Bleeding and coagulation changes during spinal fusion surgery: a comparison of neuromuscular and idiopathic scoliosis patients

Does tranexamic acid reduce transfusion requirements in children with cerebral palsy undergoing osteotomies? A systematic review and meta-analysis

Introduction

Children with cerebral palsy have postural alterations and hip displacements are common among them, for which osteotomies must be carried out, involving great blood loss. Tranexamic acid (TXA), a fibrinolysis inhibitor, has been shown to reduce bleeding in osteotomies. However, the effectiveness of TXA in children with cerebral palsy has not been well studied, so a comprehensive meta-analysis is required to evaluate its impact.

Objective

We conducted a meta-analysis to investigate the effectiveness of tranexamic acid administration in reducing blood loss and transfusions during osteotomies in children with cerebral palsy.

Methods

Databases were searched until April 17, 2024, for randomized controlled trials and observational cohort studies comparing TXA use versus a control group. The primary outcome was overall transfusion.Secondary outcomes included intraoperative transfusion, postoperative transfusion, postoperative hemoglobin (Hb), postoperative hematocrit (Hct), drop in Hct, drop in Hb, length of stay, total blood loss (TBL) and estimated blood loss (EBL). The analysis utilized pooled relative risk ratios (RR) for categorical variables, and mean difference (MD) for numerical variables. We utilized the fixed-effects model utilizing the Mantel-Haenszel method.

Results

The analysis included 7 articles, which collectively provided data on 943 patients. It was found thatTXA administration decreases overall transfusion rate (RR = 0,65, 95 % CI: 0.47 to 0,90, p = 0,008),postoperative transfusion rate (RR = 0.53, 95 % CI: 0.36 to 0,79, p = 0.002) and TBL (MD = -139,41, 95 % CI: 221,34 to -57,48, p = 0,0009). There was less length of stay in the control group (MD = 0,47, 95 % CI: 0.10 to0,84, p = 0,01). TXA doesn't demonstrate significant differences in EBL, intraoperative transfusion rate, postoperative Hb, postoperative Hct, drop in Hct or drop in Hb.

Conclusion

TXA reduces the need of transfusion and total blood loss and increased length of hospital stay. And TXA doesn't demonstrate significant differences in EBL, intraoperative transfusion rate, postoperative Hb, postoperative Hct, drop in Hct or drop in Hb.

The role of scoliosis on the comorbidity and demographics of neurofibromatosis type 1 patients: A retrospective analysis of the National Inpatient Sample database

Neurofibromatosis type 1 (NF1) is the most common neurocutaneous syndrome in the United States, affecting every 1 in 3000 individuals. NF1 occurs due to non-functional mutations in the NF1 gene, which expresses neurofibromin, a protein involved in tumour suppression. As a result, NF1 typically presents with non-cancerous neoplasm masses called neurofibromas across the body. Out of all NF1 abnormalities, the most common skeletal abnormality seen in around 10%-30% of NF1 patients is scoliosis, an improver curvature of the spine. However, there is a lack of research on the effects of scoliosis on demographics and morbidities of NF1 patients. We performed a national analysis to investigate the complex relationship between NF1 and scoliosis on patients' demographics and comorbidities. We conducted a retrospective cross-sectional analysis of the 2017 US National Inpatient Sample database using univariable Chi-square analysis and multivariable binary logistic regression analysis to determine the interplay of NF1 and scoliosis on patients' demographics and comorbidities. Our query resulted in 4635 total NF1 patients, of which 475 (10.25%) had scoliosis and 4160 (89.75%) did not. Demographic analysis showed that NF1 patients with scoliosis were typically younger, female and white compared to NF1 patients without scoliosis. Comorbidity analysis showed that NF1 patients with scoliosis were more likely to develop malignant brain neoplasms, epilepsy, hydrocephalus, pigmentation disorders, hypothyroidism, diabetes with chronic complications and coagulopathy disorders. NF1 patients with scoliosis were less likely to develop congestive heart failure, pulmonary circulation disease, peripheral vascular disease, paralysis, chronic pulmonary disease, lymphoma and psychosis. NF1 patients with scoliosis were predominantly younger, female, white patients. The presence of scoliosis in NF1 patients increases the risks for certain brain neoplasms and disorders but serves a protective effect against some pulmonary and cardiac complications.

Distal fusion in Duchenne scoliosis: the relevance of preoperative pelvic obliquity. A case series study

PURPOSE

The aim of this study was to determine clinical and radiographic outcomes for Duchenne Muscular Dystrophy (DMD) patients who underwent posterior spinal fusion from T2/3 to L5 (without pelvic fixation), at this single centre.

METHODS

From January 2012 to January 2020, 29 consecutive DMD scoliosis patients underwent posterior spinal fusion using pedicle screws from T2/3 to L5 in a single center with a minimum of 3 years follow-up (FU). Radiologic measurements and chart review were performed.

RESULTS

Twenty nine patients aged 14 ± 1.5 years were included. No patient was lost to FU. All patients had significant correction in Cobb angle, pelvic obliquity (PO) and lumbar lordosis (LL), without loss of correction at last FU. The mean values for preoperative, immediate postoperative and last FU were CA 62o, 15o and 17o, PO: 21o, 8o and 9o; and LL 10o, -41o and -41o respectively. Correction in CA was independent of any variable analysed including implant density, rod diameter, traction, or bone density. Regarding PO, it was inversely related to age and independent of all other variables. Factors associated with postoperative complications were age and respiratory function.

CONCLUSIONS

It appears from our results that pelvic fixation might not always be required in DMD scoliosis surgery, when using pedicle screws with lowest instrumented vertebra at L5. However, larger preoperative PO values can be related with residual PO. It seems that probably related to the underlying condition, early surgery may decrease incidence of complications.

LEVEL OF EVIDENCE

IV.

Comparison of baseline characteristics and postoperative complications in neuromuscular, syndromic and congenital scoliosis

Nonidiopathic scoliosis encompasses a group of diagnoses, including neuromuscular scoliosis, syndromic scoliosis and congenital scoliosis. The objective of this study was to compare the preoperative and postoperative clinical differences in pediatric nonidiopathic scoliosis patients with neuromuscular scoliosis vs. syndromic scoliosis/congenital scoliosis. This is a single-center retrospective review of all pediatric patients undergoing spinal instrumentation for nonidiopathic scoliosis during a 5-year period. Neuromuscular scoliosis patients ( n  = 144), syndromic scoliosis patients ( n  = 44) and congenital scoliosis patients ( n  = 52) were compared. Demographics, patient characteristics and outcomes were compared. Neuromuscular scoliosis patients had lower BMI z-scores and were more likely to have pulmonary disease, technology dependence and seizure disorder. Additionally, neuromuscular scoliosis patients underwent bigger procedures with more levels fused and a higher rate of pelvis fixation. By direct comparison, neuromuscular scoliosis patients tended to have more complications including deep surgical site infections, readmission in 30 days, return to operating room in 90 days and emergency care visits in 90 days. When controlling for the differences in their preexisting conditions and surgical procedure, we found that pelvic fixation was a major confounding factor, whereas the others had no effect. We further subanalyzed cerebral palsy patients and found this group to exhibit no difference in complications compared to other neuromuscular scoliosis subtypes. Neuromuscular scoliosis patients have different characteristics and subsequent postoperative complications than those with syndromic scoliosis and congenital scoliosis. The difference in complication profile is mainly due to differences in surgical procedure and a higher rate of pelvic fixation. This should be considered when planning nonidiopathic scoliosis surgery among multidisciplinary teams.

Anesthesia and Perioperative Management for Surgical Correction of Neuromuscular Scoliosis in Children: A Narrative Review

Scoliosis is the most frequent spinal deformity in children. It is defined as a spine deviation of more than 10° in the frontal plane. Neuromuscular scoliosis is associated with a heterogeneous spectrum of muscular or neurological symptoms. Anesthesia and surgery for neuromuscular scoliosis have a higher risk of perioperative complications than for idiopathic scoliosis. However, patients and their relatives report improved quality of life after the surgery. The challenges for the anesthetic team result from the specifics of the anesthesia, the scoliosis surgery itself, or factors associated with neuromuscular disorders. This article includes details of preanesthetic evaluation, intraoperative management, and postoperative care in the intensive care unit from an anesthetic view. In summary, adequate care for patients who have neuromuscular scoliosis requires interdisciplinary cooperation. This comprehensive review covers information about the perioperative management of neuromuscular scoliosis for all healthcare providers who take care of these patients during the perioperative period, with an emphasis on anesthesia management.

Perioperative Risk Factors for Bleeding in Adolescents Undergoing Pedicle Screw Instrumentation for Scoliosis

Progressive scoliosis eventually leads to extensive spinal fusion surgery, which carries a risk for significant bleeding. Neuromuscular scoliosis (NMS) patients have an additional inherent risk of major perioperative bleeding. The purpose of our research was to investigate the risk factors for measured (intraoperative, drain output) and hidden blood loss related to pedicle screw instrumentation in adolescents, divided into adolescent idiopathic scoliosis (AIS) and NMS patient groups. A retrospective cohort study with prospectively collected data of consecutive AIS and NMS patients undergoing segmental pedicle screw instrumentation at a tertiary level hospital between 2009 and 2021 was conducted. In total, 199 AIS (mean age 15.8 years, 143 females) and 81 NMS patients (mean age 15.2 years, 37 females) were included in the analysis. In both groups, levels fused, increased operative time, and smaller or larger size of erythrocytes were associated with perioperative blood loss (p < 0.05 for all correlations). In AIS, male sex (p < 0.001) and the number of osteotomies correlated with more drain output. In NMS, levels fused correlated with drain output, p = 0.00180. In AIS, patients' lower preoperative MCV levels (p = 0.0391) and longer operation times, p = 0.0038, resulted into more hidden blood loss, but we did not find any significant risk factors for hidden blood loss in NMS patients.

