3%). There were 42 additional surgeries for an overall unplanned return to the operating room rate of 16% (Peri-op: 8.6%, Delayed: 7.8%). Thirty-six (14.0%) reoperations were spine related surgeries (wound or instrumentation-related). Eleven (4.3%) patients died between 3 months to 5.6 years postoperatively; 4 occurred ≤ 1 year of surgery. Two deaths were directly related to the spinal deformity surgery.

CONCLUSION

Spinal deformity surgery in CP patients with greater than 2 years of follow-up have a postoperative major complication rate of 36% with a spine-related reoperation rate of 14.0%.

LEVEL OF EVIDENCE

Therapeutic-IV.

Correction of adult spinal deformity with a minimally invasive fusionless bipolar construct: Preliminary results

INTRODUCTION

Fusion in adult spinal deformity has a high rate of complications. Fusionless constructs in children and percutaneous fixation in adults are now being used routinely. The aim of this study was to evaluate the preliminary results of a minimally invasive fusionless surgical technique used to correct adult spinal deformity.

MATERIALS AND METHODS

Thirty-eight patients with an average age of 45 years (15-76) with major spinal deformity requiring extensive arthrodesis from the upper thoracic region to the pelvis were operated consecutively and followed prospectively. Two hooks were implanted at the top and two iliosacral screws at the bottom. Two large rods connected by dominos to two small rods joined the upper hooks to the lower screws. The surgical data (operative time and bleeding), the radiological findings (Cobb angle, sagittal parameters, C7-plumbline AP and lateral), the complication rate and the morbidity were evaluated at the last follow-up visit.

RESULTS

The primary curvature was reduced by 40% from a mean of 58.5° (26-146) to 35.2° (3-109) (p<0.001). A clear decrease in operating time (270min) and blood loss (50cc/level) were observed. The length of hospitalization averaged 18 days (6-66), including an 8-15 day long preoperative traction period for 11 patients. We found 7 infectious complications, 11 early mechanical complications and one case of paraplegia due to severe kyphoscoliosis.

CONCLUSION

The corrections obtained are comparable to those reported in the literature for standard constructs. Most patients had an uneventful postoperative course. The early complications observed led us to very carefully select the indications. Long-term follow-up is essential.

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.

The Pros and Cons of Operating Early Versus Late in the Progression of Cerebral Palsy Scoliosis

STUDY DESIGN

Retrospective review of prospective data.

OBJECTIVE

To delineate a curve threshold where further delay of surgery significantly increased the risks for patients with cerebral palsy (CP) scoliosis.

SUMMARY OF BACKGROUND DATA

Two approaches exist in the management of CP scoliosis: a proactive one where surgery is recommended once there is a risk of progression (Cobb > 50°) and a reactive one where surgery is recommended after the patient/caregiver may have significant challenges caused by a large deformity.

METHODS

A prospectively collected CP scoliosis surgical registry was queried for patients with minimum two years of follow-up. Three groups were delineated based on the distribution of curve magnitudes: <70° (proactive), 70°-90°, and >90° (reactive). Radiographic, surgical, and quality of life outcome data were compared between the groups using analysis of variance and chi-square analyses.

RESULTS

There were 38 patients in the <70° group, 44 in the 70°-90° group, and 42 in the >90° group. They were similar in age. The >90° group had significantly longer operative time (p < .001), a higher percentage of anterior/posterior procedures (31% vs 5%), and a higher infection rate requiring I&D (16.7%) than the other groups (<70°: 5.3%; 70°-90°: 6.8%; p < .05). The percentage blood volume loss was significantly higher in the >90° group compared to <70°. There were no differences in length of hospitalization or intensive care unit stay. Preoperatively, the Caregiver Priorities and Child Health Index of Life with Disabilities (CPchild) QOL score was significantly higher for the <70° group. At two years, the <70° and 70°-90° groups reached similar QOL scores, whereas the >90° trended toward a lower postoperative QOL.

CONCLUSIONS

Being proactive (Cobb <70°) has no advantage in terms of decreasing risks or improving outcomes compared to curves 70°-90°. However, delaying surgery to a curve greater than 90° increases the risk of infection, blood loss, and the need for anterior/posterior procedures. Ideally, surgery should be recommended for curves less than 90°.

Gross Motor Function Classification System Specific Growth Charts-Utility as a Risk Stratification Tool for Surgical Site Infection Following Spine Surgery

BACKGROUND

There is currently minimal evidence that preoperative malnutrition increases surgical site infection (SSI) risk in children with cerebral palsy (CP) undergoing spinal deformity surgery. Growth charts specifically for patients with CP have been created to aid in the clinical interpretation of body mass index (BMI) as a marker of nutritional status, but to our knowledge these charts have never been used to risk stratify patients before orthopaedic surgery. We hypothesize that patients with CP who have BMI-for-age below the 10th percentile (BMI≤10) on CP-specific growth charts are at increased risk of surgical site infection following spinal deformity surgery compared with patients with BMI-for-age above the 10th percentile (BMI>10).

