Financial analysis of circumferential fusion versus posterior-only with thoracic pedicle screw constructs for main thoracic idiopathic curves between 70 degrees and 100 degrees

Complications of Posterior Column Osteotomies in the Pediatric Spinal Deformity Patient

BACKGROUND

In spinal deformity surgery, posterior column osteotomies (PCOs) are used to increase spinal flexibility and permit greater deformity correction, while avoiding the morbidity of anterior column surgery. Complications related to use of PCOs have been well characterized in adults; however, there is a paucity of information in the pediatric population.

METHODS

A single-surgeon retrospective analysis was completed of 484 PCOs in 142 patients (average age: 14.5 years) undergoing spinal deformity surgery. All surgeries were completed by a standard posterior approach using a midline incision and dual-rod, pedicle screw constructs. PCO-related complications were recorded (intraoperative monitoring alerts, postoperative neurologic deficit, dural tear/violations, cerebrospinal fluid [CSF] leak, pseudarthrosis, etc.) and analyzed by diagnosis (idiopathic, congenital, neuromuscular, syndromic).

RESULTS

The diagnoses for the 142 patients were idiopathic (103 patients), neuromuscular (23 patients), syndromic (14 patients), and congenital (2 patients). In a subset of 87 patients with 2-year radiographic follow-up, the preoperative major coronal Cobb measurement was 75.5° ± 17.6°, which corrected to 34.9° ± 17.5° postoperatively and 37.8° ± 17.9° at last follow-up (p < .0001, p < .0001). Complications evaluated were postoperative neurologic deficit (0% of patients, 0/142), dural tears/violations at site of PCO (0.4% of PCOs, 2/484), CSF leak (0% of patients, 0/142), and pseudoarthrosis at site of PCO (0% of PCOs, 0/290).

CONCLUSION

The overall frequency of complications related to PCOs was 0.4% (0.4% dural tears/violations) with 0% postoperative neurologic deficit, CSF leak, or pseudarthrosis. Based on these data, PCOs appear to be a safe technique in pediatric spine deformity surgery, with a low rate of technique-related complications.

STUDY DESIGN

Retrospective case series.

OBJECTIVES

To report the frequency of posterior column osteotomy complications (neurologic deficit, dural tear, cerebrospinal fluid leak, and pseudarthrosis) in pediatric patients undergoing spinal deformity surgery.

LEVEL OF EVIDENCE

Level IV.

Pedicle screw instrumentation and spinal deformities: have we gone too far?

INTRODUCTION

Placement of pedicle screws within the thoracic and lumbar spine has become the "state of the art" for the treatment of spinal deformities. Newly trained surgeons are often trained only with the placement of pedicle screws within the thoracic and lumbar spine and not with hooks or other means of fixation. However, if the benefits of pedicle screw instrumentation in terms of correction ability cannot be questioned on some issues pertaining to their safety, their rationale for all situations as well as their long-term adverse consequence and or early or late complications start to arise.

MATERIALS AND METHODS

We therefore present four case examples that illustrate the advantages, questions and complications inherent to pedicle screw instrumentation in spinal deformities. These four cases serve as discussion supported by a review of the literature. The literature search was performed to include pedicle screws associated risks, costs and complications. Articles focusing on instrumentation of the thoracic and lumbar spine for the treatment of adult and pediatric scoliosis were reviewed.

RESULTS

Pedicle screw instrumentation in the treatment of spinal deformity is here to stay, however a fair number of issues have come up since their widespread use that started 10 years ago: these include their misplacement with the inherent risks to the vascular or neurologic structures, the rate of misplaced pedicle screw not per number of screws inserted, but per patient operated, the number of screws really necessary to achieve a satisfactory outcome while maintaining costs, their contraindications in some very challenging deformities where the risks clearly outweigh their advantage compared to hooks. At last, the use of pedicle screw instrumentation has driven many centers in increasing the safety of such procedures using intraoperative spinal cord monitoring as well as improved imaging technologies.

CONCLUSION

To answer our provocative title "Pedicle screw instrumentation have we gone too far?" Definitively we can answer that for some spinal deformities instrumented with all-pedicle-screw instrumentation, we have observed cases where the surgeons have gone way too far; in other cases, where such instrumentation was used in a comprehensive and rational manner, the answer to "Have we gone too far" is no, and such use of pedicle screw has improved outcome with minimum complications.