Hemodynamic Consideration in Intraoperative Neurophysiological Monitoring in Neuromuscular Scoliosis Surgery

OBJECTIVE

To prove the hypothesis that the parameters of intraoperative neurophysiological monitoring (IONM) during will be more deteriorated in neuromuscular scoliosis (NMS) than in adolescent idiopathic scoliosis (AIS).

METHODS

This retrospective study reviewed the data of 69 patients (NMS=32, AIS=37) who underwent scoliosis surgery under IONM. The amplitude of motor evoked potentials (MEPs), and the amplitude and the latency of somatosensory evoked potentials (SEPs) were examined. Demographic, preoperative, perioperative and postoperative data were analyzed to determine whether they affected the IONM parameters for each group.

RESULTS

Of the items analyzed, the bleeding amount was the only significant risk factor for SEP latency deterioration in the NMS group only. The amplitude of SEP and MEP did not correlate with the hemodynamic parameters. The NMS/AIS ratios of the bleeding-related parameters were higher in the order of bleeding amount/weight (2.62, p<0.01), bleeding amount/body mass index (2.13, p<0.01), and bleeding amount (1.56, p<0.01). This study suggests that SEP latency is more vulnerable than SEP or MEP amplitude in ischemic conditions during scoliosis surgery.

CONCLUSION

In NMS patients, it should be considered that the bleeding amount can have a critical effect on intraoperative electrophysiological deterioration.

Factors affecting need for blood transfusion in paediatric patients undergoing open surgery for hip dysplasia

BACKGROUND AND OBJECTIVES

The management of intraoperative blood loss in the surgical treatment of paediatric hip dysplasia is resource intensive. There are numerous clinical factors that impact the need for intraoperative transfusion. Identification of patient and surgical factors associated with increased blood loss may reduce the unnecessary use of resources. This study aimed to identify factors predictive of intraoperative transfusion in children undergoing hip dysplasia surgery.

MATERIALS AND METHODS

This is a single-centre retrospective review of patients undergoing surgery for hip dysplasia from 1 January 2012 to 15 April 2021. Patient demographic factors, anaesthetic, surgical and transfusion histories were reviewed. Multivariable logistic regression analysis was performed to identify factors predictive of allogeneic red blood cell transfusion requirements during the intraoperative period.

RESULTS

This study includes 595 patients who underwent open surgery for hip dysplasia, including 297 (52.6%) classified as developmental dysplasia (DD) and 268 (47.3%) as neuromuscular (NM) with a mean age of 9.1 years (interquartile range 3-14). Intraoperative allogeneic transfusion was identified in 26/297 (8.8%) DD and 73/268 (27.2%) NM patients. Adjusted factors associated with increased odds of intraoperative transfusion were NM (odds ratio [OR] = 2.96, 95% confidence interval [CI] [1.76, 5.00]) and the number of osteotomies performed (OR = 1.82/osteotomy, 95% CI [1.40, 2.35]). Adjusted factors that reduced the odds of transfusion were the use of antifibrinolytics (OR = 0.35, 95% CI [0.17, 0.71]) and regional anaesthesia (OR = 0.52, 95% CI [0.29, 0.94]).

CONCLUSION

For children undergoing surgery for hip dysplasia, the number of osteotomies performed is predictive of the need for allogeneic blood transfusion. Antifibrinolytics and regional anaesthesia are associated with reduced risk for allogeneic blood transfusion. Blood management initiatives, such a preoperative optimization of haemoglobin and the use of antifibrinolytics, could target patients at increased risk of intraoperative bleeding and transfusion.

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.

Does Abnormal Preoperative Coagulation Status Lead to More Perioperative Blood Loss in Spinal Deformity Correction Surgery?

This study aims to analyze the potential association between the preoperative coagulation status and perioperative blood loss in spinal deformity correction surgery. The preoperative coagulation status and estimated blood loss (EBL) during operation, postoperative wound drainage, and allogeneic transfusion during and after operation were recorded and analyzed. Among the 164 patients, 26 had a longer prothrombin time (PT), 13 had a lower fibrinogen level, 55 had a longer activated partial thromboplastin time (APTT), and 2 had a longer thrombin time (TT), and the platelet count (PLT) was all normal or higher than the normal level. The mean EBL per surgical level was 77.8 ml (range, 22–267 ml), and the mean drainage per surgical level was 52.7 ml (range, 7–168 ml). Fifty-five patients and 12 patients underwent allogeneic transfusion during and after the operation, respectively. The differences in EBL per surgical level, mean drainage per surgical level, the occurrences of allogeneic transfusion during and after operation between the patients with a longer PT, lower fibrinogen level, longer APTT or longer TT, and the normal controls were not significant (all P’s > 0.05). The Spearman correlation analysis showed that there was no correlation between PT, fibrinogen, APTT, TT or PLT with EBL per surgical level, mean drainage per surgical level, or allogeneic transfusion during and after the operation (all P’s > 0.05). The abnormal preoperative coagulation status but not hemophilia does not lead to more perioperative blood loss or a higher rate of perioperative allogeneic transfusion in spinal deformity correction surgery.

Variable Response to Antifibrinolytics Correlates with Blood-loss and Transfusion in Posterior Spinal Fusion

PURPOSE

Posterior spinal fusion (PSF) activates the fibrinolytic protease plasmin, which is implicated in blood loss and transfusion. While antifibrinolytic drugs have improved blood loss and reduced transfusion, variable blood loss has been observed in similar PSF procedures treated with the same dose of antifibrinolytics. However, both the cause of this and the appropriate measures to determine antifibrinolytic efficacy during high-blood-loss spine surgery are unknown, making clinical trials to optimize antifibrinolytic dosing in PSF difficult. We hypothesized that patients undergoing PSF respond differently to antifibrinolytic dosing, resulting in variable blood loss, and that specific diagnostic markers of plasmin activity will accurately measure the efficacy of antifibrinolytics in PSF.

METHODS

A prospective study of 17 patients undergoing elective PSF with the same dosing regimen of TXA was conducted. Surgery-induced plasmin activity was exhaustively analyzed in perioperative blood samples and correlated to measures of inflammation, bleeding, and transfusion.

RESULTS

While markers of in vivo plasmin activation (PAP and D-dimer) suggested significant breakthrough plasmin activation and fibrinolysis (P < 0.01), in vitro plasmin assays, including TEG, did not detect plasmin activation. In vivo measures of breakthrough plasmin activation correlated with blood loss (R2 = 0.400, 0.264; P < 0.01), transfusions (R2 = 0.388; P < 0.01), and complement activation (R2 = 0.346, P < 0.05).

CONCLUSIONS

Despite all patients receiving a high dose of TXA, its efficacy among patients was variable, indicated by notable intra-operative plasmin activity. Markers of in vivo plasmin activation best correlated with clinical outcomes. These findings suggest that the efficacy of antifibrinolytic therapy to inhibit plasmin in PSF surgery should be determined by markers of in vivo plasmin activation in future studies.

LEVEL OF EVIDENCE

Level II-diagnostic.

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.

Ambulatory Neuromuscular Scoliosis Patients Have Superior Perioperative Results Than Nonambulatory Neuromuscular Scoliosis Patients and Can Approach Adolescent Idiopathic Scoliosis Outcomes After Posterior Spinal Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

This study aims to identify differences in perioperative outcomes between ambulatory patients with neuromuscular scoliosis (ANMS) and adolescent idiopathic scoliosis (AIS) following spinal fusion.

SUMMARY OF BACKGROUND DATA

NMS patients have severe curves with more comorbidities and procedural complexity. These patients require extensive fusion levels, increased blood loss, and suffer increased periop complications. However, NMS patients have a variable severity spectrum, including ambulation status.

METHODS

Chart and radiographic review of NMS and AIS patients undergoing PSF from 2005 to 2018. NNMS included NMS patients who were completely dependent (GMFCS IV-V). ANMS consisted of community ambulators without significant reliance on wheeled assistive devices (GMFCS I-III). Subanalysis matched by age, sex, levels fused and preoperative Cobb angle was conducted as well. Wilcoxon Rank-Sum, Kruskal-Wallis, χ2, and Fisher exact tests were performed.

RESULTS

There were 120 patients in the NNMS group, 54 in ANMS and 158 in the AIS group. EBL was significantly lower for ANMS and AIS patients (P < 0.001). Complications within 30 days were similar between ANMS and AIS (P = 1.0), but significantly higher for NNMS (P < 0.001). Two (1.3%) AIS patients, (1.7%) nonambulatory NMS patients, and one (1.9%) ANMS patient required revision surgery (P = 1.0). However, all NMS patients had increased fusion levels, fixation points, and surgery time (P < 0.05). NNMS had significantly longer ICU (P < 0.001), hospital stay (P < 0.001), intraoperative transfusions (P < 0.001), and fewer patients extubated in the OR (P < 0.001) than ANMS and AIS patients. In the subanalysis, ANMS had similar radiographic measurements, EBL, transfusion, surgery time, extubation rate, and complication rate (P > 0.05) to AIS.

