Surgical correction of spinal deformity in patients with cerebral palsy using pedicle screw instrumentation

Long-term reoperation rates following spinal fusion for neuromuscular scoliosis in nonambulatory patients with cerebral palsy

PURPOSE

To describe the incidence of reoperation and factors contributing to surgical revision within a minimum of 10 years after spinal fusion for scoliosis in patients with nonambulatory cerebral palsy (CP).

METHODS

We conducted a retrospective review of consecutive nonambulatory patients with CP who underwent primary spinal fusion at a single specialty care center with a minimum of 10 years from their index surgery (surgery dates 2001-2011). Causes of reoperation were classified as implant failure/pseudoarthrosis, surgical site infection (SSI), proximal junctional kyphosis, prominent/symptomatic implants, and implant removal. Reoperation rates with 95% confidence intervals were calculated for each time interval, and an actuarial survival curve was generated.

RESULTS

144 patients met inclusion criteria (mean age = 14.3 ± 2.6 years, 62.5% male); 85.4% had 5 years follow-up data; and 66.0% had 10 years follow-up data. Estimates from the actuarial analysis suggest that 14.9% (95% CI: 10.0-22.0) underwent reoperation by 5 years postsurgery, and 21.7% (95% CI: 15.4-30.1) underwent reoperation by 10 years postsurgery. The most common causes for reoperation were implant failure/pseudoarthrosis, SSI, and prominent/symptomatic implants.

CONCLUSIONS

To our knowledge, this study is the largest long-term follow-up of nonambulatory patients with CP and neuromuscular scoliosis who underwent spinal fusion. Approximately 22% of these patients required reoperation 10 years after their index surgery, primarily due to implant failure/pseudoarthrosis, SSI, and prominent/symptomatic implants. Complications and reoperations continued throughout the 10 years period after index surgery, reinforcing the need for long-term follow-up as these patients transition into adulthood.

LEVEL OF EVIDENCE

III.

Fifteen Years of Spinal Fusion Outcomes in Children With Cerebral Palsy: Are We Getting Better?

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVE

We reviewed 15-year trends in operative factors, radiographic and quality of life outcomes, and complication rates in children with cerebral palsy (CP)-related scoliosis who underwent spinal fusion.

SUMMARY OF BACKGROUND DATA

Over the past two decades, significant efforts have been made to decrease complications and improve outcomes of this population.

MATERIALS AND METHODS

We retrospectively reviewed a multicenter registry of pediatric CP patients who underwent spinal fusion from 2008 to 2020. We evaluated baseline and operative, hospitalization, and complication data as well as radiographic and quality of life outcomes at a minimum 2-year follow-up.

RESULTS

Mean estimated blood loss and transfusion volume declined from 2.7±2.0 L in 2008 to 0.71±0.34 L in 2020 and 1.0±0.5 L in 2008 to 0.5±0.2 L in 2020, respectively, with a concomitant increase in antifibrinolytic use from 58% to 97% (all, P <0.01). Unit rod and pelvic fusion use declined from 33% in 2008 to 0% in 2020 and 96% in 2008 to 79% in 2020, respectively (both, P <0.05). Mean postoperative intubation time declined from 2.5±2.6 to 0.42±0.63 days ( P< 0.01). No changes were observed in preoperative and postoperative coronal angle and pelvic obliquity, operative time, frequency of anterior/anterior-posterior approach, and durations of hospital and intensive care unit stays. Improvements in the Caregiver Priorities and Child Health Index of Life with Disabilities postoperatively did not change significantly over the study period. Complication rates, including reoperation, superficial and deep surgical site infection, and gastrointestinal and medical complications remained stable over the study period.

CONCLUSIONS

Over the past 15 years of CP scoliosis surgery, surgical blood loss, transfusion volumes, duration of postoperative intubation, and pelvic fusion rates have decreased. However, the degree of radiographic correction, the rates of surgical and medical complications (including infection), and health-related quality of life measures have broadly remained constant.

Growing rods in meningomyelocele lead to increased risk for complications in comparison with fusion; a retrospective study of 30 patients treated for at the University Hospital of Uppsala

PURPOSE

To compare the complication rates of two different types of posterior instrumentation in patients with MMC, namely, definitive fusion and fusionless surgery (growing rods).

METHODS

Single-center retrospective study of 30 MMC patients that underwent posterior instrumentation for deformity (scoliosis and/or kyphosis) treatment from 2008 until 2020. The patients were grouped based on whether they received definitive fusion or a growth-accommodating system, whether they had a complication that led to early surgery, osteotomy or non-osteotomy. Number of major operations, Cobb angle correction and perioperative blood loss were the outcomes.

RESULTS

18 patients received a growing system and 12 were fused at index surgery. The growing system group underwent a mean of 2.38 (± 1.03) surgeries versus 1.91 (± 2.27) in the fusion group, p = 0.01. If an early revision was necessitated due to a complication, then the number of major surgeries per patient was 3.37 (± 2.44) versus 1.77 (± 0.97) in the group that did not undergo an early revision, p = 0.01. Four patients developed a superficial and six a deep wound infection, while loosening/breakage occurred in 10 patients. The Cobb angle was improved from a mean of 69 to 22 degrees postoperatively. Osteotomy did not lead to an increase in perioperative blood loss or number of major operations.

CONCLUSION

Growing systems had more major operations in comparison with fusion surgery and early revision surgery led to higher numbers of major operations per patient; these differences were statistically significant. Definitive fusion at index surgery might be the better option in some MMC patients with a high-risk profile.

Distal level in scoliosis surgery for non-ambulatory patients with cerebral palsy: is L5 an option? A case series study

PURPOSE

This study aimed to determine the radiographic outcomes of patients with cerebral palsy (CP) who underwent posterior spinal fusion from T2/3 to L5 at two quaternary hospitals.

METHODS

From January 2010 to January 2020, 167 non-ambulatory patients with CP scoliosis underwent posterior spinal fusion using pedicle screws from T2/3 to L5 in both centers, with a minimum of 2 years follow-up (FU). Radiological measurements and chart reviews were performed.

RESULTS

A total of 106 patients aged 15.6 ± 0.4 years were included. None of the patients was lost to FU. All patients had significant correction of the Cobb angle (MC) and pelvic obliquity (PO), thoracic kyphosis (TK), and lumbar lordosis (LL), without loss of correction at the last FU (LFU). The mean values for preoperative, immediate postoperative, and LFU were MC 93.4°, 37.5°, and 42.8°; PO 25.8°, 9.9°, and 12.7°; TK 52.2°, 44.3°, and 45°; and LL - 40.9°, - 52.4°, and - 52.9°, respectively. Higher residual PO at LFU was associated with more severe MC and PO baselines, lower implant density, and an apex located at L3.

CONCLUSIONS

CP scoliosis and PO can be corrected, and this correction is maintained over time with posterior spinal fusion using pedicle screws, with L5 as the lowest instrumented vertebra. Larger preoperative MC and PO values associated with the apex at L3 appear to be related to residual PO. Comparative large-scale studies of patient-related clinical outcomes are required to determine whether this intervention is associated with improved surgical outcomes and reduced complication rates.

LEVEL OF EVIDENCE

IV.

Spontaneous induced bone fusion in minimally invasive fusionless bipolar fixation in neuromuscular scoliosis: a computed tomography analysis

PURPOSE

Posterior spinal fusion (PSF) at skeletal maturity is still the gold standard in children with neuromuscular scoliosis (NMS) who underwent fusionless surgery. The aim of this computed tomography (CT) study was to quantify the spontaneous bone fusion at the end of a lengthening program by minimally invasive fusionless bipolar fixation (MIFBF), that could avoid PSF.

METHODS

NMS operated on with MIFBF from T1 to the pelvis and at final lengthening program were included. CT was performed at least five years postoperatively. The autofusion was classified as completely or not fused at the facets joint (on both coronal and sagittal plane, right and left side, from T1 to L5), and around the rods (axial plane, right and left side, from T5 to L5). Vertebral body heights were assessed.

