Traumatic C6-C7 dislocation in a 14 year old with posterior spinal fusion for idiopathic scoliosis

Timelines for returning to physical activity following pediatric spinal surgery: recommendations from the literature and preliminary data

Objective

Participation in physical activity and sports is known to have positive implications for physical health, and for social and emotional wellbeing of children. Following corrective spinal surgery for scoliosis, the timeline for the return to activities and sports varies from surgeon to surgeon and from location to location, and return to activities can be limited due to pain, fear, and decreased flexibility. It is critical that patients know best-practice guidelines, and it is equally critical that medical professionals know whether their patients are following those guidelines. This paper includes a summary of recommendations published in the literature, and a pilot study to address a gap in the literature on determining how long, post-surgery, adolescents with idiopathic scoliosis waited before returning to various self-care and physical activities, and what factors influenced return to activities. We used a mixed-method approach that involved two phases: a questionnaire (n = 8), and subsequent interviews of some participants (n = 3). Participants were ages 14–17 (M = 15.4) and had had posterior instrumentation and fusion for scoliosis in the past 2 years.

Results

Some patients were cautious about return to activities, either because of emotional or medical reasons. However, in many instances, participants returned to physical activities earlier than was recommended, primarily for emotional and social reasons.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-021-05571-2.

Allograft versus autograft for pediatric posterior cervical and occipito-cervical fusion: a systematic review of factors affecting fusion rates

OBJECT Fusion rates are high for children undergoing posterior cervical fusion (PCF) and occipito-cervical fusion (OCF). Autologous bone has been widely used as the graft material of choice, despite the risk of donor-site morbidity associated with harvesting the bone, possibly because very low fusion rates were reported with posterior allograft cervical fusions in children several decades ago. Higher overall fusion rates using allograft in adults, associated with improvements in internal fixation techniques and the availability of osteoinductive substances such as bone morphogenetic protein (BMP), have led to heightened enthusiasm for the use of bank bone during pediatric PCF. A systematic review was performed to study factors associated with successful bone fusion, including the type of bone graft used. METHODS The authors performed a comprehensive PubMed search of English-language articles pertaining to PCF and OCF in patients less than 18 years old. Of the 561 abstracts selected, 148 articles were reviewed, resulting in 60 articles that had sufficient detail to be included in the analysis. A meta-regression analysis was performed to determine if and how age, fusion technique, levels fused, fusion substrate, BMP use, postoperative bracing, and radiographic fusion criteria were related to the pooled prevalence estimates. A systematic review of the literature was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. RESULTS A total of 604 patients met the specific inclusion and exclusion criteria. The overall fusion rate was 93%, with a mean age of 9.3 years and mean follow-up of 38.7 months. A total of 539 patients had fusion with autograft (94% fusion rate) and 65 patients with allograft (80% fusion rate). Multivariate meta-regression analysis showed that higher fusion rates were associated with OCF compared with fusions that excluded the occiput (p < 0.001), with the use of autograft instead of allograft (p < 0.001), and with the use of CT to define fusion instead of plain radiography alone. The type of internal fixation, the use of BMP, patient age, and the duration of follow-up were not found to be associated with fusion rates in the multivariate analysis. CONCLUSIONS Fusion rates for PCF are high, with higher rates of fusion seen when autograft is used as the bone substrate and when the occiput is included in the fusion construct. Further study of the use of allograft as a viable alternative to autograft bone fusion is warranted because limited data are available regarding the use of allograft in combination with more rigid internal fixation techniques and osteoinductive substances, both of which may enhance fusion rates with allograft.

Outcomes of instrumented fusion in the pediatric cervical spine

Object

The most common cause of cervical spine arthrodesis in the pediatric population is instability related to congenital or traumatic pathology. Instrumenting the cervical spine can be challenging given smaller anatomical structures, less ossified bone, and future growth potential and development. Studies in adult patients have suggested that using screw constructs results in improved outcomes with lower rates of instrumentation failure. However, the pediatric literature is limited to small retrospective series. Based on a review of the literature and their own patient series, the authors report that instrumenting the pediatric cervical spine with screw constructs may be safer and more effective than using wiring techniques.

Methods

The authors reviewed the existing pediatric cervical spine arthrodesis literature and contributed 31 of their own cases from September 1, 2007, to January 1, 2011. They reviewed 204 abstracts from January 1, 1966, to December 31, 2010, and 80 manuscripts with 883 total patients were included in the review. They recorded demographic, radiographic, and outcomes data—as well as surgical details—with a focus on fusion rates and complications.

Patients were then grouped into categories based upon the procedure performed: 1) patients who underwent fusions bridging the occipitocervical junction and 2) patients who underwent fusion of the cervical spine that did not include the occiput, thus including atlantoaxial and subaxial fusions. Patients were further subdivided according to the type of instrumentation used—some had posterior cervical fusion with wiring (with or without rod implantation); others had posterior cervical fusion with screws.

Results

The entire series comprised 914 patients with a mean age of 8.30 years. Congenital abnormalities were encountered most often (in 55% of cases), and patients had a mean follow-up of 32.5 months. From the entire cohort, 242 patients (26%) experienced postsurgical complications, and 50 patients (5%) had multiple complications. The overall fusion rate was 94.4%.

For occipitocervical fusions (N = 285), both screw and wiring groups had very high fusion rates (99% and 95%, respectively, p = 0.08). However, wiring was associated with a higher complication rate. From a sample of 252 patients, 14% of those treated with screw instrumentation had complications, compared with 50% of patients treated with wiring (p < 0.05).

In cervical fusions not involving the occipitocervical junction (N = 181), screw constructs had a 99% fusion rate, whereas wire instrumentation only had an 83% fusion rate (p < 0.05). Similarly, patients who underwent screw fixation had a lower complication profile (15%) when compared with those treated with wiring constructs (54%, p < 0.05).