CONCLUSION

Our data show radiographic outcomes, infections, revisions, and overall complications for ANMS were similar to the AIS population. This suggests that NMS patients who ambulate primarily without assistance can expect surgical outcomes comparable to AIS patients with further room for improvement in length of ICU and hospital stay.Level of Evidence: 4.

Tranexamic acid use decreases transfusion rate in children with cerebral palsy undergoing proximal femoral varus derotational osteotomy

ABSTRACT

Previous studies demonstrated the safety of tranexamic acid (TXA) use in cerebral palsy (CP) patients undergoing proximal femoral varus derotational osteotomy (VDRO), but were underpowered to determine if TXA alters transfusion rates or estimated blood loss (EBL). The purpose of this study was to investigate if intraoperative TXA administration alters transfusion rates or EBL in patients with CP undergoing VDRO surgery.We conducted a retrospective review of 390 patients with CP who underwent VDRO surgery between January 2004 and August 2019 at a single institution. Patients without sufficient clinical data and patients with preexisting bleeding or coagulation disorders were excluded. Patients were divided into 2 groups: those who received intraoperative TXA and those who did not.Out of 390 patients (mean age 9.4 ± 3.8 years), 80 received intravenous TXA (TXA group) and 310 did not (No-TXA group). There was no difference in mean weight at surgery (P = .25), Gross Motor Function Classification System level (P = .99), American Society of Anesthesiologist classification (P = .50), preoperative feeding status (P = .16), operative time (P = .91), or number of procedures performed (P = .12) between the groups. The overall transfusion rate was lower in the TXA group (13.8%; 11/80) than the No-TXA group (25.2%; 78/310) (P = .04), as was the postoperative transfusion rate (7.5%; 6/80 in the TXA group vs 18.4%; 57/310 in the No-TXA group) (P = .02). The intraoperative transfusion rate was similar for the 2 groups (TXA: 7.5%; 6/80 vs No-TXA: 10.3%; 32/310; P = .53). The EBL was slightly lower in the TXA group, although this was not significant (TXA: 142.9 ± 113.1 mL vs No-TXA: 177.4 ± 169.1 mL; P = .09). The standard deviation for EBL was greater in the No-TXA group due to more high EBL outliers. The percentage of blood loss based on weight was similar between the groups (TXA: 9.2% vs No-TXA: 10.1%; P = .40). The number needed to treat (NNT) with TXA to avoid one peri-operative blood transfusion in this series was 9.The use of intraoperative TXA in patients with CP undergoing VDRO surgery lowers overall and postoperative transfusion rates.Level of evidence: III, Retrospective Comparative Study.

Intravenous Tranexamic Acid Reduces Blood Loss and Transfusion Volume in Scoliosis Surgery for Spinal Muscular Atrophy: Results of a 20-Year Retrospective Analysis

Intravenous tranexamic acid (TXA) has been administered to reduce intraoperative blood loss in scoliosis surgery. However, the therapeutic effect of TXA on spinal muscular atrophy (SMA) scoliosis surgery is not well demonstrated. Therefore, this study aimed to assess the efficacy of intravenous TXA in SMA scoliosis surgery. From December 1993 to August 2020, 30 SMA patients who underwent scoliosis surgery (posterior fusion with fusion level of thoracic second or third to pelvis) were retrospectively enrolled and divided into the TXA group and non-TXA (control) group, with 15 patients in each group. Survey parameters were the amount of blood loss, blood transfusion, crystalloid transfusion volume, intubation time, and associated pulmonary complications (including pneumonia, pulmonary edema, and pulmonary atelectasis). The TXA group had significantly lesser blood loss than the control group (p = 0.011). Compared with the control group, the TXA group had significantly lower blood transfusion (p < 0.001), crystalloid volume (p = 0.041), and total transfusion volume (p = 0.005). In addition, the TXA group had fewer postoperative pulmonary complications, and patients with pulmonary complications were associated with a higher relative crystalloid volume and relative total transfusion volume (p = 0.003 and 0.022, respectively). In conclusion, TXA can be effective in reducing intraoperative blood loss and crystalloid fluid transfusions during scoliosis surgery in SMA patients, which may aid in reducing postoperative pulmonary complications.

Multi-Organ Dysfunction in Cerebral Palsy

Cerebral Palsy (CP) describes a heterogenous group of non-progressive disorders of posture or movement, causing activity limitation, due to a lesion in the developing brain. CP is an umbrella term for a heterogenous condition and is, therefore, descriptive rather than a diagnosis. Each case requires detailed consideration of etiology. Our understanding of the underlying cause of CP has developed significantly, with areas such as inflammation, epigenetics and genetic susceptibility to subsequent insults providing new insights. Alongside this, there has been increasing recognition of the multi-organ dysfunction (MOD) associated with CP, in particular in children with higher levels of motor impairment. Therefore, CP should not be seen as an unchanging disorder caused by a solitary insult but rather, as a condition which evolves over time. Assessment of multi-organ function may help to prevent complications in later childhood or adulthood. It may also contribute to an improved understanding of the etiology and thus may have an implication in prevention, interventional methods and therapies. MOD in CP has not yet been quantified and a scoring system may prove useful in allowing advanced clinical planning and follow-up of children with CP. Additionally, several biomarkers hold promise in assisting with long-term monitoring. Clinicians should be aware of the multi-system complications that are associated with CP and which may present significant diagnostic challenges given that many children with CP communicate non-verbally. A step-wise, logical, multi-system approach is required to ensure that the best care is provided to these children. This review summarizes multi-organ dysfunction in children with CP whilst highlighting emerging research and gaps in our knowledge. We identify some potential organ-specific biomarkers which may prove useful in developing guidelines for follow-up and management of these children throughout their lifespan.

Preoperative hematocrit and platelet count are associated with blood loss during spinal fusion for children with neuromuscular scoliosis

AIM

To assess the relationship of preoperative hematology laboratory results with intraoperative estimated blood loss and transfusion volumes during posterior spinal fusion for pediatric neuromuscular scoliosis.

METHODS

Retrospective chart review of 179 children with neuromuscular scoliosis undergoing spinal fusion at a tertiary children's hospital between 2012 and 2017. The main outcome measure was estimated blood loss. Secondary outcomes were volumes of packed red blood cells, fresh frozen plasma, and platelets transfused intraoperatively. Independent variables were preoperative blood counts, coagulation studies, and demographic and surgical characteristics. Relationships between estimated blood loss, transfusion volumes, and independent variables were assessed using bivariable analyses. Classification and Regression Trees were used to identify variables most strongly correlated with outcomes.

RESULTS

In bivariable analyses, increased estimated blood loss was significantly associated with higher preoperative hematocrit and lower preoperative platelet count but not with abnormal coagulation studies. Preoperative laboratory results were not associated with intraoperative transfusion volumes. In Classification and Regression Trees analysis, binary splits associated with the largest increase in estimated blood loss were hematocrit ≥44% vs. <44% and platelets ≥308 vs. <308 × 10⁹/L.

CONCLUSIONS

Preoperative blood counts may identify patients at risk of increased bleeding, though do not predict intraoperative transfusion requirements. Abnormal coagulation studies often prompted preoperative intervention but were not associated with increased intraoperative bleeding or transfusion needs.

Perioperative Optimization of Patients With Neuromuscular Disorders Undergoing Scoliosis Corrective Surgery: A Multidisciplinary Team Approach

STUDY DESIGN

Narrative review.

OBJECTIVE

The high rate of complications associated with the surgical management of neuromuscular spinal deformities is well documented in the literature. This is attributed to attenuated protective physiological responses in multiple organ systems.

METHODS

Review and synthesis of the literature pertaining to optimization of patients with neuromuscular scoliosis undergoing surgery. Our institutional practice in the perioperative assessment and management of neuromuscular scoliosis is also described along with a clinical vignette.

RESULTS

Respiratory complications are the most common to occur following surgery for neuromuscular disorders. Other categories include gastrointestinal, cardiac, genitourinary, blood loss, and wound complications. A multidisciplinary approach is required for perioperative optimization of these patients and numerous strategies are described, including respiratory management.

CONCLUSION

Perioperative optimization for patients with neuromuscular disorders undergoing corrective surgery for spinal deformity is multifaceted and complex. It requires a multidisciplinary evidence-based approach. Preadmission of patients in advance of surgery for assessment and optimization may be required in certain instances to identify key concerns and formulate a tailored treatment plan.

Efficacy of antifibrinolytics in pediatric orthopedic surgery: a systematic review and meta-analysis

Antifibrinolytics (AFs) stabilize blood clot formation and reduce bleeding. The purpose of this systematic review and meta-analysis was to determine the impact of AF use on intraoperative blood loss and the need for blood transfusion in pediatric orthopedic surgery. A systematic review was performed using Medline and Embase to identify studies that utilized AFs during pediatric orthopedic surgery. The primary outcome measure was intraoperative blood loss in ml. Secondary outcomes included blood transfusion and thromboembolic events. Pooled estimates were derived from a random-effects model. Heterogeneity was assessed using the Cochrane Q and I statistic. Meta-regression assessed if age or study quality modified the effect of AFs on blood loss. Publication bias was assessed using a funnel plot, Egger regression analysis, and the Kendall τ-test. Twenty studies, with a total of 1356 patients, were included. The mean difference in intraoperative blood loss was 653 ml [95% confidence interval (CI): 464-842 ml, P < 0.001]. Similarly, the mean difference in percent of blood volume lost was 22% less in patients treated with AFs compared with controls (95% CI: 12-32, P < 0.001). Patients treated with AFs had a lower odds of transfusion compared to controls (OR: 0.324; 95% CI: 0.105-0.997, P = 0.049). The use of AF in pediatric orthopedic surgery results in decreased intraoperative blood loss and a lower risk of blood transfusion. The majority of studies included involve spine surgery; the benefits of AFs in extremity surgery in the pediatric population have yet to be delineated. Level of Evidence: Level II.