RESULTS

Ten patients were included (10.7y ± 2 at initial surgery). Mean Cobb angle was 82 ± 20 preoperatively and 37 ± 13 at last follow-up. CT were performed on average 6.7y ± 1.7 after initial surgery. Mean preoperative and last follow-up thoracic vertebrae height were respectively 13.5 mm ± 1.7 and 17.4 mm ± 1.7 (p < 0.001). 93% facets joints were fused (out of 320 analyzed joints), corresponding to 15/16 vertebral levels. Ossification around the rods was observed in 6.5±2.4 levels out of 13 in the convex side, and 4.2 ± 2.2 in the concave side (p = 0.04).

CONCLUSIONS

This first computed quantitative study showed MIFBF in NMS preserved spinal growth, while it induced 93% of facet joints fusion. This could be is an additional argument when questionning the real need for PSF at skeletal maturity.

Paraspinal muscle approach for neuromuscular scoliosis: A comparative study evaluating deformity correction and perioperative morbidity in 91 patients with minimum 2-year follow-up

PURPOSE

We present the paraspinal approach use for neuromuscular scoliosis with focus on deformity correction, perioperative (≤30 days) morbidity and outcome at a minimal follow-up length of 2 years.

METHODS

We prospectively collected data of 61 neuromuscular scoliosis patients operated using a paraspinal (Wiltse) approach between 2013 and 2019. We additionally collected data of 104 control cases, operated using a midline approach between 2005 and 2016. Fifteen Wiltse, respectively 37 control patients were excluded due to a short follow-up (<2 years), and 22 controls were excluded secondary to lacking follow-up data. Hence, 46 Wiltse and 45 control patients were compared.

RESULTS

Wiltse and control patients had comparable follow-up lengths, demographics, deformity corrections, complication rates, number of levels fused, and intensive care unit and hospital lengths of stay. Wiltse cases had a lower estimated blood loss (535 vs 1187 mL; p-value < 0.001), allogenic transfusion rate (48% vs 96%; p-value < 0.001), and operating time (ORT) (337 vs 428 min; p-value < 0.001) than controls. This was also the case when selecting for patients without pelvic fixation (p-values < 0.001). When selecting the cases with pelvic fixation (20 among 91 cases), only the number of levels fused and the ORT differed significantly according to the approach (p-value <0.015 and <0.041).

CONCLUSION

The paraspinal approach for neuromuscular scoliosis is safe, associated with significant deformity correction, reduced estimated blood loss, and allogenic transfusion rate. These potential benefits still need to be evaluated, especially for cases with pelvic fixation, with further follow-up of larger cohorts.

LEVEL OF EVIDENCE

level III.

Current concepts in the treatment of neuromuscular scoliosis: clinical assessment, treatment options, and surgical outcomes

The development of spinal deformity in children with underlying neurodisability can affect their ability to function and impact on their quality of life, as well as compromise provision of nursing care. Patients with neuromuscular spinal deformity are among the most challenging due to the number and complexity of medical comorbidities that increase the risk for severe intraoperative or postoperative complications. A multidisciplinary approach is mandatory at every stage to ensure that all nonoperative measures have been applied, and that the treatment goals have been clearly defined and agreed with the family. This will involve input from multiple specialities, including allied healthcare professionals, such as physiotherapists and wheelchair services. Surgery should be considered when there is significant impact on the patients’ quality of life, which is usually due to poor sitting balance, back or costo-pelvic pain, respiratory complications, or problems with self-care and feeding. Meticulous preoperative assessment is required, along with careful consideration of the nature of the deformity and the problems that it is causing. Surgery can achieve good curve correction and results in high levels of satisfaction from the patients and their caregivers. Modern modular posterior instrumentation systems allow an effective deformity correction. However, the risks of surgery remain high, and involvement of the family at all stages of decision-making is required in order to balance the risks and anticipated gains of the procedure, and to select those patients who can mostly benefit from spinal correction.

Transition of Caregiver Perceptions after Pediatric Neuromuscular Scoliosis Surgery

Introduction

Spinal fusion for children with neuromuscular scoliosis has been known to improve sitting balance and quality of life as well as for high caregiver satisfaction. However, most studies performed were single surveys, and it remains unclear whether high satisfaction levels are maintained. Thus, in this article, we report the short- and medium-term improvements in caregiver standing assessment after neuromuscular scoliosis surgery in children with Gross Motor Function Classification System (GMFCS) level IV or V.

Methods

In total, 18 patients with GMFCS levels IV and V were included in this study. The underlying diseases were typical cerebral palsy in 12 cases, chromosomal abnormalities in 5 cases, and congenital myopathy in 1 case. The median age at the time of surgery was 14.5 years. The medians for the first and second follow-up surveys were after 1.4 and 5.9 years, respectively. All the patients had undergone posterior spinal fusion, whereas 12 had undergone pelvic fixation. These patients were assessed using a caregiver questionnaire, in addition to patient demographic data and radiographic assessments.

Results

The median BMI was 15.4 kg/m² preoperatively, 16.6 kg/m² at the first survey, and 17.1 kg/m² at the second survey. The main Cobb angles were 97.5°, 36.5°, and 37.0° and the spino-pelvic obliquity angles were 22.5°, 6.0°, and 6.5° preoperatively, at the first survey and at the second survey, respectively. In the questionnaire, most domains were rated similarly in the first and second surveys, but the ratings for the “children's QOL” and “digestion and defecation” domains were noted to increase, while that for the “transfer” and “satisfaction with treatment” domains have decreased.

Conclusions

Neuromuscular scoliosis surgery in children has been associated with extremely high treatment satisfaction in the early postoperative period. However, some caregivers showed a decline in the “transfer” and “treatment satisfaction” domains over time.

One-Way Self-Expanding Rod in Neuromuscular Scoliosis: Preliminary Results of a Prospective Series of 21 Patients

Fusionless techniques for the treatment of neuromuscular early-onset scoliosis (EOS) are increasingly used to preserve spinal and thoracic growth and to postpone posterior spinal fusion (PSF). These techniques have greatly improved thanks to magnetically controlled growing rods, which allow the avoidance of repeated surgery. However, the surgery-related complication rate remains high. The objective of the current study was to report the preliminary outcomes of 21 patients with neuromuscular EOS who were treated with a 1-way self-expanding rod (OWSER). This device was designed to avoid repeated surgery and preserve spinal and thoracic growth thanks to its free rod sliding.

Minimally Invasive Surgery for Neuromuscular Scoliosis: Results and Complications at a Minimal Follow-up of 5 Years

STUDY DESIGN

A prospective study.

OBJECTIVE

The aim of this study was to report the results of an alternative technique to growing rods (GR) for neuromuscular scoliosis using a minimally invasive fusionless surgery with a minimum of 5 years' follow-up.

SUMMARY OF BACKGROUND DATA

Conservative treatment is not effective in progressive neuromuscular scoliosis. Early surgery using GR is increasingly advocated to control the deformity while preserving spinal and thoracic growth before arthrodesis. These techniques still provide a high rate of complications.

METHODS

The technique relies on a bilateral double rod sliding instrumentation anchored proximally by four hooks claws and distally to the pelvis by iliosacral screws through a minimally invasive approach. The clinical and radiological outcomes of 100 consecutive patients with neuromuscular scoliosis who underwent this fusionless surgery with a minimum follow-up of 5 years were reviewed.

RESULTS

6.5 ± 0.7 years after initial surgery, six patients were lost of follow-up and 11 died of unrelated raison. Of the 83 remaining patients at latest follow-up, mean Cobb angle was stable to 35.0° which correspond to 61% correction of the initial deformation. Mean pelvic obliquity was 29.6° (0.3°-80.0°) preoperatively and 7.2 (0.2°-23.5°) at latest follow-up. Correction of the hyper kyphosis remained stable. Skeletal maturitywas reached in 42 of 83 patients (50.6%). None of these patients has required spinal fusion. The global complication rate was 31.3%.

