Same-day versus staged anterior-posterior spinal surgery in a neuromuscular scoliosis population: the evaluation of medical complications

Evaluating Trends and Outcomes of Spinal Deformity Surgery in Cerebral Palsy Patients

Background

There is a paucity of literature examining surgical trends and outcomes in both child and adult cerebral palsy (CP) patients. We aimed to evaluate surgical trends, complications, length of stay, and charges for spinal deformity surgery in CP patients.

Methods

Using the Nationwide Inpatient Sample (NIS) from 2001 to 2013, patients with CP scoliosis who underwent spinal fusion surgery were identified. Patient characteristics and comorbidities were recorded. Trends in spinal fusion approaches were grouped as anterior (ASF), posterior (PSF), or combined anterior-posterior (ASF/PSF). Complication rates, length of stay, and charges for each approach were analyzed. Bivariate analyses using adjusted Wald tests and multivariate analyses using linear (logarithmic transformation) and logistic regressions were performed.

Results

Of the 5191 adult CP patients who underwent spinal fusion the majority underwent PSF (86.5%), followed by the ASF/PSF approach (9.3%). The rate of PSF for cerebral palsy patients with spinal deformity increased significantly per 1 million people in the US population (0.90 to 1.30; P = .048). Complication rate, hospital length of stay, and charges were higher for patients undergoing ASF/PSF (P < .05). The overall complication rate for all surgical approaches was 25.7%. Patient comorbidities and combined ASF/PSF increased the odds of complication. Combined ASF/PSF was also associated with an increased length of stay and charges.

Conclusion

Combined ASF/PSF in patients with CP accounted for only 9.3% of surgical cases but was associated with the longest hospital stay, highest charges, and increased complications. Further scrutiny of the surgical indications and preoperative risk stratification should be undertaken to minimize complications, reduce length of stay, and decrease charges for CP patients undergoing spinal fusion.

Level of Evidence

IV.

Factors associated with surgical approach and outcomes in cerebral palsy scoliosis

BACKGROUND

Neuromuscular scoliosis is often treated with posterior spinal fusion, with or without anterior release, and either a same-day or staged, 2-day procedure.

METHODS

We retrospectively reviewed 222 patients from a prospectively collected, multi-center database of patients with cerebral palsy scoliosis with 2-year follow-up. Baseline characteristics, perioperative, radiographic, and HRQoL measures were compared in six sub-analyses: (1) staged versus same-day surgeries, (2) posterior-only fusion (PSF) versus anterior-posterior spinal fusion (APSF), (3) same-day versus staged PSF, (4) staged versus same-day APSF, (5) same-day PSF versus same-day APSF, (6) staged PSF versus staged APSF.

RESULTS

Staged patients had larger curves and more pelvic obliquity, longer anesthesia and surgical times, longer hospital and ICU stays (p < 0.001), and more days intubated (p = 0.021). The staged PSF group had larger curves (p = 0.006), longer anesthesia (p = 0.020) and surgeries (p = 0.007), hospital (p = 0.009) and ICU stays (p = 0.028) compared to same-day PSF. The staged APSF group had longer hospital (p < 0.001) and ICU stays (p = 0.004) and anesthesia and surgeries (p < 0.001). Same-day APSF was associated with larger curves (p < 0.002), longer anesthesia (p = 0.012) and surgeries (p = 0.042), greater residual curves (p = 0.035), and greater absolute correction (p = 0.007) compared to same-day PSF. The staged APSF group had longer anesthesia times (p < 0.001) compared to the staged PSF group. No sub-analysis revealed significant differences in baseline characteristics, complications, or HRQoL.

CONCLUSION

Staged and circumferential approaches tend to be used for greater deformity, but were not associated with superior deformity correction, and were associated with longer operative time, hospital stays, ICU stays, and days intubated. However, for the most severe deformity, other patient factors may play more important roles in treatment decisions given that patients treated with a staged PSF or an APSF, whether staged or not, were similar at baseline.

LEVEL OF EVIDENCE

III. These slides can be retrieved under Electronic Supplementary Material.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

2.

Development and treatment of spinal deformity in patients with cerebral palsy

Scoliosis is a common deformity in children and adolescents with cerebral palsy. This is usually associated with pelvic obliquity due to extension of the curve to the sacrum. Sagittal plane deformity is less common and often develops along with scoliosis. Spinal deformity in patients with severe neurological handicaps can affect their ability to sit and cause significant back pain or pain due to rib impingement against the elevated side of the pelvis on the concavity of the curvature. Surgical correction followed by spinal arthrodesis is indicated in patients with progressive deformities which interfere with their level of function and quality of life. Spinal deformity correction is a major task in children with multiple medical co-morbidities and can be associated with a high risk of complications including death. A well-coordinated multidisciplinary approach is required in the assessment and treatment of this group of patients with the aim to minimize the complication rate and secure a satisfactory surgical outcome. Good knowledge of the surgical and instrumentation techniques, as well as the principles of management is needed to achieve optimum correction of the deformity and balancing of the spine and pelvis. Spinal fusion has a well-documented positive impact even in children with quadriplegia or total body involvement and is the only surgical procedure which has such a high satisfaction rate among parents and caregivers.