Development of Consensus Based Best Practice Guidelines for Perioperative Management of Blood Loss in Patients Undergoing Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

STUDY DESIGN

Delphi process with multiple iterative rounds using a nominal group technique.

OBJECTIVE

The aim of this study was to use expert opinion to achieve consensus on various methods for minimizing blood loss in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

BACKGROUND DATA

Perioperative blood loss management represents a critical component of safely performing PSF in children with AIS. Little consensus exists on ways to mitigate excessive blood loss after PSF.

METHODS

An expert panel composed of 21 pediatric spine surgeons was selected. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were presented with a detailed literature review and asked to voice opinion collectively during three rounds of voting. Agreement >80% was considered consensus. Interventions without consensus were discussed and revised, if feasible.

RESULTS

Consensus was reached to support 21 best practice guideline measures for perioperative management of blood loss in patients undergoing PSF for AIS. Areas included preoperative assessment and preparation, intraoperative strategies to decrease blood loss, and postoperative transfusion indications.

CONCLUSION

We present a consensus-based best practice guideline consisting of 21 recommendations for strategies to minimize and manage blood loss during PSF. This can serve to reduce variability in practice in this area, help develop hospital specific protocols, and guide future research.

Unexpected higher blood loss associated with higher dose ε-aminocaproic acid in pediatric scoliosis surgery

The purpose of this study was to determine if a higher dosing of ε-aminocaproic acid (EACA) is associated with less perioperative blood loss than a lower dose. A total of 74 patients having scoliosis surgery were analyzed. Of the 74 patients, 36 patients received EACA (10 mg/kg/h) and 38 patients received EACA (33 mg/kg/h). After controlling for key variables, an infusion of 33 mg/kg/h of EACA was associated with an increase in intraoperative blood loss of 8.1 ml/kg compared with an infusion of 10 mg/kg/h of EACA. A 33 mg/kg/h intraoperative infusion is associated with higher intraoperative blood loss than an infusion at 10 mg/kg/h.

Bipolar Sealer Devices Used in Posterior Spinal Fusion for Neuromuscular Scoliosis Reduce Blood Loss and Transfusion Requirements

BACKGROUND

Reducing perioperative blood loss and the need for transfusions in patients undergoing spinal surgery is especially important for those with neuromuscular disorders. These patients require extensive spino-pelvic exposure and are often medically fragile. We have used Amicar to decrease blood loss since 2001. As an effort to further reduce blood loss and transfusions, we use a bipolar sealer device (Aquamantys) as an adjunct to electrocautery. We present the results of our first 64 neuromuscular patients to show the efficacy of the device.

METHODS

Using a prospectively maintained database we reviewed the operative time, estimated perioperative blood loss, cell saver use, and intraoperative and postoperative transfusion rate in patients who underwent posterior spinal fusion for neuromuscular scoliosis. Sixty-four patients were identified who fit these criteria since the use of the bipolar sealer device was instituted.We compared these patients with a control group of the preceding 65 patients in whom this device was not used for hemostasis. All patients, including those in the study group, received Amicar (infusion of 100 mg/kg over 15 to 20 min, then 10 mg/kg/h throughout the remainder of the procedure). The surgical technique did not differ between the 2 groups.

RESULTS

Baseline characteristics between the 2 groups were similar except for the number of patients having an all-screw construct which was larger in the investigational group (25% vs. 8%, P=0.03). There were no significant differences in operative time or duration of hospital stay. Intraoperative blood loss was lower in the study group (741 mL) as compared with the control group (1052 mL, P=0.003). Total perioperative blood loss, however, showed no significant difference. Thirty-five (55%) patients in the study group and 50 (77%) patients in the control group required additional intraoperative or postoperative transfusions (P=0.01). The number of packed red cell units transfused per patient was 0.81 in the study group and 1.57 in the control group (P=0.001). Although the intraoperative cell saver transfusion was same, the total blood volume transfused, which includes cell saver and any other transfusions, was significantly lower in the study group, 425 mL versus 671 mL (P=0.002).

CONCLUSIONS

Use of a bipolar sealer device in posterior spinal fusion for neuromuscular scoliosis significantly reduced intraoperative blood loss and transfusion rate when compared with a control group in this retrospective review.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Incidence of and Risk Factors for Loss of 1 Blood Volume During Spinal Fusion Surgery in Patients With Cerebral Palsy

BACKGROUND

Spinal fusion surgery is associated with greater blood loss in patients with cerebral palsy (CP) than in patients with adolescent idiopathic scoliosis. Risk factors for loss of 1 blood volume (LOBV) in patients with CP have not been well studied. We investigated the incidence of and risk factors for LOBV during spinal fusion surgery in young patients with CP.

METHODS

We queried a multicenter registry of CP patients for all patients 21 years or younger who had undergone spinal fusion from 2008 through 2013; 272 patients met these criteria. We analyzed data on patient characteristics, preoperative laboratory values, radiographic measures, and surgical characteristics. For univariate analysis, we used χ tests and logistic regression models. Factors that were significant in the univariate analysis were used to construct a multivariate logistic regression model. Significance was set at P<0.01.

RESULTS

Incidence of LOBV was 39.7%. On multivariate analysis, unit rod construct and coronal curve magnitude were significantly associated with LOBV (P<0.01). The multivariate model accounted for 32.2% of variance in LOBV. Compared with patients with pedicle screw-rod constructs, patients with unit rod constructs had 12.6-fold higher odds of LOBV (P<0.01). For each 1-degree increase in coronal curve magnitude, odds of LOBV increased 1.03-fold (P<0.01).

CONCLUSIONS

In patients with CP, there is a substantial risk of LOBV during spinal fusion surgery. Use of unit rod constructs and greater preoperative coronal curves were significant risk factors for LOBV during surgery.

LEVEL OF EVIDENCE

Level II.

Incidence, influencing factors, and prognostic impact of intraoperative massive blood loss in adolescents with neuromuscular scoliosis: A STROBE-compliant retrospective observational analysis

Factors influencing massive blood loss for neuromuscular scoliosis (NMS) patients.Despite advances in surgical and anesthetic techniques, scoliosis surgery is still associated with intraoperative massive blood loss, which can result in postoperative mortality and morbidity. The aim of this study was to assess the incidence, influencing factors, and prognostic impact of intraoperative massive blood loss in adolescents with NMS.A retrospective review of adolescents who underwent posterior spinal instrumentation and fusion for NMS was performed. Perioperative variables and data were recorded. Massive blood loss was defined as an estimated blood loss that exceeds 30% of total blood volume.We obtained data for 114 patients, of whom 63 (55%) had intraoperative massive blood loss. Compared with those without, patients with massive blood loss were more likely to be older, have lower body mass indexes (BMIs), larger Cobb angles, more fused levels, more osteotomy procedures, and prolonged duration of operation. Logistic regression analysis identified the number of fused levels to be more than 12 (P = 0.003, odds ratio = 6.614, 95% confidence interval [CI]: 1.891-23.131), BMI lower than 16.8 kg/m (P = 0.025, odds ratio = 3.293, 95% CI: 1.159-9.357), age greater than 15 years (P = 0.014, odds ratio = 3.505, 95% CI: 1.259-9.761), and duration of operation longer than 4.4 hours (P = 0.016, odds ratio = 3.746, 95% CI: 1.428-9.822) as influencing factors. Patients with massive blood loss are associated with more intraoperative colloids infusion and blood transfusions (red blood cell and fresh frozen plasma), as well as postoperative drainage volume.In adolescents with NMS who underwent posterior spinal instrumentation and fusion operations, intraoperative massive blood loss is common. The number of fused levels, BMI, age, and duration of operation are factors influencing intraoperative massive blood loss.

Coagulation Profile of Patients with Adolescent Idiopathic Scoliosis Undergoing Posterior Spinal Fusion

BACKGROUND

Blood loss and transfusion requirements during posterior spinal fusion for adolescent idiopathic scoliosis remain a concern. The mechanism of bleeding in these patients is poorly characterized. Thromboelastography is a comprehensive test of a patient's coagulation system commonly used in cardiac surgical procedures. It has not been well studied for use in patients with adolescent idiopathic scoliosis.

METHODS

A prospective, observational study of the coagulation profile of patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion is presented. Healthy patients with adolescent idiopathic scoliosis without a bleeding abnormality were analyzed during posterior spinal fusion. Standard coagulation laboratory and thromboelastogram measures were obtained at the time of the incision and at 1-hour intervals during the surgical procedure. Laboratory values were analyzed in relation to outcomes such as bleeding, transfusion, and a fibrinolysis score.

RESULTS

Fifty-eight patients were observed. Eighty-one percent of patients were female, the mean age was 13.5 years, a mean of 11.1 levels were fused, the median estimated blood loss was 645 mL, and 47% of patients received blood products. Overall, laboratory values remained stable throughout the surgical procedure. Mild increases in prothrombin time and partial thromboplastin time were observed, and platelets remained stable. From thromboelastogram analysis, an acceleration of clot formation (decreased reaction time) and a slight increase in clot lysis (increased lysis percentage at 30 minutes) were observed. A fibrinolysis score compiled from the presence of fibrin degradation products, the presence of D-dimers, and increased prothrombin time rose steadily over surgical time. The fibrinolysis score was predictive of both transfusion and greater estimated blood loss per level.