CONCLUSION

The outcomes of this minimally invasive fusionless technique at 5 years follow-up showed a stable correction of spinal deformities and pelvic obliquity over time, with a reduced rate of complication. The arthrodesis was not required for all patients at skeletal maturity. This technique could be a good alternative to arthrodesis for neuromuscular scoliosis.Level of Evidence: 3.

Do seizures compromise correction maintenance after spinal fusion in cerebral palsy scoliosis?

Seizure disorder in cerebral palsy (CP) has been described as a risk factor for postoperative complications after posterior spinal fusion. However, the effect of seizures on the maintenance of curve correction has not been reported. The aim of this study is to investigate associations between seizure history and maintenance of curve correction after posterior spinal fusion in children with CP. We analyzed records of 201 children with CP who underwent posterior spinal fusion with two-year follow-up. Patients were classified as having no seizures (31%); controlled seizures (54%); or poorly controlled seizures (PCS, 15%). Perioperative data, radiographic measurements, and complications were compared between groups. Groups were similar in operative time, estimated blood loss, and rates of deep wound infection and implant-related complications. The PCS group had a higher rate of respiratory complications (27%) than the no seizures (10%; P = 0.03) and controlled seizures (12%; P = 0.04) groups. Controlled seizures and PCS groups had longer ICU stays than the no seizures group (P= 0.02 and P= 0.04). Major coronal curve and pelvic obliquity were corrected significantly in all groups, and correction was maintained at 2 years. Loss of correction during follow-up was similar between groups. Although seizures were associated with longer ICU stays and more respiratory complications, there was no association between seizure history and loss of curve correction at two years of follow-up after CP scoliosis surgery.

One stage or two? A cohort analysis of anterior-posterior spinal fusions for severe pediatric scoliosis

STUDY DESIGN

Retrospective case-series study of prospectively collected data.

OBJECTIVE

We sought to identify the differences in outcomes between one-stage (single surgical episode) and two-stage (separate day) anterior and posterior spinal fusion and segmental spinal instrumentation surgeries in severe non-idiopathic and idiopathic scoliosis cases.

BACKGROUND

Patients with severe pediatric spine deformity may require combined anterior and posterior fusion procedures. Given their increased complexity and morbidity, surgeons may consider staging these procedures on separate days.

METHODS

A retrospective cohort study was performed on a prospective Pediatric Spine Database. Patients 21 years of age or under with pediatric scoliosis who underwent primary anterior and posterior spinal deformity correction surgery either through a one-stage or planned two-stage sequence with greater than 2-year follow-up were included. Differences in demographics, comorbidities, surgical details, perioperative morbidity, complications, and outcomes were assessed based on scoliosis etiology. Multivariate models were utilized to control for confounders.

RESULTS

There were 70 non-idiopathic (14 two-stage vs. 56 one-stage) and 65 idiopathic scoliosis (8 two-stage vs. 57 one-stage) patients. Mean follow-up was 90.1  ± 54.7 months. In non-idiopathic scoliosis patients, two-stage surgery was independently associated with a 140-min increased surgical time (95% confidence interval: 52-229 min, p = 0.002) and an 8.2-day (95% confidence interval: 2.3-14.1 days, p = 0.007) increased hospital length of stay. In idiopathic scoliosis patients, two-stage surgery was independently associated with a 2108 ml increase in crystalloid use (95% confidence interval: 834-3381 ml p = 0.002) and a 5.3-day increased hospital length of stay (95% confidence interval: 4.0-6.5 days, p < 0.001). There were no significant differences in blood loss, transfusions, complications, or post-operative curves on multivariate analysis between one-stage and two-stage surgery cohorts in either non-idiopathic or idiopathic scoliosis patient groups.

CONCLUSION

Two-stage surgery was associated with increased crystalloid use in idiopathic scoliosis patients and longer operative times in non-idiopathic scoliosis patients, and longer hospital length of stay in both populations, without significant difference in complications or deformity correction. In the appropriate patient, one-stage anterior-posterior scoliosis surgery may be preferable to two-stage surgery.

LEVEL OF EVIDENCE

Level III Retrospective Comparative Study.

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

Background

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

Methods

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

Results

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

Conclusion

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

Level of Evidence

IV.

Incidence of Surgical Site Infection After Spine Surgery: A Systematic Review and Meta-analysis

STUDY DESIGN

A systematic review and meta-analysis.

OBJECTIVE

The objective of this study was to investigate the incidence of surgical site infection (SSI) in patients following spine surgery and the rate of microorganisms in these cases.

SUMMARY OF BACKGROUND DATA

Many studies have investigated the incidence and risk factors of SSI following spinal surgery, whereas no meta-analysis studies have been conducted regarding the comprehensive epidemiological incidence of SSI after spine surgery.

METHODS

We searched the PubMed, Embase, and Cochrane Library databases for relevant studies that reported the incidence of SSI after spine surgery, and manually screened reference lists for additional studies. Relevant incidence estimates were calculated. Subgroup analysis, sensitivity analysis, and publication bias assessment were also performed.

RESULTS

Our meta-analysis included 27 studies, with 603 SSI cases in 22,475 patients. The pooled SSI incidence was 3.1%. Subgroup analysis revealed that the incidence of superficial SSI was 1.4% and the incidence of deep SSI was 1.7%. Highest incidence (13.0%) was found in patients with neuromuscular scoliosis among the different indications. The incidences of SSI in cervical, thoracic, and lumbar spine were 3.4%, 3.7%, and 2.7%, respectively. Compared with posterior approach surgery (5.0%), anterior approach showed a lower incidence (2.3%) of SSI. Instrumented surgery had a higher incidence of SSI than noninstrumented surgery (4.4% vs. 1.4%). Patients with minimally invasive surgery (1.5%) had a lower SSI incidence than open surgery (3.8%). Lower incidence of SSI was found when vancomycin powder was applied locally during the surgery (1.9%) compared with those not used (4.8%). In addition, the rates of Staphylococcus aureus, Staphylococcus epidermidis, and methicillin-resistant Staphylococci in microbiological culture results were 37.9%, 22.7%, and 23.1%, respectively.

CONCLUSION

The pooled incidence of SSI following spine surgery was 3.1%. These figures may be useful in the estimation of the probability of SSI following spine surgery.

LEVEL OF EVIDENCE

3.

Pelvic Obliquity Correction in Distraction-Based Growth Friendly Implants

DESIGN

Multicenter retrospective review.

OBJECTIVE

To evaluate radiographic outcomes and complication rates of patients treated with distraction based implants and pelvic fixation with either screws (sacral-alar-iliac [SAI] screws or iliac screws) or hooks (S hook iliac fixation).

SUMMARY OF BACKGROUND DATA

Multiple options exist for pelvic fixation in distraction-based growing rod systems; however, limited comparative data are available.

METHODS

Early-onset scoliosis (EOS) patients of all diagnoses with distraction-based implants that had pelvic fixation from 2000 to 2013 were reviewed from two EOS multicenter databases. Patients were divided into two groups by type of pelvic fixation: (1) screw group (SAI screws or iliac screws) or (2) S hooks. Exclusion criteria were as follows: index instrumentation ≥10 years old and follow up <2 years. A total of 153 patients met the inclusion criteria. Mean age at index surgery was 6.1 years (range 1.0-9.9 years) and mean follow-up was 4.9 years.

RESULTS

Pelvic fixation in the 153 patients was as follows: screw group = 42 and S hook group = 111. When comparing patients with >20° of initial pelvic obliquity, the screw group had significantly more correction; mean 26° ± 13° for the screw group versus mean 17° ± 7° in the S hook group (p = .039). There was no significant difference in change in T1-S1 length (40 vs. 39 mm, p = .89) or correction of Cobb angle (30° vs. 24°, p = .24). The total complication rate for the screw group was 14% (6/42) versus 25% (28/111) in the S hook group, though this did not achieve significance (p = .25). The most common complications were device migration (13), implant failure (8), and implant prominence (4) for S hooks and implant failure (3), implant prominence (2), and device migration (1) for the screw group.