Conclusions

The results of this study are limited by variations in construct design, use of orthoses, follow-up duration, and newer adjuvant products promoting fusions. However, a literature review and the authors' own series of pediatric cases suggest that instrumentation of the cervical spine in children may be safer and more efficacious using screw constructs rather than wiring techniques.

Is physical activity contraindicated for individuals with scoliosis? A systematic literature review

OBJECTIVE

The purpose of this study was to perform a systematic review of the literature and other authoritative sources for recommendations regarding the appropriateness of physical and sporting activity for those with scoliosis.

METHODS

The literature was systematically searched in PubMed, the Cumulative Index to Nursing and Allied Health Literature, the Index to Chiropractic Literature, and the National Guidelines Clearinghouse from the earliest date of each database through July 2008. All languages and research designs were included. Web sites of respected organizations were searched for position/white papers on scoliosis and physical activity. Included articles were rated using the Oxford Centre for Evidence-Based Medicine criteria, and recommendations for physical activity were made using the Oxford Centre's criteria for grades of recommendation.

RESULTS

Of 42 articles retrieved, 11 met the inclusion criteria. The Internet review of 18 organizations yielded no previous guidelines or position papers for physical activity and scoliosis. Recommendations were made from 3 level 3b studies and 8 level 5 studies; they include the following: (1) brace-treated and surgically treated scoliosis patients have demonstrated that they can physically participate in physical activities at the same level as nonsurgical patients (grade C recommendation); (2) nonsurgically treated patients are encouraged to participate in sports and physical activity and (3) scoliosis is not a contraindication to participation in most sports (grade D recommendation); (4) brace-treated scoliosis patients are encouraged to exercise with their brace on; however, exercise may also be done outside of the brace (grade D recommendation); and (5) physical activity may be commenced after surgery for scoliosis; however, no high-quality evidence exists that guides the timing of return to physical activity (grade D recommendation). A potential association between elite-level competition in specific sports at an early age and an increased prevalence of scoliosis has been reported (grade C recommendation).

CONCLUSION

This article offers evidence-based guidance to health care providers and to patients with scoliosis when making decisions to participate in physical and sporting activities.

Rate of complications in scoliosis surgery - a systematic review of the Pub Med literature

Background

Spinal fusion surgery is currently recommended when curve magnitude exceeds 40–45 degrees. Early attempts at spinal fusion surgery which were aimed to leave the patients with a mild residual deformity, failed to meet such expectations. These aims have since been revised to the more modest goals of preventing progression, restoring 'acceptability' of the clinical deformity and reducing curvature.

In view of the fact that there is no evidence that health related signs and symptoms of scoliosis can be altered by spinal fusion in the long-term, a clear medical indication for this treatment cannot be derived. Knowledge concerning the rate of complications of scoliosis surgery may enable us to establish a cost/benefit relation of this intervention and to improve the standard of the information and advice given to patients. It is also hoped that this study will help to answer questions in relation to the limiting choice between the risks of surgery and the "wait and see – observation only until surgery might be recommended", strategy widely used. The purpose of this review is to present the actual data available on the rate of complications in scoliosis surgery.

Materials and methods

Search strategy for identification of studies; Pub Med and the SOSORT scoliosis library, limited to English language and bibliographies of all reviewed articles. The search strategy included the terms; 'scoliosis'; 'rate of complications'; 'spine surgery'; 'scoliosis surgery'; 'spondylodesis'; 'spinal instrumentation' and 'spine fusion'.

Results

The electronic search carried out on the 1^st February 2008 with the key words "scoliosis", "surgery", "complications" revealed 2590 titles, which not necessarily attributed to our quest for the term "rate of complications". 287 titles were found when the term "rate of complications" was used as a key word. Rates of complication varied between 0 and 89% depending on the aetiology of the entity investigated. Long-term rates of complications have not yet been reported upon.

Conclusion

Scoliosis surgery has a varying but high rate of complications. A medical indication for this treatment cannot be established in view of the lack of evidence. The rate of complications may even be higher than reported. Long-term risks of scoliosis surgery have not yet been reported upon in research. Mandatory reporting for all spinal implants in a standardized way using a spreadsheet list of all recognised complications to reveal a 2-year, 5-year, 10-year and 20-year rate of complications should be established. Trials with untreated control groups in the field of scoliosis raise ethical issues, as the control group could be exposed to the risks of undergoing such surgery.

Impact of spine surgery on signs and symptoms of spinal deformity

Paediatric scoliosis is associated with signs and symptoms including reduced pulmonary function, increased pain and impaired quality of life, all of which worsen during adulthood, even when the curvature remains stable. Spinal fusion has been used as a treatment for nearly 100 years. In 1941, the American Orthopedic Association reported that for 70% of patients treated surgically, outcome was fair or poor: an average 65% curvature correction was reduced to 27% at >2 year follow-up and the torso deformity was unchanged or worse. Outcome was worse in children treated surgically before age 10, despite earlier intervention. Today, a reduced magnitude of curvature obtained by spinal fusion in adolescence can be maintained for decades. However, successful surgery still does not eliminate spinal curvature and it introduces irreversible complications whose long-term impact is poorly understood. For most patients there is little or no improvement in pulmonary function. Some report improved pain after surgery, some report no improvement and some report increased pain. The rib deformity is eliminated only by rib resection which can dramatically reduce respiratory function even in healthy adolescents. Outcome for pulmonary function and deformity is worse in patients treated surgically before the age of 10 years, despite earlier intervention. Research to develop effective non-surgical methods to prevent progression of mild, reversible spinal curvatures into complex, irreversible structural deformities, is long overdue.