CONCLUSIONS

The stress of posterior spinal fusion induces a hypercoagulable state in patients with adolescent idiopathic scoliosis. Over the first 2 hours of a surgical procedure, varying degrees of fibrinolysis develop. Platelets and coagulation factors are not depleted. Our data support the use of antifibrinolytic therapy for patients with adolescent idiopathic scoliosis.

Intraoperative Cardiopulmonary Arrest in Children Undergoing Spinal Deformity Correction: Causes and Associated Factors

STUDY DESIGN

Retrospective review.

OBJECTIVE

To report the incidence of and risk factors for intraoperative cardiopulmonary arrest (ICA) in children undergoing spinal deformity surgery.

SUMMARY OF BACKGROUND DATA

Spinal deformities in children are associated with comorbidities that can pose substantial risks during surgery.

METHODS

We reviewed records of patients who underwent surgery at two pediatric tertiary-care hospitals from 2004 through 2014. Fisher exact test and the Student t test were used to compare ICA and non-ICA groups by patient diagnosis, estimated blood loss, number of vertebral levels fused, and proportion of blood volume lost (significance, P < 0.05). We classified proximate causes of ICA based on hemoglobin, metabolic panel/electrolyte imbalance, electrocardiogram/echocardiography, and vital signs.

RESULTS

ICA occurred in 11 of 2524 (0.4%) patients. Patients with neuromuscular disorders had a 3-fold higher risk of ICA compared with those without neuromuscular disorders. At the time of ICA, hemoglobin levels were 5  g/dL or less in four patients, potassium was higher than 5.5  mEq/L in six patients, and ionized calcium was less than or equal to 1  mmol/L in two patients. There were significant differences between the ICA and non-ICA groups in mean number of vertebral levels fused (15 vs. 12), patient weight (34 vs. 49  kg), estimated blood loss (2623 vs. 959  mL), and proportion of blood volume lost (1.03 vs. 0.33) (all P < 0.01). Suspected causes of ICA were cardiovascular causes (eight patients) and anaphylaxis, primary rhythm disturbance, and respiratory/airway cause (one patient each). The incidence of ICA for patients with idiopathic scoliosis was 0.13%. Ten of the 11 patients were successfully resuscitated, and one patient died.

CONCLUSION

ICA occurs in approximately 0.4% of children undergoing spinal fusion surgery. Patients with neuromuscular disorders are at greater risk of ICA than those without these disorders.

LEVEL OF EVIDENCE

3.

Clinical relevance of echocardiogram in patients with cerebral palsy undergoing posterior spinal fusion

BACKGROUND

Spinal deformity is one of the secondary musculoskeletal problems that occur with cerebral palsy (CP). Of the co morbidities associated with CP and spinal deformity, cardiac function is of theoretical concern.

OBJECTIVE

The goal of our study was to determine the clinical relevance of routine preoperative cardiology evaluation via echocardiogram for patients with CP presenting for posterior spine fusion (PSF) surgery.

METHODS

A retrospective chart review was performed of CP patients presenting for scoliosis surgery. The data collected for each patient included: age, sex, height, weight, Cobb angle, and medical history. All patients had a preoperative cardiac evaluation.

RESULTS

Seventy-two patients were included. The mean age was 13.6 ± 3.4 years. Left ventricular systolic function was normal in all patients; the mean shortening fraction was 39.3 ± 6.2%. No patient had more than mild insufficiency of either the semilunar or atrioventricular valve. One patient was diagnosed with aortic root dilation as well as aortic valve insufficiency. All patients had PSF surgery without changes in anesthetic or surgical plans, and no patient experienced complications attributable to a cardiac origin.

CONCLUSION

The results suggest that routine preoperative cardiology evaluation via echocardiogram for children with CP in the absence of clinical history or physical examination findings suggestive of cardiac disease is not necessary.

Perioperative changes in PIVKA-II

BACKGROUND AND AIMS

Proteins induced by vitamin K absence for factor II (PIVKA-II) is an enzyme-linked immunosorbent assay that monitors uncarboxylated prothrombin and responds to vitamin K deficits prior to changes in the prothrombin test. The aim of this project was to study perioperative PIVKA-II changes during various types of surgery in a prospective observational study.

METHODS

Patients undergoing abdominal or orthopaedic surgery were included. Blood was sampled on the day of surgery (preoperatively) and up to 5 days after surgery. The activated partial thromboplastin time, Quick and Owren prothrombin times were analyzed, together with PIVKA-II.

RESULTS

Thirty-nine patients were included, 27 +male and 12 +female. All but 7 +patients had elevated PIVKA-II levels preoperatively. PIVKA-II levels had already increased significantly (p < 0.017) on day 1 after surgery as compared to presurgery plasma levels. The median PIVKA-II was highest on day 5. Routine tests were mostly normal. No significant difference in PIVKA-II was seen when comparing patients undergoing abdominal versus orthopaedic surgeries. There was no significant correlation between PIVKA-II and routine coagulation tests. Patients with anterior resection, emergency laparotomy and emergency hip fractures had higher postoperative increases, which could be linked to increased gastrointestinal recovery times, paralytic ileus, peritonitis and comorbidities.

CONCLUSIONS

PIVKA-II levels increase during the perioperative period, despite mostly normal routine coagulation tests. Pre- and perioperative vitamin K supplementation in patients with elevated PIVKA-II levels should be studied, and its clinical significance be defined in future studies.

Getting there--working toward minimizing blood loss in scoliosis surgery

Ryan KM, O'Brien K, Reqan I, O'Byrne JM, Moore D, Kelly PM, et al. The prevalence of abnormal preoperative coagulation tests in pediatric patients undergoing spinal surgery for scoliosis. Spine J 2015;15:1217-22 (in this issue).

The prevalence of abnormal preoperative coagulation tests in pediatric patients undergoing spinal surgery for scoliosis

BACKGROUND CONTEXT

Multilevel spinal fusion surgery for deformity correcting spinal surgery in pediatric patients with scoliosis has typically been associated with significant blood loss. The mechanism of bleeding in such patients is not fully understood. Coagulation abnormalities, which may be associated with scoliosis, are thought to play a role.

PURPOSE

To document and compare the prevalence of preoperative coagulation abnormalities among patients with scoliosis attending a pediatric orthopedic department for spinal fusion surgery with patients attending for minor surgery.

STUDY DESIGN

An observational study. All patients were recruited from a pediatric tertiary referral center in Dublin, Ireland.

PATIENT SAMPLE

Coagulation profile results were prospectively collected over a 2-year period from 165 spinal surgery patients. In total, 175 patients were included in the non-scoliosis group. These patients attended the day ward for minor procedures and were recruited over a 4-month period.

OUTCOME MEASURES

The primary outcome measure was the coagulation profiles, which included prothrombin time, activated partial thromboplastin time (APTT), and thrombin time (TT). Levels of Coagulation Factors II, V, VII, and X were also recorded.

METHODS

All blood samples were sent to the haematology laboratory to establish the coagulation profile. The primary outcome was the presence of an abnormal coagulation screening test (if any of PT, APTT, or TT were abnormal). Prothrombin time, APTT, and TT were also analyzed as individual continuous variables, as well as Coagulation Factors II, V, VII, and X. Regression analysis was used to compare the coagulation profile of scoliosis patients with that of non-scoliosis patients. There were no outside funding sources or any potential conflict of interest associated with this study.

RESULTS

The scoliosis patients were more likely to have an abnormal preoperative screening test compared with non-scoliosis patients, with an odds ratio of 2.6. Further analysis showed statistically significant longer clotting times for patients with scoliosis compared with those without; PT (t=3.37, p=.001), APTT (t=4.26, p<.001), TT (t=4.52, p<.001). Of the coagulation factors analyzed, only factor X was significantly different in scoliosis patients compared with non-scoliosis controls (t=-4.41, p<.001).

CONCLUSIONS

Children with scoliosis have a higher prevalence of preoperative coagulation abnormalities compared with normal healthy patients.

Influence of blood coagulability after spinal surgeries

Objective:

To verify whether spinal surgery causes relevant changes in the blood clotting process and define which factors have the greatest influence on changes found.

Method:

This is a not randomized, cross-sectional study, Forty seven patients were evaluated between August 2011 and February 2013, whose clinical, surgical, laboratory and image daata were collected. The data obtained were crossed with the epidemiological data of each patient in a moment prior to and another after surgery searching which variables have been directly influenced.

Result:

Our analysis showed that the most important changes occurred in patients with BMI classified, according to the World Health Organization (WHO) as out of healthy range. Other smaller correlations were also found. Another important consideration was the tendency to observe hypercoagulability in smoker patients, a fact that is not influenced by spinal procedures.

Conclusion:

We concluded that spinal surgeries cause few relevant changes in the blood clotting process and that among the factors studied, BMI (when out of the healthy range, according to the WHO classification) showed closer relationship with changes in laboratory coagulation tests. Level of Evidence III, Cross-Sectional Study.

Blood loss during posterior spinal fusion for adolescent idiopathic scoliosis

STUDY DESIGN

Retrospective uncontrolled case series.

OBJECTIVE

The purpose of this study was to determine the association, if any, between intraoperative blood loss and need for transfusion with the use of periapical (Ponte) osteotomies, as well as other patient and surgical variables among patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal instrumentation and fusion.