CONCLUSION

In distraction-based growth-friendly constructs, pelvic fixation with screws achieved better correction of pelvic obliquity than S hooks. Complications were almost twice as common with S hooks than screws, though this did not reach statistical significance.

Three Methods of Pelvic Fixation for Scoliosis in Children With Cerebral Palsy: Differences at 5-year Follow-Up

STUDY DESIGN

A retrospective review.

OBJECTIVE

The aim of this study was to assess correction of pelvic obliquity in children with cerebral palsy (CP) scoliosis postoperatively and 5 years after posterior spinal fusion with pelvic fixation using unit rods, sacral-alar-iliac (SAI) screws, or iliac screws.

SUMMARY OF BACKGROUND DATA

There are multiple options for pelvic fixation in children with scoliosis secondary to CP. The long-term differences in outcomes between these fixation methods are still unclear.

METHODS

A multicenter review identified records of 70 children with CP who underwent posterior spinal fusion for scoliosis using unit rods (n = 9), SAI screws (n = 19), or iliac screws (n = 42). Patients younger than 18 years with 5-year follow-up were included. Pelvic obliquity and major coronal curve measurements were compared using preoperative, (first erect) postoperative, and 5-year follow-up radiographs. Implant-related complications were noted. Alpha = 0.05.

RESULTS

For all groups, there was a significant difference between preoperative and postoperative pelvic obliquity that was maintained at 5 years. At 5-year follow-up, pelvic obliquity was significantly higher in the IS group (12°) compared with the unit rod group (4°, P = 0.001) and SAI screw group (6°) (P = 0.006). Implant-related complications were as follows: unit rod group, one patient (reoperation); SAI screw group, none; iliac screw group, six patients, including three cases of loss of connection between the rod and the iliac screw, two prominent screws, and one loose screw.

CONCLUSION

Correction of pelvic obliquity for children with CP-related scoliosis was achieved postoperatively using unit rods, SAI screws, and iliac screws. Implant-related complications and reoperations were most common in the iliac screw group. At 5-year follow-up, the iliac screw group had loss of major curve correction and less correction of pelvic obliquity than the unit rod and SAI screw groups.

LEVEL OF EVIDENCE

3.

Pedicle Subtraction Osteotomy Versus Multiple Posterior Column Osteotomies in Severe and Rigid Neuromuscular Scoliosis

STUDY DESIGN

Retrospective analysis.

OBJECTIVE

The aim of this study is to compare the safety and efficacy of the apical pedicle subtraction osteotomy (PSO) technique with multiple posterior column osteotomies (PCOs) in nonambulatory patients with severe, rigid neuromuscular scoliosis.

SUMMARY OF BACKGROUND DATA

Neuromuscular scoliosis frequently causes intolerance to sitting due to pelvic obliquity, trunk decompensation, and associated back and rib impingement pain which diminish the patient's functional capacity. In the case of rigid curves, spinal osteotomy techniques are occasionally required for effective correction.

METHODS

We retrospectively reviewed our patients with severe and rigid neuromuscular scoliosis with associated pelvic obliquity who were treated with posterior instrumented fusion extending to pelvis with more than 1-year postoperative follow-up. We compared radiological and clinical results of PSO and multiple PCO techniques in severe rigid neuromuscular scoliosis with pelvic obliquity of more than 15° in traction radiograph under general anesthesia. Hospital records were also reviewed for operative time, intraoperative blood loss, amount of blood transfusion, duration of hospital stay, and complications.

RESULTS

There were 12 patients in the PSO group and 10 patients in the PCO group. There was no significant difference between groups in terms of major curve magnitude, sagittal parameters or pelvic obliquity. Although not statistically significant, PSO technique did trend toward better scoliosis correction (post-op Cobb angle 56.1° vs. 66.7° [P = 0.415]). PSO technique provided a significantly better correction in pelvic obliquity (59% vs. 84%) (P = 0.001). There was no significant difference in average intraoperative blood loss, transfusion, and operative times including anesthesia time, hospital stay, or complications.

CONCLUSION

PSO may be an option in correction of severe and rigid neuromuscular scoliosis. It provides better correction of pelvic obliquity without increasing operative time, need for transfusion, or duration of hospitalization as compared to multiple apical PCO technique. Traction radiograph under general anesthesia is a valuable tool in surgical decision making.

LEVEL OF EVIDENCE

4.

Minimally Invasive Surgery for Neuromuscular Scoliosis: Results and Complications in a Series of One Hundred Patients

STUDY DESIGN

A retrospective review.

OBJECTIVE

To report the results of an alternative technique using a minimally invasive fusionless surgery. The originality is based on the progressive correction of the deformities with proximal and distal fixation and on the reliability of the pelvic fixation using iliosacral screws on osteoporotic bones.

SUMMARY OF BACKGROUND DATA

Spinal deformities are common in neuromuscular diseases. Conventional treatment involves bracing, followed by spinal instrumented fusion. Growing rod techniques are increasingly advocated but have a high rate of complications.

METHODS

The technique relies on a bilateral double rod sliding construct anchored proximally by four hooks claws and distally to the pelvis by iliosacral screws through a minimally invasive approach. Hundred patients with neuromuscular scoliosis underwent the same fusionless surgery extended from T1 to the pelvis. The average age at initial surgery was 11 + 6 years. Diagnoses included cerebral palsy (61), spinal muscular atrophy (22), muscular dystrophy (10), and other neurological etiologies (7). Cobb angle and pelvic obliquity were measured before and after initial surgery, and at final follow-up. Complications were reviewed.

RESULTS

At latest follow-up 3 + 9 years (range 2 yr-6 + 3 yr), the mean Cobb angle improved from 89° to 35° which corresponds to 61% correction. Mean pelvic obliquity improved from 29° to 5°, which corresponds to 83% correction. Mean T1-S1 length increased from 30.02 to 37.28 cm. Mean preoperative hyper kyphosis was reduced from 68.44° to 33.29°. Complications occurred in 26 patients including mechanical complications (12) and wound infections (16). No arthrodesis was required at last follow-up.

CONCLUSION

This original fusionless technique is safe and effective, preserving spinal and thoracic growth. It provides a significant correction of spinal deformities and pelvic obliquity with a reduced complications rate. The strength and stability of this modular construct over time allow the avoidance of final arthrodesis.

LEVEL OF EVIDENCE

4.

The Effect of Two Attending Surgeons on Patients With Large-Curve Adolescent Idiopathic Scoliosis Undergoing Posterior Spinal Fusion

STUDY DESIGN

Retrospective, chart review.

OBJECTIVES

The objective of this study is to investigate the impact of using two surgeons for posterior spinal fusion (PSF) in patients with AIS with large-magnitude curves (greater than 70°).

SUMMARY OF BACKGROUND DATA

Previous studies have shown that intraoperative risk factors can be reduced by having two surgeons operate simultaneously.

METHODS

A retrospective chart review identified 47 patients between January 1, 2009, and December 31, 2014, who underwent a posterior spinal fusion (PSF) with AIS with large-magnitude curves (greater than 70°). Patients with large-magnitude curves due to neuromuscular diseases or any defined pathology other than idiopathic scoliosis were excluded, as well as patients with kyphotic or kyphoscoliotic curves.

RESULTS

There was no statistical difference between the total operative time, anesthesia time, estimated blood loss (EBL), %EBL, and blood transfusion units. Total operative time for the two-surgeon group and single-surgeon group was 212.11 and 238.07 minutes, respectively (p = .078). The two-surgeon group averaged 0.26 blood transfusion units versus 0.39 units for the single-surgeon group (p = .50). Average hospital length of stay was decreased in the two-surgeon group (5.16 vs. 6.82 days, p = .002).

CONCLUSIONS

The use of two surgeons for PSF for AIS has previously been shown to decrease operative time and blood loss, factors that are correlated with prolonged hospital stay and increased risk of both neurologic and nonneurologic complications. However, in this study, the technique of having two experienced orthopedic spine surgeons work simultaneously to perform pedicle screw-only posterior spinal fusion on large-magnitude AIS curves greater than 70° did not improve blood loss or operative time. Further study needs to continue to identify ways to minimize complications for patients who undergo spinal fusion.