METHODS

Single-center, retrospective review comparing the rate of SSI in patients with CP stratified by BMI-for-age percentiles on CP-specific growth charts who underwent spinal deformity surgery. Odds ratios with 95% confidence intervals and Pearson χ tests were used to analyze the association of the measured nutritional indicators with SSI.

RESULTS

In total, 65 patients, who underwent 74 procedures, had complete follow-up data and were included in this analysis. Ten patients (15.4%) were GMFCS I-III and 55 (84.6%) were GMFCS IV-V; 39 (60%) were orally fed and 26 (40%) were tube-fed. The rate of SSI in this patient population was 13.5% with 10 SSIs reported within 90 days of surgery. There was a significant association between patients with a BMI below the 10th percentile on GMFCS-stratified growth charts and the development of SSI (OR, 13.6; 95% CI, 2.4-75.4; P=0.005). All SSIs occurred in patients that were GMFCS IV-V. There was no association between height, weight, feeding method, or pelvic instrumentation and development of SSI.

CONCLUSIONS

CP-specific growth charts are useful tools for identifying patients at increased risk for SSI following spinal instrumentation procedures, whereas standard CDC growth charts are much less sensitive. There is a strong association between preoperative BMI percentile on GMFCS-stratified growth charts and SSI following spinal deformity surgery.

LEVEL OF EVIDENCE

Level III-Retrospective Study.

Do All Patients With Cerebral Palsy Require Postoperative Intensive Care Admission After Spinal Fusion?

STUDY DESIGN

Retrospective review of a prospective cohort.

OBJECTIVE

To identify patient and surgical factors that alter the length of postoperative intensive care unit (ICU) stays after spinal fusion/instrumentation in patients with neuromuscular scoliosis secondary to cerebral palsy (CP).

SUMMARY OF BACKGROUND DATA

High perioperative complication rates in patients with CP contribute to the practice of utilizing the ICU postoperatively for monitoring. However, this is costly and little is known regarding which patients truly need this increased acuity of care.

METHODS

A prospective, multicenter database was queried for patients with CP who underwent spinal fusion and instrumentation. Patients with an ICU length of stay (LOS) ≤1 day were assumed to not have required postoperative ICU admission. Demographic and surgical characteristics were compared between those with ICU LOS of ≤1 day versus >1 day. A classification and regression tree (CART) analysis was utilized to create a decision algorithm for postoperative ICU admission.

RESULTS

Three hundred twenty-four patients were identified with a mean ICU LOS of 4.7 days (range 0-47). Sixty-eight patients (21%) had an ICU LOS ≤1 day and 256 patients (79%) had an ICU LOS >1 day. CART analysis demonstrated that the institution where the surgery was performed was the primary predictor with two groups: sites that almost routinely had ICU stay >1 day (92%) and those that were split (50.5% >1 day). In the latter group, an operative time greater than 4 hours was a risk factor for a longer ICU stay.

CONCLUSION

Because of their heterogeneous makeup, CP patients should be evaluated individually and their postoperative disposition should not be based on institutional tradition but instead on objective surgical factors. For those patients with surgical times less than 4 hours, discussions should be held regarding the safety of a postoperative disposition to a regular floor.

LEVEL OF EVIDENCE

Level III.

Caregiver Perceptions and Health-Related Quality-of-Life Changes in Cerebral Palsy Patients After Spinal Arthrodesis

STUDY DESIGN

A retrospective analysis of a prospective registry.

OBJECTIVE

Our objective was to prospectively assess caregivers' perceptions regarding changes in the health-related quality of life (HRQL) of patients with cerebral palsy (CP) after spinal arthrodesis. We assessed caregiver perceptions from three perspectives: 1) qualitative assessment of changes in global quality of life, comfort, and health; 2) relative valuation of spine surgery versus other common interventions in CP patients; and 3) quantitative changes in HRQL scores.

SUMMARY OF BACKGROUND DATA

Studies of children with CP who undergo surgical treatment of spinal deformity have focused largely on radiographic changes.

METHODS

We queried a multicenter prospective registry of CP patients with level IV or V motor function according to the Gross Motor Function Classification System who were treated with spinal arthrodesis, and whose caregivers completed preoperative and 2-year postoperative qualitative and quantitative HRQL surveys. A total of 212 caregivers and their patients were included in the study.

RESULTS

At 2-year follow-up, most caregivers reported that patients' global quality of life, comfort, and health were "a lot better" after spinal arthrodesis. Spinal arthrodesis was ranked as the most beneficial intervention in the patients' lives by 74% of caregivers, ahead of hip, knee, and foot surgeries and baclofen pump insertion. Gastrostomy tube insertion was the only intervention ranked superior to spinal arthrodesis in terms of impact. Quantitative HRQL scores improved significantly during 2-year follow-up across various domains.

CONCLUSION

In qualitative and quantitative HRQL assessments, caregivers reported overall improvement in patients' lives after spinal arthrodesis. Caregivers ranked spine surgery as the most beneficial intervention in the patients' lives, secondary only to gastrostomy tube insertion.

LEVEL OF EVIDENCE

2.