SUMMARY OF BACKGROUND DATA

Blood loss during posterior spinal fusion for AIS can be substantial. Numerous techniques are used to minimize intraoperative blood loss and the need for allogeneic transfusion. However, it is unclear which patient and surgeon variables affect blood loss most significantly.

METHODS

A review was conducted on consecutive patients with AIS who had undergone posterior spinal fusion from July 1997 to February 2013 by a single primary surgeon at 1 institution. The relationship of estimated blood loss, normalized blood loss (normalized blood loss = estimated blood loss/number of levels fused/patient's weight in kilograms), autologous blood retrieved, and allogeneic transfusion received with various patient- and procedure-related variables were analyzed.

RESULTS

Estimated blood loss, normalized blood loss, and autologous blood retrieved were higher in patients who underwent periapical Ponte osteotomies (n = 38) (P < 0.0001, P < 0.001, P < 0.01, respectively). The mean major curve correction was 64% in patients without osteotomies, and 65% in patients with osteotomies (P = 0.81). All patients who underwent osteotomies (38/38) received allogeneic transfusion versus 26% (19/73) of those without osteotomies (P < 0.001). The likelihood of transfusion correlated with increasing number of osteotomies and a lower preoperative hemoglobin level (odds ratio, 3.34; P = 0.003; and odds ratio, 0.51; P = 0.02, respectively).

CONCLUSION

In patients with AIS undergoing posterior spinal fusion with instrumentation, performing periapical osteotomies increased all measures of intraoperative blood loss and need for transfusion without substantially improving major curve correction. As expected, a lower preoperative hemoglobin level was observed in patients who received a blood transfusion after posterior instrumentation and fusion.

LEVEL OF EVIDENCE

4.

Major surgical procedures in children with cerebral palsy

There are 3 surgical procedures that patients with cerebral palsy (CP) undergo that may be considered major procedures: femoral osteotomies combined with pelvic osteotomies, spine fusion, and intrathecal baclofen pump implant for the treatment of spasticity. Many complications are known to occur at a higher rate in this population, and some may be avoided with prior awareness of the preoperative pathophysiology of the patient with CP.

Low body mass index in adolescent idiopathic scoliosis: relationship with pre- and postsurgical factors

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine the association between low preoperative body mass index (BMI) and outcome of spinal fusion in adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Several studies report a lower weight and BMI in untreated subjects with AIS than nonscoliotic age-matched controls. However, very little is known about the clinical impact of low BMI on pre- or postsurgical parameters in this patient group.

METHODS

Seventy-seven eligible patients with AIS who underwent 1-stage posterior spinal fusion and correction at 2 tertiary centers (January 2010-April 2012) were included. Preoperative weight, corrected height, and BMI values were converted to z scores using the British 1990 growth reference data. Relationships between anthropometric indices and comorbidities, laboratory blood data, radiographical outcomes, length of hospital stay, and perioperative complications were examined, and the independent factors associated with low BMI (z score < -1) evaluated using binary logistic regression analysis.

RESULTS

In this AIS cohort (mean age, 15.04 yr; n = 72 females), 21 subjects (27.3%) had a low preoperative BMI; of these, 5 cases (6.5%) were considered severely thin. Lower BMI and weight z scores correlated with a greater percent correction of thoracic curves (rs = -0.287 and rs = -0.257, respectively, P < 0.05). In both the univariate and multivariate regression analysis, low BMI was significantly associated with preoperative asthma incidence (adjusted odds ratio 5.33, P = 0.023) and prolonged prothrombin time (adjusted odds ratio 4.53, P = 0.027), in addition to postoperative ileus development (adjusted odds ratio 11.96, P = 0.019). Preoperative Cobb angle, estimated intraoperative blood loss and length of hospital stay did not significantly differ between the BMI groups.

CONCLUSION

Significantly increased preoperative coagulation abnormality and asthma incidence as well as a greater percent correction of thoracic curves were associated with low BMI in this series. It was also found that postoperative ileus was independently associated with low BMI.

LEVEL OF EVIDENCE

3.

Cardiac considerations in the operative management of the patient with Duchenne or Becker muscular dystrophy

Duchenne muscular dystrophy/Becker muscular dystrophy (DMD/BMD) is a progressive multisystem neuromuscular disorder. In addition to the skeletal muscle, the myocardium in the DMD/BMD patient is dystrophin deficient which results in a progressive cardiomyopathy. The myopathic myocardium poses significant risk of increased morbidity and mortality at the time of major surgical procedures. Careful attention must be given to the DMD/BMD patient during the intraoperative and postoperative period. Anesthesia selection is critical and anesthetics should be avoided which have been shown to be harmful in this patient population. Preanesthesia assessment should include cardiac consultation and detailed preoperative evaluation. Intraoperative management needs to insure that the weakened myocardium is not compromised by physiologic changes such as hypotension or major fluid shifts. Finally, attention to the cardiac status of the patient must continue into the postoperative period. The surgical care of the DMD/BMD patient requires a multispecialty approach to insure operative success.

Predicting operative blood loss during spinal fusion for adolescent idiopathic scoliosis

BACKGROUND

Patient and surgical factors are known to influence operative blood loss in spinal fusion for adolescent idiopathic scoliosis (AIS), but have only been loosely identified. To date, there are no established recommendations to guide decisions to predonate autologous blood, and the current practice is based primarily on surgeon preference. This study is designed to determine which patient and surgical factors are correlated with, and predictive of, blood loss during spinal fusion for AIS.

METHODS

Retrospective analysis of 340 (81 males, 259 females; mean age, 15.2 y) consecutive AIS patients treated by a single surgeon from 2000 to 2008. Demographic (sex, age, height, weight, and associated comorbidities), laboratory (hematocrit, platelet, PT/PTT/INR), standard radiographic, and perioperative data including complications were analyzed with a linear stepwise regression to develop a predictive model of blood loss.

RESULTS

Estimated blood loss was 907±775 mL for posterior spinal fusion (PSF, n=188), 323±171 mL for anterior spinal fusion (ASF, n=124), and 1277±821 mL for combined procedures (n=28). For patients undergoing PSF, stepwise analysis identified sex, preoperative kyphosis, and operative time to be the most important predictors of increased blood loss (P<0.05). For ASF, the mean arterial pressure at incision and the operative time were predictive (P<0.05). The following formula was developed to estimate blood loss in PSF: blood loss (mL)=C+Op-time (min)×(6.4)-pre-op T2-T12 kyphosis (degrees)×(8.7), C=233 if male and -270 if female.

CONCLUSION

We find sex, operative time, and preoperative kyphosis to be the most important predictors of increased blood loss in PSF for AIS. Mean arterial pressure and operative time were predictive of estimated blood loss in ASF. For posterior fusions, we also present a model that estimates blood loss preoperatively and can be used to guide decisions regarding predonation of blood and the use of antifibrinolytic agents.

LEVEL OF EVIDENCE

Retrospective study: Level II.

The effect of tranexamic acid in blood loss and transfusion volume in adolescent idiopathic scoliosis surgery: a single-surgeon experience

PURPOSE

Intraoperative blood loss in scoliosis surgery often requires transfusions. Autogenous blood decreases but does not eliminate risks typically associated with allogenic blood transfusion. Costs associated with transfusions are significant. Tranexamic acid (TXA) has been shown to decrease blood loss in cardiac and joint surgery. Few studies have examined its use in pediatric spine surgery, and the results are inconsistent. The aim of this study was to determine whether TXA decreases intraoperative blood loss and transfusion requirements in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion by a single surgeon.

METHODS

The medical records and operative reports of surgically treated patients with adolescent idiopathic scoliosis between 2000 and 2009 were retrospectively reviewed. The inclusion criteria were: (1) patients who underwent instrumented posterior spinal fusion, (2) had complete medical records, and (3) were treated by the same surgeon. Forty-nine patients who met the inclusion criteria were divided into two groups: Group A (25 patients) received TXA, while Group B (24 patients) did not receive TXA.

RESULTS

After controlling for age at the time of surgery, gender, and number of vertebral levels fused, the mean intraoperative blood loss was significantly lower in Group A (537 ml) than in Group B (1,245 ml) (p = 0.027). The mean volume of blood transfused intraoperatively was 426 and 740 ml for Group A and Group B, respectively. The difference was not statistically significant after controlling for age, gender, and number of levels fused (p = 0.078).

CONCLUSION

TXA significantly decreased intraoperative blood loss in posterior spinal fusions performed for adolescent idiopathic scoliosis.

Changes in cardiac index and blood pressure on positioning children prone for scoliosis surgery

In this prospective observational study we investigated the changes in cardiac index and mean arterial pressure in children when positioned prone for scoliosis correction surgery. Thirty children (ASA 1-2, aged 13-18 years) undergoing primary, idiopathic scoliosis repair were recruited. The cardiac index and mean arterial blood pressure (median (IQR [range])) were 2.7 (2.3-3.1 [1.4-3.7]) l.min(-1).m(-2) and 73 (66-80 [54-91]) mmHg, respectively, at baseline; 2.9 (2.5-3.2 [1.7-4.4]) l.min(-1).m(-2) and 73 (63-81 [51-96]) mmHg following a 5-ml.kg(-1) fluid bolus; and 2.5 (2.2-2.7 [1.4-4.8]) l.min(-1).m(-2) and 69 (62-73 [46-85]) mmHg immediately after turning prone. Turning prone resulted in a median reduction in cardiac index of 0.5 l.min(-1).m(-2) (95% CI 0.3-0.7 l.min(-1).m(-2), p=0.001), or 18.5%, with a large degree of inter-subject variability (+10.3% to -40.9%). The changes in mean arterial blood pressure were not significant. Strategies to predict, prevent and treat decreases in cardiac index need to be developed.