LEVEL OF EVIDENCE

Level III, retrospective, comparative study.

Outcomes after scoliosis surgery for children with cerebral palsy: a systematic review

AIM

This study aims (1) to evaluate and synthesize the evidence for the postoperative outcomes after scoliosis surgery for children with cerebral palsy (CP), and (2) to identify preoperative risk factors for adverse outcomes after surgery.

METHOD

Medline, EMBASE, CINAHL, and PubMed were searched for relevant literature. Included studies were assessed for risk of bias using the Cochrane Effective Practice and Organisation of Care tool. Quality of evidence for overall function, quality of life (QoL), gross motor function, caregiver outcomes, deformity correction, and postoperative complications were assessed using GRADE (Grades of Recommendation, Assessment, Development and Evaluation).

RESULTS

Fifty-one studies met inclusion criteria, including 35 case series designs. Risk of bias was high across all studies. On average good deformity correction was achieved, the trend appears positive for caregiver and QoL outcomes, but there was minimal to no change for gross motor or overall function. Inconsistent measurement limited synthesis. A mean overall complication rate of 38.1% (95% confidence interval 27.3-53.3) was found. The quality of evidence was very low across all functional outcomes.

INTERPRETATION

Limited high-quality evidence exists for outcomes after scoliosis surgery in children with CP, a procedure associated with a moderately high complication rate. The intervention appears indicated for deformity correction, but currently there is insufficient evidence to make recommendations for this surgery as a way to also improve functional outcomes, caregiver outcomes, and quality of life.

Safety and efficacy of sublaminar bands and Ponte osteotomies in rigid deformity: preliminary results in a prospective series of 20 neuromuscular scoliosis patients

This prospective cohort study investigated radiographic outcomes and complications over time in patients with rigid neuromuscular scoliosis treated with sublaminar bands and Ponte osteotomies. Twenty consecutive patients with neuromuscular scoliosis were treated with sublaminar bands in addition to Ponte osteotomies at and around the apex of the deformity and prospectively included. All curves were rigid, with less than 30% reduction on preoperative bending films. Cobb angle, pelvic obliquity, and shoulder obliquity were significantly corrected (P<0.01). Normal thoracic kyphosis was achieved for 85% of patients at the last follow-up. No intraoperative complications were observed. The association between Ponte osteotomies and sublaminar bands appears to be efficient for the management of rigid neuromuscular deformities in children and adolescents. No death and no permanent neurological impairment, as well as no sublaminar bands associated events were recorded.

The management of scoliosis in children with cerebral palsy: a review

Children who suffer with cerebral palsy (CP) have a significant chance of developing scoliosis during their early years and adolescence. The behavior of this scoliosis is closely associated with the severity of the CP disability and unlike idiopathic scoliosis, it continues to progress beyond skeletal maturity. Conservative measures may slow the progression of the curve, however, surgery remains the only definitive management option. Advances in surgical technique over the last 50 years have provided methods to effectively treat the deformity while also reducing complication rates. The increased risk of surgical complications with these complex patients make decisions about treatment challenging, however with careful pre-operative optimization and post-operative care, surgery can offer a significant improvement in quality of life. This review discusses the development of scoliosis in CP patient, evaluates conservative and surgical treatment options and assesses post-operative outcome.

Factors influencing the evaluation and management of neuromuscular scoliosis: A review of the literature

Neuromuscular scoliosis (NMS) is the second most prevalent spinal deformity (after idiopathic scoliosis) and is usually first identified during early childhood. Cerebral palsy (CP) is the most common cause of NMS, followed by Duchenne muscular dystrophy (DMD). Progressive spinal deformity causes difficulty with daily care, walking and sitting, and can lead to back and rib pain, cardiac and pulmonary complications, altered seizure thresholds, and skin compromise. Early referral to specialist spinal services and early diagnosis of NMS is essential to ensure appropriate multidisciplinary patient management. The most important goals for patients are preservation of function, facilitation of daily care, and alleviation of pain. Non-operative management includes observation or bracing for less severe and flexible deformity in young patients as a temporising measure to provide postural support. Surgical correction and stabilisation of NMS is considered for patients with a deformity >40-50°, but may be performed for less severe deformity in patients with DMD. Post-operative intensive care, early mobilisation and nutritional supplementation aim to minimise the rate of post-surgical complications, which are relatively common in this patient group. However, surgical management of NMS is associated with good long-term outcomes and high satisfaction rates for patients, their relatives and carers.

Management of spinal infections in children with cerebral palsy

Cerebral palsy patients who undergo posterior spinal instrumentation for scoliosis are at a greater risk of surgical site infection compared to adolescents with idiopathic scoliosis. Many infecting organisms are reported. Risk factors include patients' specific factors, nutritional status as well as surgery related factors. Although surgical management is still controversial, it is always based on irrigation and debridement followed or not by implant removal. The purpose of this paper is to review the pathophysiology of surgical site infection in this patient population and to propose a treatment algorithm, based on a thorough review of the current literature and personal experience.

Efficacy and Safety of One-Stage Selective Discectomy Combined with Expansive Hemilaminectomy in the Treatment of Cervical Spondylotic Myelopathy

OBJECTIVES

We designed a novel surgical strategy named one-stage selective discectomy combined with expansive hemilaminectomy, which might theoretically reduce the postoperative complications of cervical spondylotic myelopathy (CSM). The objective of this study is to evaluate its efficacy and safety.

METHODS

Sixty-two patients with CSM were enrolled in this study. The procedure includes selective discectomy with fusion at 1 or 2 segments of maximal cord compression and expansive hemilaminectomy on the symptomatic or severe side of the body. Neurologic function was evaluated using the Japanese Orthopedics Association Score before and after surgery. Midsagittal dural sac diameter, dural sac transverse area at segments of discetomy on magnetic resonance imaging, and lordosis of the cervical spine on lateral plain film were measured. All patients were followed up for more than 1 year.

RESULTS

A total of 88 discs and 272 hemilaminas were resected from 62 patients. The Japanese Orthopedics Association Score improved from 8.7 ± 1.76 preoperatively to 13.4 ± 1.61 at 1 year follow-up (P < 0.001). The mean midsagittal dural sac diameter, dural sac area, and lordotic angle also increased from 0.45 ± 0.10 cm, 0.83 ± 0.14 cm², and 7.9 ± 2.60° to 0.81 ± 0.08 cm, 0.96 ± 0.14 cm², and 11.7 ± 3.06°, respectively (P < 0.05). No case of postoperative axial pain, C5 palsy, nonunion, or kyphosis was reported.

CONCLUSIONS

One-stage selective discectomy combined with expansive hemilaminectomy is an effective surgical approach for the treatment of CSM in patients whose neurologic function, midsagittal dura sac diameter, and dura transverse area can be improved and has few postoperative complications.

