Complication of surgery for scoliosis in children with surgically corrected congenital cardiac malformations

Conservative treatment of a scoliosis patient after two heart surgeries in early childhood - A case report

Introduction

This is a case report of a juvenile female patient with scoliosis following two heart surgeries for congenital heart disease (CHD).

Patient presentation, management and outcome

Initially, the premenarchial female was 9 years old and had a Tanner stage 2–3 with a single thoracic curve of 65° Cobb. Because of the high risk for progression, immediate brace treatment was proposed as the father declined surgery. The patient received intensive treatment according to the Schroth Best Practice® programme and a Gensingen Brace® designed for large thoracic curves. Over the 18 months following the initial visit, she received two additional braces. As a result, the progression of the main curve was prevented. The patient continues to maintain an improved cosmetic result and is currently at a Risser 2.

Conclusion

Surgery performed for CHD in rare cases may lead to stiff spinal deformity as a consequence of that surgery. Progression of a severe and stiff curve was prevented during the most vulnerable phase of the pubertal growth spurt with an improved clinical result. Therefore, we assume that the patient may have a normal life in adulthood with minor restrictions only. Supported by pattern-specific high correction exercises and braces, these typical single thoracic curves can be re-compensated to a more balanced appearance, less prone to progression in adulthood.

Clinical implications

Because of the relative high risks of spinal fusion and the long-term unknowns of such an intervention, high-impact conservative treatment should be implemented first before surgical correction is considered.

Adverse Perioperative Events in Children with Complex Congenital Heart Disease Undergoing Operative Scoliosis Repair in the Contemporary Era

Scoliosis is common in children with congenital heart disease (CHD) and may have deleterious effects on quality of life and hemodynamics. Relatively little is known about the outcomes of spinal fusion for scoliosis repair in children with complex CHD. We reviewed all cases of children with CHD undergoing first time spinal fusion excluding those with minor CHD between 1995 and 2015. Seventy-eight patients were identified and included in the study. 97.4% of patients included had undergone prior cardiac surgery and sixteen patients had single ventricle circulations. 17.9% of patients experienced a significant perioperative event defined as an aggregate of the presence of any of the following: need for early unanticipated reoperation, neurologic deficit, postoperative bleeding requiring intervention, end organ dysfunction, or death. There were no deaths in our cohort. 38.5% of patients experienced any adverse event, the majority of which were related to perioperative fluid shifts. Larger preoperative Cobb angle and longer length of spinal fusion were associated with increased risk of significant perioperative event while larger preoperative Cobb angle and longer length of spinal fusion, older age at time of surgery, single ventricle circulation, cyanosis and patients taking cardiac medications at the time of surgery were more likely to experience any adverse event. Operative repair of scoliosis in children with complex CHD has been performed without mortality over a 20-year period in a single institution, albeit with a higher rate of perioperative complication than is seen in the general pediatric population. Patients with large preoperative Cobb angles and cyanotic single ventricle circulations appear to be at the highest risk for perioperative complications.

Perioperative Complications After Spinal Fusion in Pediatric Patients With Congenital Heart Disease

BACKGROUND

Children with congenital heart disease (CHD) have been reported to be at increased risk of developing scoliosis following cardiac surgery. Previous sample studies have reported that these patients may safely undergo posterior spinal fusion (PSF) with low complication rates. The goal of this study is to provide an updated analysis of the perioperative complication profile for posterior spinal fusion in a large cohort of pediatric patients with CHD, using a nationwide database.

METHODS

A retrospective cohort study was conducted using 30-day perioperative outcomes data from the NSQIP-P database. Our inclusion criteria were all pediatric patients who underwent posterior spinal fusion by CPT code. Patients were subdivided into two groups: those with a history of cardiac surgery for CHD and those without. Postoperative complications were classified according to the Clavien-Dindo system. Risk factors were assessed in univariate and multivariate logistic regression analyses, with significance set at p < .05.

RESULTS

Our results included 3,426 pediatric patients (68.2% female, 31.8% male) with a median age at spinal fusion of 13.7 ± 2.87 years. A CHD diagnosis was present in 312 patients, with 128 having had prior cardiac surgery. The overall complication rate was 6.68%, with a 10.9% rate in the prior cardiac surgery cohort (p = .068). The most common overall perioperative complications were unplanned readmission (3.5%), reoperation (2.6%), and superficial wound dehiscence (2.5%). Patients with a history of cardiac surgery were not at increased risk for postoperative complications; however, blood transfusion (p < .001), bronchopulmonary dysplasia (p < .001), combined bronchopulmonary dysplasia and previous cardiac surgery (p = .004), and a neuromuscular diagnosis (p < .001) were all risk factors for major postoperative complications in this cohort.