Validity of Estimates of Intraoperative Blood Loss in Pediatric Spinal Deformity Surgery

INTRODUCTION

Intraoperative blood loss is a significant concern in pediatric spinal deformity surgery, and numerous reports exist in the literature regarding this issue. Multiple interventions are used to minimize intraoperative blood loss and subsequent need for blood product replacement during and after these procedures. However, a basic question remains regarding the overall accuracy of intraoperative blood loss measurements used to generate these studies.

MATERIALS AND METHODS

We performed an institutional review board-approved study that compared estimated blood loss (EBL) by the anesthesia provider and surgeon after the completion of surgery for pediatric spinal deformity by a single surgeon. We used the estimate by the anesthesia provider that was to be part of the anesthesia record. The surgeon's estimate was generated based on a formula employing the volume of blood products processed by a Cell-Saver device and available for reinfusion.

RESULTS

We collected data from 51 patients. The mean EBL (surgeon) was 795.84 mL and mean EBL (anesthesia) was 669.30 mL. The mean percent estimated blood volume loss (%EBVL) (surgeon) was 22.9% and mean %EBVL (anesthesia) was 19.8%. Student t-test analysis demonstrated statistical significance between both sets of values (EBL, p = .010; %EBVL, p = .010).

CONCLUSIONS

There was a statistically significant difference in EBL values for this patient sample between the anesthesiologist and orthopedic surgeon; the surgeon's estimates were significantly higher. This difference may be important in interpreting existing studies regarding interventions used to minimize surgical blood loss. In addition, this lack of agreement highlights the need for authors to be more accurate and consistent regarding the source of blood loss data in future clinical studies.

Does patient diagnosis predict blood loss during posterior spinal fusion in children?

STUDY DESIGN

A retrospective review.

OBJECTIVE

To assess the relationship between diagnosis and blood loss in children undergoing posterior spinal fusion surgery for deformity correction.

SUMMARY OF BACKGROUND DATA

To our knowledge, this relationship is not well established. It has important implications for understanding the mechanisms for blood loss and planning for surgery.

METHODS

Clinical records were reviewed for all patients 10 to 18 years of age who underwent spinal fusion surgery (at least 5 levels) by the senior author from 2001 through 2011. Patients were excluded for antifibrinolytic use, vertebral column resections, history of spinal surgery, nonpedicle screw instrumentation, cervical spine fusion, or anterior approaches. The 617 patients (with 37 diagnoses) were categorized into 5 groups: idiopathic scoliosis (IS), Scheuermann kyphosis (SK), cerebral palsy, other neuromuscular disorders, and genetic and syndromic disorders. Analysis of covariance was used to assess differences in blood loss across the diagnostic groups. Normalized blood loss (NBL) was calculated by dividing blood loss by number of levels fused and by patient's weight; NBL differences between groups were analyzed using Bonferroni correction method. Significance was set at P < 0.05.

RESULTS

Blood loss differed significantly by diagnostic group, adjusting for extent of fusion and patient weight (P < 0.001). Patients with cerebral palsy had a significantly higher NBL than patients with IS (P < 0.001), SK (P < 0.001), other neuromuscular disorders (P = 0.049), or genetic and syndromic disorders (P = 0.006). Patients with other neuromuscular disorders had a significantly higher NBL than patients with IS (P < 0.001) or SK (P < 0.001). Patients with genetic and syndromic disorders also had a significantly higher NBL than patients with IS (P < 0.001) or SK (P < 0.001).

CONCLUSION

There is a significant relationship between patient diagnosis and blood loss during posterior spinal fusion surgery in children.

Are antifibrinolytics helpful in decreasing blood loss and transfusions during spinal fusion surgery in children with cerebral palsy scoliosis?

STUDY DESIGN

Therapeutic comparative study.

OBJECTIVE

To evaluate the safety and efficacy of antifibrinolytic (AF) agents in reducing blood loss and transfusions during posterior spinal fusion (PSF) in children with cerebral palsy (CP) scoliosis.

SUMMARY OF BACKGROUND DATA

Scoliosis surgery in CP children is associated with substantial blood loss. Few reports on the role of AFs exist.

METHODS

A multicenter, retrospective review of a prospectively collected database of 84 consecutively enrolled patients with CF (age < 18 years) with spinal deformity who underwent PSF and instrumentation. The use of AFs, tranexamic acid (TXA), epsilon-aminocaproic acid (EACA), or none was based on the surgeon preference. Estimated blood loss (EBL), transfusion requirements, and length of stay were recorded. Analysis was performed with the independent-samples t test and 1-way analysis of variance with post hoc Bonferroni analysis.

RESULTS

The average age at the time of surgery was 14.4 ± 2.6 years. The groups were well matched in preoperative major deformity, age, levels fused, and operating time. Forty-four patients received AFs (30 TXA and 14 EACA), and 40 received no antifibrinolytics (NAF). The EBL averaged 1684 mL for the AFs group and 2685 mL for the NAF group (P = 0.002). There was more cell salvage transfusion in the NAF group. No significant differences were found in total transfusion requirements. There was a trend for decreased hospital stay in the AFs group. No adverse effects were seen. On comparison of the 3 groups (NAF, TXA, and EACA), a significant difference was observed between the TXA and the other groups with respect to EBL and cell salvage transfusion.

CONCLUSION

AFs significantly reduced intraoperative EBL associated with PSF, with no adverse effects; however, we could not demonstrate significant differences in total transfusion, except in cell salvage. TXA was more effective than EACA in decreasing the EBL and cell salvage transfusion.

Results and complications after spinal fusion for neuromuscular scoliosis in cerebral palsy and static encephalopathy using luque galveston instrumentation: experience in 93 patients

STUDY DESIGN

Retrospective cohort analysis.

OBJECTIVE

To evaluate the results of spine fusion for neuromuscular scoliosis in cerebral palsy and static encephalopathy, using Luque-Galveston technique, with emphasis on the early and late complications, especially those increasing the hospital stay or requiring additional surgery.

SUMMARY OF BACKGROUND DATA

There are numerous studies in the literature on the treatment of neuromuscular scoliosis using Luque-Galveston instrumentation analyzing the results and complications. Most series are small and evaluate some of the complications, with none evaluating all the early and late complications and none assessing the impact of the complication on length of hospitalization or the need for additional surgical intervention.

METHODS

This was a retrospective review of a consecutive series of patients operated on for neuromuscular scoliosis in cerebral palsy and static encephalopathy with Luque-Galveston instrumentation at 1 institution from January 1997 to December 2003. Ninety-three patients were identified.

RESULTS

The average age at surgery was 14.3 years, with an average age at follow-up of 18.2 years, and an average follow-up of 3.8 years. The mean preoperative scoliosis was 72° with correction postoperatively to a mean of 33°, maintained at 36° at final follow-up. There were 83 early complications in 54 patients, for a complication rate of 58% of patients for the entire study. There were no perioperative deaths or neurological complications. There was only 1 deep wound infection, for an infection rate of 1.1%. Patients with 1 complication had a longer length of stay, 9 versus 7 days, the difference being statistically significant (Mann-Whitney U test, P < 0.001). Two patients required reoperation during the initial hospitalization (1.1%): 1, one for infection and 1 for proximal hook cutout and proximal junction kyphosis. There were a total of 81 late complications in 44 patients, for a late complication rate of 47% of patients for the entire study. The majority of the complications were minor, not requiring additional care or surgery. Seven patients had a pseudarthrosis (7.5%), presenting at an average of 30 months postoperatively. Eight patients underwent 9 procedures for late complications: 5 for repair of a pseudarthrosis, 3 for removal of a prominent iliac screw, and 1 for superior junctional kyphosis. All the pseudarthrosis repairs were solid at follow-up.

CONCLUSION

Spinal fusion in neuromuscular scoliosis with Luque-Galveston technique is a safe and effective procedure. Any early complication increased the length of stay, with a low rate of reoperation during the hospitalization. The majority of late complications were minor, not requiring additional care. Pseudarthroses were detected late and were the main reason for additional surgery.

[Intrathecal opioid medication for perioperative analgesia in severely handicapped children undergoing spinal operations]

PURPOSE OF THE STUDY

Intrathecal opioids have been shown to be safe and effective for postoperative analgesia in healthy children for spinal surgery. The aim of this study was to evaluate the applicability of intrathecal opioids in severely handicapped children scheduled for spinal surgery.

METHODS

With hospital ethical committee approval, patients with physical states III and IV of the ASA classification requiring spinal surgery were retrospectively studied. In addition to inhalational anesthesia with sevoflurane or intravenous anesthesia using propofol, morphine 20 microg/kgBW and sufentanil 1.5 microg/kgBW were administered intrathecally before surgery. After surgery an infusion of nalbuphine was started. Need for additional intraoperative and postoperative analgesics, time of extubation, postoperative pain scores and p(a)CO2 values as well as adverse effects were recorded.

RESULTS

A total of 28 patients aged from 2.8 to 18.5 years (median 11.6 years) were studied. Immediate tracheal extubation in the operating room was possible in 17 patients and for 11 patients delayed extubation was elected. All patients were extubated within 24 h except for 1 patient who received massive postoperative transfusions. In 26 out of 28 patients (93%) the combination of intrathecal opioids with postoperative nalbuphine provided adequate analgesia. Observed side effects were post-operative nausea and vomiting (PONV), pruritus and moderate hypoventilation. In two patients a change to intravenous morphine therapy was necessary.