Spinal fusion for pediatric neuromuscular scoliosis: national trends, complications, and in-hospital outcomes

OBJECTIVE The objective of this study was to determine if the recent changes in technology, surgical techniques, and surgical literature have influenced practice trends in spinal fusion surgery for pediatric neuromuscular scoliosis (NMS). In this study the authors analyzed recent trends in the surgical management of NMS and investigated the effect of various patient and surgical factors on in-hospital complications, outcomes, and costs, using the Nationwide Inpatient Sample (NIS) database. METHODS The NIS was queried from 2002 to 2011 using International Classification of Diseases, Ninth Edition, Clinical Modification codes to identify pediatric cases (age < 18 years) of spinal fusion for NMS. Several patient, surgical, and short-term outcome factors were included in the analyses. Trend analyses of these factors were conducted. Both univariate and multivariable analyses were used to determine the effect of the various patient and surgical factors on short-term outcomes. RESULTS Between 2002 and 2011, a total of 2154 NMS fusion cases were identified, and the volume of spinal fusion procedures increased 93% from 148 in 2002 to 286 in 2011 (p < 0.0001). The mean patient age was 12.8 ± 3.10 years, and 45.6% of the study population was female. The overall complication rate was 40.1% and the respiratory complication rate was 28.2%. From 2002 to 2011, upward trends (p < 0.0001) were demonstrated in Medicaid insurance status (36.5% to 52.8%), presence of ≥ 1 comorbidity (40.2% to 52.1%), and blood transfusions (25.2% to 57.3%). Utilization of posterior-only fusions (PSFs) increased from 66.2% to 90.2% (p < 0.0001) while combined anterior release/fusions and PSF (AR/PSF) decreased from 33.8% to 9.8% (< 0.0001). Intraoperative neurophysiological monitoring (IONM) underwent increasing utilization from 2009 to 2011 (15.5% to 20.3%, p < 0.0001). The use/harvest of autograft underwent a significant upward trend between 2002 and 2011 (31.3% to 59.8%, p < 0.0001). In univariate analysis, IONM use was associated with decreased complications (40.7% to 33.1%, p = 0.049) and length of stay (LOS; 9.21 to 6.70 days, p <0.0001). Inflation-adjusted mean hospital costs increased nearly 75% from 2002 to 2011 ($36,805 to $65,244, p < 0.0001). In the multivariable analysis, nonwhite race, highest quartile of median household income, greater preexisting comorbidity, long-segment fusions, and use of blood transfusions were found to increase the likelihood of complication occurrence (all p < 0.05). In further multivariable analysis, independent predictors of prolonged LOS included older age, increased preexisting comorbidity, the AR/PSF approach, and long-segment fusions (all p < 0.05). Lastly, the likelihood of increased hospital costs (at or above the 90th percentile for LOS, 14 days) was increased by older age, female sex, Medicaid insurance status, highest quartile of median household income, AR/PSF approach, long-segment fusion, and blood transfusion (all p < 0.05). In multivariable analysis, the use of autograft was associated with a lower likelihood of complication occurrence and prolonged LOS (both p < 0.05). CONCLUSIONS Increasing use of IONM and posterior-only approaches may combat the high complication rates in NMS. The trends of increasing comorbidities, blood transfusions, and total costs in spinal fusion surgery for pediatric NMS may indicate an increasingly aggressive approach to these cases.

Correction of Pelvic Obliquity After Spinopelvic Fixation in Children With Cerebral Palsy: A Comparison Study With Minimum Two-Year Follow-up

STUDY DESIGN

Single institution cohort data were collected prospectively and reviewed retrospectively.

OBJECTIVES

This study aims to compare outcomes among three different instrumentation types: unit rod, iliac screws, and sacral alar iliac (SAI) screws in terms of pelvic obliquity correction in children with cerebral palsy (CP).

SUMMARY OF BACKGROUND DATA

The optimal choice for spinopelvic fixation in CP scoliosis with pelvic obliquity is controversial.

METHODS

Patients with minimum 2 years' follow-up were divided into three groups according to instrumentation type and matched based on preoperative pelvic obliquity and coronal major curve magnitude. Radiographic measurements included horizontal pelvic obliquity angle (PO), spinopelvic angle (SPA), coronal and sagittal Cobb angles, and T1 pelvic angle. Procedures were performed in one pediatric institution between 2004 and 2012. All measurements were performed by a single independent reviewer who was not involved in the procedures.

RESULTS

Seventy-seven patients (42 unit rod, 14 iliac screw, and 21 SAI screw) were included. Gender and age distribution was similar across all groups (56% males, 44% females, mean age 13.5 years). Mean follow-up was 3.6 years. Comparing pre- and postoperative measurements, there was a significant decrease (p < .05) in PO, SPA, and coronal major cob angle in all groups. No significant loss of correction occurred during follow-up. Postoperatively, TPA improved in all groups. Nonsymptomatic loosening was noted in 59% of unit rods, 57% of iliac screws, and 52% of SAI screws. One prominent iliac screw needed removal. One nonsymptomatic rod fracture, one infected pseudarthrosis, and one rod malposition occurred in unit rod group.

CONCLUSIONS

This study suggests that for correction of pelvic obliquity in cerebral palsy scoliosis, iliac and SAI screws were similar to the unit rod in comparative effectiveness and implant safety profile.

LEVEL OF EVIDENCE

Therapeutic study, Level III.

Are S1 Screws a Useful Adjunct to Iliac Screws in Long Fusions to the Sacrum in Cerebral Palsy?

STUDY DESIGN

Multicenter prospective database review of patients with cerebral palsy (CP) and spinal deformity.

OBJECTIVE

To determine if the type of distal fixation is associated with improved correction of coronal deformity or pelvic obliquity (PO) at 2 years in long posterior fusions to the sacrum.

SUMMARY OF BACKGROUND DATA

Multiple techniques are utilized for distal fixation in patients with CP. Although there is emerging evidence that the augmentation of iliac screws with S1 screws may be beneficial, this remains controversial.

METHODS

A prospective, multicenter database was used to identify patients with CP who underwent long posterior fusions to the sacrum. Eighty-eight patients were included, 52 with iliac screws (I) and 36 with iliac and S1 screws (IS) for distal fixation. Preoperative, first erect, and 2-year follow-up radiographs and complications were analyzed. Statistical analysis was performed using ANOVA and repeated measures ANOVA with significance set at P < 0.05.

RESULTS

Scoliosis was the primary deformity in greater than 90% of patients in both groups (P=0.84). Preoperative coronal deformity was similar (I = 83°, IS = 87°, P = 0.49), but correction was better with the use of S1 screws on the first erect radiograph and at 2 years (I = 35°, IS = 22°, P = 0.001), reflecting correction of 58% and 74% for iliac and iliac-S1 screws, respectively (P < 0.001). Preoperative PO was similar (I = 29°, IS = 30°, P = 0.71) and was noted to improve more in the iliac-S1 group by 2 years (I = 11°, IS = 5°, P = 0.004), representing correction of 60% and 77% for the iliac and iliac-S1 groups, respectively (P = 0.018). There was no difference in the rate of major (P = 0.27) or minor (P = 0.65) complications in either group.

CONCLUSION

Bilateral S1 and iliac screws are associated with improved spinal deformity and PO correction at 2 years in the CP population. Two points of distal fixation, S1, and ilium should be considered for this population.

LEVEL OF EVIDENCE

3.

Minimally Invasive Scoliosis Surgery: A Novel Technique in Patients with Neuromuscular Scoliosis

Minimally invasive surgery (MIS) has been described in the treatment of adolescent idiopathic scoliosis (AIS) and adult scoliosis. The advantages of this approach include less blood loss, shorter hospital stay, earlier mobilization, less tissue disruption, and relatively less pain. However, despite these significant benefits, MIS approach has not been reported in neuromuscular scoliosis patients. This is possibly due to concerns with longer surgery time, which is further increased due to more levels fused and instrumented, challenges of pelvic fixation, size and number of incisions, and prolonged anesthesia. We modified the MIS approach utilized in our AIS patients to be implemented in our neuromuscular patients. Our technique allows easy passage of contoured rods, placement of pedicle screws without image guidance, partial/complete facet resection, and all standard reduction maneuvers. Operative time needed to complete this surgery is comparable to the standard procedure and the majority of our patients have been extubated at the end of procedure, spending 1 day in the PICU and 5-6 days in the hospital. We feel that MIS is not only a feasible but also a superior option in patients with neuromuscular scoliosis. Long-term results are unavailable; however, short-term results have shown multiple benefits of this approach and fewer limitations.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

2.

Postoperative quality of life in patients with progressive neuromuscular scoliosis and their parents

BACKGROUND CONTEXT

The functional level of children with progressive neuromuscular disease is a major factor that affects the quality of life (QOL) of parents. However, only a few publications have reported changes in the QOL of parents after correctional spinal surgery.

PURPOSE

The purpose was to compare changes in QOL for both patients and parents after spinal correctional surgery for better sitting balance and to analyze correlation among radiographic parameters, functional outcome, and QOL questionnaires. Finally, the QOL of patients and parents was compared with the population norm.