CONCLUSIONS

Children with scoliosis who have undergone cardiac surgery to address CHD are not at an increased risk of perioperative complications within 30 days of undergoing a posterior spinal fusion. However, patients who underwent cardiac surgery for CHD who also had bronchopulmonary dysplasia or an associated neuromuscular diagnosis are at increased risk for perioperative complications. It is important for pediatric orthopedic spine surgeons to be familiar with an updated profile of potential perioperative obstacles they may face when treating these patients, as seen in a large and representative cohort.

LEVEL OF EVIDENCE

Level III.

Scoliosis surgery in children with congenital heart disease

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To describe preoperative evaluation, anesthetic and perioperative management, and complications in patients with congenital heart disease (CHD) who underwent surgery to correct a spine deformity.

SUMMARY OF BACKGROUND DATA

Patients with surgically palliated or repaired CHD may have nearly normal circulation or may have important residual abnormalities that affect the planning and conduct of surgery to correct a spine deformity.

METHODS

We examined the records of 21 patients with spine deformity who had previous surgical intervention for CHD. Three types of spine surgery and instrumentation were examined, posterior spinal fusion with instrumentation (PSFI), growing rod (GR) instrumentation, and vertical expandable prosthetic titanium rib instrumentation (VEPTR). To objectify the degree of preoperative cardiac physiological derangement, patients were classified into 3 groups: single ventricle physiology and Fontan circulation (S), two ventricles with no residual abnormal cardiac physiology condition (2N), and two ventricles with residual cardiac physiology problem (2R).

RESULTS

Subjects were 8 boys and 13 girls with mean age of 11.1 ± 5.2 years. Sixteen patients underwent surgery to correct scoliosis, 1 to correct kyphosis, and 4 did not undergo surgery. Total number of surgical procedures was 23 (16 PSFI, 5 GR, and 2 VEPTR). On the basis of cardiac physiology, 2 patients belonged 2N, 11 were 2R, and 8 were group S. Mean estimated blood loss was 1685 mL during PSFI, 515 mL during GR, and 150 mL during VEPTR. Mean volume of blood transfusion was 44 mL/kg for PSFI, 19 mL/kg for GR, whereas no transfusion was administered during VEPTR. Median intensive care unit stay was 2 days ranging from hours to 78 days. Median hospital length of stay was 7 days ranging from 3 to 93 days. There were no deaths.

CONCLUSION

Given meticulous multidisciplinary planning and execution, major spine surgery can be safely and successfully performed in patients with significant residua of CHD.

LEVEL OF EVIDENCE

4.

Spinal surgery in the univentricular heart--is it viable?

INTRODUCTION

The management of patients with Fontan physiology who undergo scoliosis surgery is difficult. The purpose of this article was to describe our experience in the management of patients with Fontan circulation undergoing spinal surgery for correction of scoliosis.

MATERIALS AND METHODS

This was a retrospective study including patients with Fontan physiology who underwent spinal orthopaedic surgery. Anaesthetic management, post-operative complications, paediatric intensive care unit and total hospital stay, and the need for blood transfusions were analysed.

RESULTS

We identified eight children with Fontan physiology who had undergone spinal surgery from 2000 to 2010. All patients were receiving cardiac medications at the time of spinal surgery. The mean age at surgery was 14.8 years (range 12-21). In all, three patients needed inotropic support with dopamine (3, 5, and 8 μg/kg/min), which was started during surgery. During the immediate post-operative period, one patient died because of hypovolaemic shock caused by massive bleeding and dysrythmia. Mean blood loss during the post-operative period was 22.2 cc/kg (7.8-44.6). Surgical drainages were maintained for a mean time of 3 days (range 1-7). The mean hospital stay was 9.2 days (range 6-19). Pleural effusions developed in two patients. On follow-up, one patient presented with thoracic pseudarthrosis and another with a serohaematoma of the surgical wound.

CONCLUSIONS

Spinal surgery in patients with Fontan circulation is a high-risk operation. These patients must be managed by a specialised team.

Safety of surgical treatment for patients with scoliosis and surgically corrected congenital cardiac malformations: a comparison with patients with scoliosis and normal hearts

OBJECT

The safety of spinal fusion has been poorly studied in children with surgically corrected congenital cardiac malformations (CCMs). The objective of this study was to evaluate the safety of spinal fusion in patients with CCMs following cardiac surgery.