CONCLUSION

The use of intrathecal opioids for perioperative pain control from spinal fusion in severely handicapped children is feasible. Intrathecal opioids provide adequate postoperative analgesia and allow early extubation without persisting relevant respiratory compromise in most of these patients.

Perioperative blood transfusion requirements in pediatric scoliosis surgery: the efficacy of tranexamic acid

BACKGROUND

Previous studies have noted that the use of antifibrinolytic medications can help reduce blood loss and transfusion requirements during cardiac, total joint arthroplasty, and spine surgery. Tranexamic acid (TXA) has been investigated in these patient groups but consensus with respect to the dosing regimen has not been achieved, especially in the pediatric scoliosis literature. The purpose of this study was to compare the effects of 2 TXA dosing regimens on reducing transfusion requirements.

METHODS

A retrospective chart review was performed on all idiopathic scoliosis patients undergoing posterior spinal instrumentation and fusion from 2005 to 2006 to determine total perioperative transfusion requirements. Transfusion requirements for those patients receiving either a low (10 mg/kg loading, 1 mg/kg/h infusion) or high (20 mg/kg loading, 10 mg/kg/h infusion) dose of TXA were compared.

RESULTS

High-dose TXA (n = 11) showed a trend toward a reduction in transfusion requirements compared with the low dose (n = 15) for idiopathic scoliosis patients undergoing posterior only instrumentation and fusion (687.9 +/- 778.1 mL vs 1372.6 +/- 1077.3 mL; P = 0.07; 95% confidence interval for the mean difference, -66.3 mL to 1435.7 mL). Although substantial, this difference was underpowered to show a difference.

CONCLUSIONS

The use of the higher dose of TXA resulted in a 50% reduction in transfusion requirements for idiopathic scoliosis patients. Given previous studies, there appears to be a dose-response effect. A prospective dose-ranging study is now required to determine the optimal dose for pediatric patients with idiopathic scoliosis.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Role of Amicar in surgery for neuromuscular scoliosis

STUDY DESIGN

A retrospective case-control study.

OBJECTIVE

Evaluate the effectiveness of Amicar in decreasing perioperative blood loss in patients with neuromuscular scoliosis undergoing posterior spinal fusion (PSF) and segmental spinal instrumentation (SSI).

SUMMARY OF BACKGROUND DATA

Previously, a preliminary prospective; prospective randomized double-blind; same-day anterior and posterior spinal fusion; and fibrinogen studies have demonstrated Amicar to be effective in decreasing total perioperative blood loss and transfusion requirements in surgery for idiopathic scoliosis. Increased fibrinogen secretion is a possible explanation. We are now analyzing its effectiveness in neuromuscular scoliosis.

METHODS

Amicar was administered at 100 mg/kg over 15 minute not to exceed 5 g after anesthesia induction. Maintenance is 10 mg/kg/h until wound closure. There were 2 study groups: group 1 (n = 34), no Amicar and group 2 (n = 62) who received Amicar. The majority of patients in both groups had cerebral palsy. Total perioperative blood loss was determined from the estimated intraoperative blood loss and measured postoperative suction drainage. Total perioperative blood loss and transfusion requirements (cell saver and allogeneic) were compared using chi or Fisher exact test.

RESULTS

There was statistically less estimated intraoperative blood loss, total perioperative blood loss, and transfusion requirements in group 2. Postoperative suction drainage was also less but did not reach statistical significance. In group 1, estimated intraoperative blood loss, measured postoperative suction drainage, and total perioperative blood loss were 2194 +/- 1626 mL, 903 +/- 547 mL, and 3055 +/- 1852 mL, whereas in group 2, it was 1125 +/- 715 mL, 695 +/- 489 mL, and 1805 +/- 940 mL. Transfusion requirements were 1548 +/- 962 mL in group 1 but only 660 +/- 589 mL in group 2 (P < 0.0001). Amicar was equally effective in all diagnoses. There were no complications related to the use of Amicar.

CONCLUSION

Amicar was highly effective in decreasing perioperative blood loss and transfusion requirements in patients with neuromuscular scoliosis undergoing PSF and SSI. It was most effective in decreasing estimated intraoperative blood loss. This results in decreased transfusion requirements, costs, and potential transfusion-related complications.

Aprotinin in pediatric neuromuscular scoliosis surgery

Reduction of blood transfusions in patients with neuromuscular scoliosis can decrease potential complications such as immune suppression, infection, hemolytic reaction and viral transmission. Aprotinin (Trasylol), Bayer), an antifibrinolytic, has proven to be effective in reducing blood loss in cardiac and liver surgery, but little data exists in patients undergoing spinal fusion for neuromuscular scoliosis. The purpose of this study was to evaluate the safety and efficacy of aprotinin in pediatric neuromuscular scoliosis patients undergoing spinal fusion. The medical records of all patients undergoing initial spinal fusions for neuromuscular scoliosis between January 1999 and March 2003 were reviewed to determine demographic data, perioperative data, wound drainage and number of transfusion required. Cases were compared to a matched group of historical controls. We had 14 patients in the aprotinin group and 17 in the control group. Total blood loss in the aprotinin group was significantly lower compared to the control group (715 vs. 2,110 ml; P = 0.007). Significantly less blood loss occurred in the aprotinin group when blood loss per kilogram was evaluated as well (23 vs. 60 ml/kg, respectively; P = 0.002). Intra-operative packed red blood cell (PRBC) transfusions were also significantly lower in the aprotinin group (1.25 vs. 3.16 units; P = 0.001). No clinical evidence of anaphylaxis, deep vein thrombosis (DVT) or renal failure was observed in the aprotinin group. After considering the price of drug therapy, operating room time, and the cost of blood products, the use of aprotinin saved an average of $8,577 per patient. In our series, the use of aprotinin resulted in decreased blood loss and a decreased rate of transfusions in children with neuromuscular scoliosis undergoing extensive spinal fusion. At out institution, the use of aprotinin is safe and cost effective for patients with neuromuscular scoliosis.

Treatment of neuromuscular scoliosis with posterior-only pedicle screw fixation

Background

To determine whether posterior-only approach using pedicle screws in neuromuscular scoliosis population adequately addresses the correction of scoliosis and maintains the correction over time.

Methods

Between 2003 and 2006, 26 consecutive patients (7 cerebral palsy, 10 Duchenne muscular dystrophy, 5 spinal muscular atrophy and 4 others) with neuromuscular scoliosis underwent posterior pedicle screw fixation for the deformity. Preoperative, immediate postoperative and final follow-up Cobb's angle and pelvic obliquity were analyzed on radiographs. The average age of the patients was 17.5 years (range, 8–44 years) and the average follow-up was 25 months (18–52 months).

Results

Average Cobb's angle was 78.53° before surgery, 30.70° after surgery (60.9% correction), and 33.06° at final follow-up (57.9% correction) showing significant correction (p < 0.0001). There were 9 patients with curves more than 90° showed an average pre-operative, post operative and final follow up Cobb's angle 105.67°, 52.33° (50.47% correction) and 53.33° (49.53% correction) respectively and 17 patients with curve less than 90° showed average per operative, post operative and final follow up Cobb's angle 64.18, 19.24(70% correction) and 21.41(66.64 correction); which suggests statistically no significant difference in both groups (p = 0.1284). 7 patients underwent Posterior vertebral column resection due to the presence of a rigid curve. The average spinal-pelvic obliquity was 16.27° before surgery, 8.96° after surgery, and 9.27° at final follow-up exhibited significant correction (p < 0.0001). There was 1 poliomyelitis patient who had power grade 3 in lower limbs pre-operatively, developed grade 2 power post-operatively and gradually improved to the pre-operative stage. There was 1 case of deep wound infection and no case of pseud-arthrosis, instrument failures or mortality.

Conclusion

Results indicate that in patients with neuromuscular scoliosis, acceptable amounts of curve correction can be achieved and maintained with posterior-only pedicle screw instrumentation without anterior release procedure.

Scoliosis correction with pedicle screws in Duchenne muscular dystrophy

This report describes the spinal fixation with pedicle-screw-alone constructs for the posterior correction of scoliosis in patients suffering from Duchenne muscular dystrophy (DMD). Twenty consecutive patients were prospectively followed up for an average of 5.2 years (min 2 years). All patients were instrumented from T3/T4 to the pelvis. Pelvic fixation was done with iliac screws similar to Galveston technique. The combination of L5 pedicle screws and iliac screws provided a stable caudal foundation. An average of 16 pedicle screws was used per patient. The mean total blood loss was 3.7 l, stay at the intensive care unit was 77 h and hospital stay was 19 days. Rigid stabilisation allowed immediate mobilisation of the patient in the wheel chair. Cobb angle improved 77% from 44 degrees to 10 degrees, pelvic tilt improved 65% from 14 degrees to 3 degrees. Lumbar lordosis improved significantly from 20 degrees to 49 degrees, thoracic kyphosis remained unchanged. No problems related to iliac fixation, no pseudarthrosis or implant failures were observed. The average percentage of predicted forced vital capacity (%FVC) of the patients was 55% (22-94%) preoperatively and decreased to 44% at the last follow-up. There were no pulmonary complications. One patient with a known cardiomyopathy died intraoperatively due to a sudden cardiac arrest. The rigid primary stability with pedicle screws allowed early mobilisation of the patients, which helped to avoid pulmonary complications.