STUDY DESIGN

This study is a retrospective analysis of prospectively gathered data.

PATIENT SAMPLE

From 2008 to 2011, 58 patients who underwent correctional surgery for progressive neuromuscular scoliosis and their parents were enrolled.

OUTCOME MEASURES

A Muscular Dystrophy Spine Questionnaire (MDSQ) and short-form questionnaire 36 (SF-36) were used.

METHODS

The gathered functional outcome and QOL data using MDSQ and SF-36 for both enrolled patients and parents were compared preoperatively, postoperatively at 3 months, and at 1-year follow-up.

RESULTS

Mean age was 15.0±4.1 years. Forty male and 18 female patients were enrolled. Mean follow-up was 38.4±13.7 months. Cobb angle was 61.5°±23.5° preoperatively, 39.0°±20.1° immediately postoperative, and 40.0°±20.2° at the final follow-up. Cobb angle, pelvic obliquity, and lumbar lordosis were significantly improved after surgery (p<.001). Among sitting-related questions, answers to questions 15 (sitting comfortably), 16 (change weight in wheelchair), 22 (sit all day), 24 (sit at table for meal), 26 (keep balance while sitting in wheelchair), and 27 (look good while sitting in wheelchair) were significantly improved after correctional surgery (p<.001). Regarding the SF-36 scales for patients, bodily pain and social functioning significantly improved postoperatively (p<.001).

CONCLUSIONS

Muscular Dystrophy Spine Questionnaire results indicated that patients had significantly improved sitting balance-related outcomes, whereas the SF-36 indicated improvements only in bodily pain and social functioning scales. For parents, no SF-36 scales improved significantly postoperatively. Accordingly, improved sitting balance and QOL for neuromuscular scoliosis patients after surgery do not necessarily increase parent QOL.

Hybrid fixation with sublaminar polyester bands in the treatment of neuromuscular scoliosis: a comparative analysis

BACKGROUND

Segmental spinal instrumentation with Luque wire fixation has been the standard treatment of neuromuscular scoliosis for >30 years. More recently, pedicle screw constructs have become the most widely utilized method of posterior spinal fixation; however, they are associated with complications such as implant malposition. We report the use of polyester bands and clamps utilized with pedicle screws in a hybrid fixation construct in the treatment of neuromuscular scoliosis.

METHODS

A retrospective review was conducted of 115 pediatric spinal deformity cases between 2008 and 2010 at a single center performed by a single surgeon. Intraoperative and postoperative complications were recorded. Radiographs were reviewed preoperatively and at the latest follow-up. A systematic review of the literature was conducted. Data from case series reporting outcomes of sublaminar wires and all-pedicle screw constructs in the treatment of neuromuscular scoliosis were compared with outcomes of the present study.

RESULTS

Twenty-nine patients with neuromuscular scoliosis who underwent segmental spinal instrumentation with a hybrid construct including sublaminar bands and pedicle screws were included. There was an average follow-up of 29 months (range, 12 to 40 mo). The average postoperative correction of coronal balance was 69% (range, 24 to 71 degrees). Sagittal balance was corrected to within 2 cm of the C7 plumbline in 97% of patients. The loss of coronal and sagittal correction at latest follow-up was 0% and 2%, respectively. There were 2 intraoperative clamp failures of the 398 implants (0.5%). There were 2 major (6.9%) and 7 minor (24%) complications in 7 patients (24% overall). These results compared favorably to previous case series of sublaminar wire and all-pedicle screw fixation techniques.

CONCLUSIONS

The polyester band technique is an excellent adjunct in the correction of spinal deformity in patients with neuromuscular scoliosis. Sublaminar bands utilized in a hybrid construct appear to be safe, can achieve corrections equivalent to all-pedicle screw constructs, and may decrease the potential complications associated with every level transpedicular fixation in the patient with a highly dysmorphic and osteoporotic spine.

LEVEL OF EVIDENCE

Level IV: cohort study.

The surgical treatment of lordoscoliosis and hyperlordosis in patients with quadriplegic cerebral palsy

We describe 13 patients with cerebral palsy and lordoscoliosis/hyperlordosis of the lumbar spine who underwent a posterior spinal fusion at a mean age of 14.5 years (10.8 to 17.4) to improve sitting posture and relieve pain. The mean follow-up was 3.3 years (2.2 to 6.2).

The mean pre-operative lumbar lordosis was 108° (80 to 150°) and was corrected to 62° (43° to 85°); the mean thoracic kyphosis from 17° (-23° to 35°) to 47° (25° to 65°); the mean scoliosis from 82° (0° to 125°) to 22° (0° to 40°); the mean pelvic obliquity from 21° (0° to 38°) to 3° (0° to 15°); the mean sacral slope from 79° (54° to 90°) to 50° (31° to 66°). The mean pre-operative coronal imbalance was 5 cm (0 cm to 8.9 cm) and was corrected to 0.6 cm (0 to 3.2). The mean sagittal imbalance of -8 cm (-16 cm to 7.8 cm) was corrected to -1.6 cm (-4 cm to 2.5 cm). The mean operating time was 250 minutes (180 to 360 minutes) and intra-operative blood loss 0.8 of estimated blood volume (0.3 to 2 estimated blood volume). The mean intensive care and hospital stay were 3.5 days (2 to 8) and 14.5 days (10 to 27), respectively. Three patients lost a significant amount of blood intra-operatively and subsequently developed chest or urinary infections and superior mesenteric artery syndrome.

An increased pre-operative lumbar lordosis and sacral slope were associated with increased peri-operative morbidity: scoliosis and pelvic obliquity were not. A reduced lumbar lordosis and increased thoracic kyphosis correlated with better global sagittal balance at follow-up. All patients and their parents reported excellent surgical outcomes.

Lordoscoliosis and hyperlordosis are associated with significant morbidity in quadriplegic patients. They are rare deformities and their treatment is challenging. Sagittal imbalance is the major component: it can be corrected by posterior fusion of the spine with excellent functional results.

Cite this article: Bone Joint J 2014;96-B:800–6.

Combined S-1 and S-2 sacral alar-iliac screws as a salvage technique for pelvic fixation after pseudarthrosis and lumbosacropelvic instability

Lumbosacropelvic pseudarthrosis after long spinal fusions for treatment of adult degenerative scoliosis remains a challenging condition. Moreover, although pelvic fixation with iliac screws is widely used in deformity surgery to provide a biomechanically strong distal anchor for long thoracolumbar constructs, there are very few options available after failed pelvic fixation with iliac screws. The authors conducted a retrospective review of the surgical charts and imaging findings of patients subjected to revision surgery for lumbosacropelvic pseudarthrosis from August 2011 to August 2012. This review identified 5 patients in whom a salvage technique combining both S-1 and S-2 sacral alar-iliac (SAI) screws had been performed. In this technical note, the authors present a detailed anatomical discussion and an appraisal of the sequential intraoperative steps of this new technique involving a combination of S-1 and S-2 SAI screws. The discussion is illustrated with a surgical case in which this technique was used to treat a patient with pseudarthrosis that had developed after fixation with classic iliac screws. In conclusion, although S-2 SAI screws have previously been reported as an interesting alternative to classic iliac wing screws, this report is the first on the use of combined S-1 and S-2 SAI screws for pelvic fixation as a salvage technique for lumbosacropelvic instability. According to the reported experience, this technique provides a biomechanically robust construct for definitive pelvic fixation during revision surgeries in the challenging scenarios of pseudarthrosis and instability of the lumbosacropelvic region.

Correction of pelvic obliquity in neuromuscular spinal deformities using the "T construct": results and complications in a prospective series of 60 patients

BACKGROUND

We present the results of a prospective series of 60 patients treated for neuromuscular spinal deformities with an original spinopelvic construct using two sacral screws and two iliac screws. Clinical and radiological results obtained with this new surgical technique were studied and discussed according to the epidemiological data and relevant literature.