METHODS

A retrospective study was conducted on 32 patients with scoliosis who received surgical treatment for their CCMs (CCM group). Sixty-four age- and sex-matched patients with scoliosis and normal hearts who received spinal fusion served as the control group. These 2 groups were compared for demographic distribution, blood loss, transfusion requirements, and incidence of postoperative complications.

RESULTS

The ages, curve pattern distributions, and number of levels fused were similar between the 2 groups before spinal fusion. Overall, a total of 7 patients in the CCM group (21.9%) and 5 (7.8%) in the control group had documented postoperative complications. The perioperative allogenic blood transfusion rate and mean red blood cell transfusion requirement in the CCM group were significantly higher than those found in patients in the control group (68.7% vs 28.1%, respectively, p = 0.000; and 2.68 ± 2.76 units/patient vs 0.76 ± 1.07 units/patient, respectively, p = 0.011). In the CCM group, a preoperative major curve magnitude ≥ 80° was the most accurate indicator of an increased risk for a major complication (p = 0.019), whereas no statistically significant correlation was noted between postoperative complications and age, type of congenital heart disease, operative duration, and estimated blood loss during the operation and transfusion.

CONCLUSIONS

Spinal fusion subsequent to prior cardiac surgery is relatively safe and effective in correcting the spinal deformity for patients with scoliosis and surgically corrected CCMs. A preoperative major curve magnitude ≥ 80° may be a risk factor in predicting postoperative complications in scoliotic patients with surgically corrected CCMs.

Pathways that distinguish simple from complex scoliosis repair and their outcomes

PURPOSE OF REVIEW

Surgical management of spinal deformities in patients with neuromuscular diseases or other underlying comorbidities is often challenging, as this population is at an increased risk of experiencing complications. Identifying these patients early on in the preoperative planning process is imperative in order to improve patient outcomes.

RECENT FINDINGS

Many recent studies have identified risk factors associated with perioperative and postoperative complications, including neuromuscular diseases, genetic syndromes, traumatic nerve/muscle injuries, seizure disorders, decreased cognitive ability, poor pulmonary status, restrictive lung disease, history of frequent pneumonias, sleep apnea, malnutrition, cardiac disease, immune-compromised patients, social status, ambulatory status, and the complexity of the procedure itself.

SUMMARY

Management of spinal deformities in patients with neuromuscular diseases or other underlying comorbidities must be approached cautiously and in a multidisciplinary manner. Identifying these comorbidities early on, understanding their influence on patient outcomes after spinal surgery and managing high-risk patients through a common therapeutic and clinical pathway can help to improve patient outcomes.

Outcomes of spinal fusion in children with congenital heart disease

BACKGROUND

The children with congenital heart disease (CHD) have an increased risk of developing scoliosis. Many children with CHD may benefit from surgical intervention for scoliosis. However, there is uncertainty about the safety of spinal fusion in children with heart disease. The purpose of this study is to assess whether spinal fusion is safe and effective for children who have CHD.

METHODS

We reviewed all the cases of children with CHD undergoing first-time spinal fusion for spinal deformity at Mayo Clinic between August 1976 and June 2008. Data were abstracted regarding cardiac history, major Cobb angle, type of spinal fusion (anterior, posterior, or both), intraoperative and postoperative complications, mortality, and follow-up.

RESULTS

Sixty-four children under the age of 18 (64% female patients; mean age=11.5 y) were included in the study. The most common types of CHD were pulmonary atresia with ventricular septal defect and tetralogy of Fallot. Sixty-three percent of all patients had had prior cardiac surgery; 22% were cyanotic at the time of spinal fusion. Nine patients had single-ventricle physiology; 5 of whom had had Fontan palliation. Nine patients had pulmonary hypertension. Posterior fusion alone was carried out for 69% of the patients. Spinal instrumentation was used in 70% of cases. Average anesthesia time was 7.3 hours. Mean hospital stay was 9 days. Eighteen children (30%) required prolonged intubation of 1 day or longer. Prolonged intubation was more common in patients with a larger Cobb angle and in patients with pulmonary hypertension. Postoperative complications occurred in 27% of all patients and were more common in the patients with pulmonary hypertension. One child died postoperatively from a hemorrhage because of an arterial-esophageal fistula unrelated to her spinal fusion.

CONCLUSIONS

Spinal fusion in children with CHD is generally safe and effective. Children with pulmonary hypertension are at higher risk for complications from spinal fusion.

LEVEL OF EVIDENCE

Level IV--Case Series.