METHODS

From January 2008 to June 2010, the clinical data of every patient who underwent spinopelvic fixation for treatment of a neuromuscular spinal deformity were recorded prospectively.

RESULTS

Sixty patients were operated on during the study period. Spinal correction and fusion was performed by posterior approach. In six patients with a residual spinopelvic imbalance more than 15° on lateral preoperative bending films, an anterior release of the thoracolumbar junction was performed on the same day, before posterior correction. Preoperative pelvic obliquity (PO) ranged from 4° to 44° (mean 21.6°). Postoperative pelvic obliquity ranged from 0° to 14 (mean 4.6°). No significant loss of correction was noted at the last follow-up. One patient died 3 months after the initial procedure due to respiratory compromise. 11 patients had early postoperative infections of the posterior approach.

CONCLUSIONS

Despite a high rate of infectious complications, optimal correction of pelvic obliquity requires extension of spinal instrumentation to the pelvis. Spinopelvic fixation remains a difficult challenge in neurological patients with hypotrophy. We think that pelvic fixation with the "T construct" did provide effective and improved spinal stabilization in these patients, while reducing the need for a postoperative cast or brace. As a result, patients had a favourable postoperative course with early mobilization and return to a comfortable sitting position.

The use of intralaminar screws in patients with spinal deformity

STUDY DESIGN

Retrospective study.

OBJECTIVE

To demonstrate that intralaminar screws (ILS) can be used as supplements in spinal deformity surgery in the thoracic and lumbar levels in pediatric and adult patients.

SUMMARY OF BACKGROUND DATA

Rigid posterior fixation of the spine is generally accomplished using pedicle screws, hooks, or wires. ILSs are useful tools when other spinal fixation techniques have failed or the bony anatomy precludes hook or screw placement.

MATERIALS AND METHODS

All spinal deformity patients (primary/revision) operated between 2007 and 2011 were retrospectively reviewed. The patients with ILS were included in the study. The anteroposterior and lateral standing x-rays were evaluated in terms of preoperative and postoperative coronal and sagittal deformities. The number and level of ILS, intraoperative complications, and postoperative complications were noted.

RESULTS

There were 20 patients (12 male and 8 female). The mean age was 21.75 years. The mean follow-up period was 17.4 months. Fifty-seven ILS were inserted. Seventeen screws were used in the uppermost to lowermost levels. Forty screws were used in the middle. There was 1 lamina fracture and screw pull out (1.75%). There were 3 canal violations (corrected intraoperative) and 2 instrument prominences which required implant removal. The mean preoperative/postoperative cobb angles were 78.5 degrees/27.8 degrees and the mean preoperative/postoperative kyphosis angles were 57.2 degrees/32.5 degrees, respectively. The loss of correction was 1.2 degrees. There were no neurological deficits and no instrument failures.

CONCLUSIONS

ILS are safe and effective when used in deformity correction. However, biomechanical studies and randomized controlled trials are needed to conclude whether ILS will be considered a first-line technique, or will remain a technique for salvage situations.

Hybrid versus total pedicle screw instrumentation in patients undergoing surgery for neuromuscular scoliosis: a comparative study with matched cohorts

We compared the clinical, radiological and quality-of-life outcomes between hybrid and total pedicle screw instrumentation in patients undergoing surgery for neuromuscular scoliosis. A matched comparison using prospectively collected data was undertaken. A total of 66 patients underwent posterior or anteroposterior correction and fusion with hybrid (n = 33, mean age at surgery 15.8 years (9.10 to 19.6)) or total pedicle screw instrumentation (n = 33, mean age 14.7 years (7.0 to 20.7)) with a minimum follow-up of two years. The major curve pre-operatively was a mean of 87° (SD 29, 25° to 141°) and 81° (SD 18, 47° to 116°) in the hybrid and total pedicle screw groups, respectively (p = 0.29) and at a minimum of two years it was 33° (SD 20; 2° to 87°) and 20° (SD 12; 1° to 55°), respectively (p = 0.0016). The mean correction of the major curve was 59% (41% to 88%) in the hybrid and 75% (43% to 99%) in the total pedicle screw groups at two-year follow-up (p = 0.0011). The mean operating time was 7.45 hours (SD 2.18) and 6.04 hours (SD 1.71) in the hybrid and total pedicle screw groups, respectively (p = 0.001), and the mean intra-operative blood loss was 3760 ml (SD 2790) and 1785 ml (SD 1110), respectively (p = 0.001). Total pedicle screw instrumentation provided shorter operating times, less blood loss and better correction of the major curve compared with hybrid constructs in patients undergoing surgery for neuromuscular scoliosis.

Growing rods for the treatment of scoliosis in children with cerebral palsy: a critical assessment

STUDY DESIGN

Retrospective analysis.

OBJECTIVE

To evaluate, in children with cerebral palsy, the following aspects of growing rod (GR) treatment for scoliosis: structural effectiveness, effect of pelvic fixation, hospital stay duration, and complications.

SUMMARY OF BACKGROUND DATA

Children with cerebral palsy frequently develop severe spinal deformity and pelvic obliquity (PO). Growth-preserving strategies are attractive, but comorbidities raise the risk/benefit ratio. To our knowledge, no previous studies have focused on growth-preserving spine surgery in these children.

METHODS

From our multicenter patient group, we identified 27 children with cerebral palsy treated with GRs (single rod in 4; dual rods in 23 [15 extending to the pelvis]). We collected radiographical, surgical, hospital stay, and major complication data. We compared Cobb angle and PO improvement between patients with and without pelvic instrumentation via the Student t test (significance, P = 0.05). No patient required anterior spinal fusion.

RESULTS

Average improvements for all patients (preoperative to latest follow-up) were: Cobb angle, 35° ± 23°; PO, 14° ± 19°; T1-S1 length, 7.9 ± 4.4 cm; and space available for lung ratio, 0.17 ± 0.21. For the 8 patients who underwent fusion, average improvements (preoperative to postfusion) were: Cobb angle, 43° ± 28°; PO, 2° ± 21°; T1-S1 length, 9.5 ± 6.0 cm; and space available for lung ratio, 0.26 ± 0.28. Pelvic GR fixation produced better PO correction (P < 0.001) but similar Cobb angle correction (P = 0.556). Hospital stays averaged 8.7 ± 12.1 days after initial surgery, 1.4 ± 2.5 days after lengthening (45% were outpatient procedures), and 13.4 ± 6.2 days after fusion. The most common complication was deep wound infection (30%).

CONCLUSION

GRs via a posterior-only approach are effective. Constructs extending to the pelvis control PO more effectively. However, 30% of patients experienced deep wound infection.

Pelvic fixation for neuromuscular scoliosis deformity correction

Pelvic fixation is most frequently indicated in the pediatric population for the treatment of neuromuscular scoliosis with significant pelvic obliquity. Neuromuscular scoliosis surgery is associated with a high risk of complications, and this is further increased by extension of fusion to the sacrum. Numerous techniques have been described for pelvic fixation associated with a long spine fusion each with its own set of specific benefits and risks. This article reviews the contemporary surgical techniques of pelvic fixation used to extend a spine fusion to the sacrum and pelvis focusing on the management of neuromuscular scoliosis, including their biomechanical rationale, results, and complications.

Pediatric scoliosis

Pediatric scoliosis is a relatively uncommon condition typically first noticed due to altered stature or by routine spine screenings by a school nurse or pediatrician. The formal diagnosis is made with spine radiographs, with coronal curvature measurement of 10° or greater. Treatment may consist of serial observation, bracing until skeletal maturity, or surgery for correction and fusion/stabilization of severe or progressive deformity. Overall success for non-operative management of scoliosis is affected by the etiology for the deformity, close follow up and monitoring for evolution of the deformity, and patient compliance with their treatment regimen. The most common surgical technique is a posterior approach spine fusion with implanted instrumentation, and patients are typically back to their activities of daily living by 6 months postoperatively. Continued intermittent monitoring of the scoliosis throughout adulthood is recommended, to detect late deformity progression, development of arthritis symptoms, or other associated issues.