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Raitio A, Heiskanen S, Soini V, Helenius L, Syvänen J, Helenius I. Hidden blood loss and bleeding characteristics in children with congenital scoliosis undergoing spinal osteotomies. INTERNATIONAL ORTHOPAEDICS 2024; 48:1569-1577. [PMID: 38228759 PMCID: PMC11076341 DOI: 10.1007/s00264-024-06090-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/07/2024] [Indexed: 01/18/2024]
Abstract
PURPOSE Spinal osteotomies are often essential in the treatment of congenital scoliosis. Risk factors for bleeding in these patients needing extracavitatory approaches, especially hidden blood loss, are sparsely investigated. We aimed to investigate the bleeding characteristics and hidden blood loss in paediatric patients undergoing spinal osteotomies for congenital scoliosis. METHODS A retrospective analysis identified all patients with congenital scoliosis were retrospectively identified from the prospectively collected spine register from 2010 to 2022. Operative technique, perioperative laboratory results and imaging studies were extracted. The primary outcome was total blood loss including intraoperative, drain output and hidden blood loss. RESULTS Fifty-seven children (32 boys) with a mean age of 8.3 years underwent spinal osteotomy for congenital scoliosis. Posterolateral hemivertebrectomy was sufficient in 34 (59%) patients, while vertebral column resection (VCR) was required in 23 patients. Total bleeding averaged 792 (523) ml accounting for 42% of the estimated blood volume. Hidden blood loss accounted for 40% of total bleeding and 21% of estimated blood volume with a mean of 317 (256) ml. VCR was associated with greater intraoperative and total bleeding than hemivertebrectomies (p = 0.001 and 0.007, respectively). After adjusting for patient weight and fusion levels, hidden blood loss was larger in hemivertebrectomies (4.18 vs. 1.77 ml/kg/fused level, p = 0.049). In multivariable analysis, intraoperative blood loss was inversely correlated with preoperative erythrocyte levels. Younger age was associated with significantly greater drain, hidden and total blood loss. CONCLUSION Hidden blood loss constitutes a significant portion (40%) of total bleeding in congenital scoliosis surgery. Younger age is a risk factor for bleeding and the hidden blood loss should be taken into consideration in their perioperative management.
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Affiliation(s)
- Arimatias Raitio
- Department of Paediatric Surgery, Orthopaedics and Traumatology, University of Turku and Turku University Hospital, Turku, Finland
| | - Susanna Heiskanen
- Department of Paediatric Surgery, Orthopaedics and Traumatology, University of Turku and Turku University Hospital, Turku, Finland
| | - Venla Soini
- Department of Paediatric Surgery, Orthopaedics and Traumatology, University of Turku and Turku University Hospital, Turku, Finland
- Department of Surgery, Vaasa Central Hospital, Wellbeing Services County of Ostrobothnia, Vaasa, Finland
| | - Linda Helenius
- Department of Anaesthesia and Intensive Care, University of Turku and Turku University Hospital, Turku, Finland
| | - Johanna Syvänen
- Department of Paediatric Surgery, Orthopaedics and Traumatology, University of Turku and Turku University Hospital, Turku, Finland
| | - Ilkka Helenius
- Department of Paediatric Surgery, Orthopaedics and Traumatology, University of Turku and Turku University Hospital, Turku, Finland.
- Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
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Ruffilli A, Traversari M, Viroli G, Manzetti M, Ialuna M, Morandi Guaitoli M, Mazzotti A, Artioli E, Zielli SO, Arceri A, Faldini C. Similar Short-Term Outcomes of Adolescent Idiopathic Scoliosis Surgery with or without Drainage: A Systematic Review of the Literature and Meta-Analysis. J Pers Med 2024; 14:339. [PMID: 38672966 PMCID: PMC11051329 DOI: 10.3390/jpm14040339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 03/18/2024] [Accepted: 03/20/2024] [Indexed: 04/28/2024] Open
Abstract
The use of closed suction drains post posterior spinal fusion for adolescent idiopathic scoliosis (AIS) is common practice, although evidence on its impact is limited compared to that for knee and hip arthroplasty. This study aimed to assess the effect of closed suction drainage on short-term post-operative outcomes in AIS surgery. A systematic review following PRISMA guidelines was conducted, including studies comparing outcomes with and without drainage. Data on blood loss, transfusions, hospital stay, and complications were collected and subjected to meta-analysis. Five studies involving 772 patients were analyzed. The meta-analysis found no significant difference in blood transfusion rates (p = 0.107) or hospital stay (p = 0.457) between groups. Complications, including surgical site infections, were more common without drainage, though not statistically significant (p = 0.356). Reintervention rates were higher in the no-drainage group, but not significantly (p = 0.260). Overall, this review found no significant short-term outcome differences, suggesting clinical judgment should guide drainage decisions. Further research, particularly with enhanced recovery protocols, is warranted to clarify drainage's role in AIS surgery.
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Affiliation(s)
- Alberto Ruffilli
- IRCCS Istituto Ortopedico Rizzoli, 1st Orthopaedics and Traumatology Clinic, University of Bologna, 40136 Bologna, Italy; (A.R.); (M.T.); (G.V.); (M.M.); (M.I.); (M.M.G.); (S.O.Z.); (A.A.)
- Department of Biomedical and Neuromotor Sciences, University of Bologna, 40123 Bologna, Italy
| | - Matteo Traversari
- IRCCS Istituto Ortopedico Rizzoli, 1st Orthopaedics and Traumatology Clinic, University of Bologna, 40136 Bologna, Italy; (A.R.); (M.T.); (G.V.); (M.M.); (M.I.); (M.M.G.); (S.O.Z.); (A.A.)
| | - Giovanni Viroli
- IRCCS Istituto Ortopedico Rizzoli, 1st Orthopaedics and Traumatology Clinic, University of Bologna, 40136 Bologna, Italy; (A.R.); (M.T.); (G.V.); (M.M.); (M.I.); (M.M.G.); (S.O.Z.); (A.A.)
- Department of Biomedical and Neuromotor Sciences, University of Bologna, 40123 Bologna, Italy
| | - Marco Manzetti
- IRCCS Istituto Ortopedico Rizzoli, 1st Orthopaedics and Traumatology Clinic, University of Bologna, 40136 Bologna, Italy; (A.R.); (M.T.); (G.V.); (M.M.); (M.I.); (M.M.G.); (S.O.Z.); (A.A.)
- Department of Biomedical and Neuromotor Sciences, University of Bologna, 40123 Bologna, Italy
| | - Marco Ialuna
- IRCCS Istituto Ortopedico Rizzoli, 1st Orthopaedics and Traumatology Clinic, University of Bologna, 40136 Bologna, Italy; (A.R.); (M.T.); (G.V.); (M.M.); (M.I.); (M.M.G.); (S.O.Z.); (A.A.)
| | - Manuele Morandi Guaitoli
- IRCCS Istituto Ortopedico Rizzoli, 1st Orthopaedics and Traumatology Clinic, University of Bologna, 40136 Bologna, Italy; (A.R.); (M.T.); (G.V.); (M.M.); (M.I.); (M.M.G.); (S.O.Z.); (A.A.)
| | - Antonio Mazzotti
- IRCCS Istituto Ortopedico Rizzoli, 1st Orthopaedics and Traumatology Clinic, University of Bologna, 40136 Bologna, Italy; (A.R.); (M.T.); (G.V.); (M.M.); (M.I.); (M.M.G.); (S.O.Z.); (A.A.)
- Department of Biomedical and Neuromotor Sciences, University of Bologna, 40123 Bologna, Italy
| | - Elena Artioli
- IRCCS Istituto Ortopedico Rizzoli, 1st Orthopaedics and Traumatology Clinic, University of Bologna, 40136 Bologna, Italy; (A.R.); (M.T.); (G.V.); (M.M.); (M.I.); (M.M.G.); (S.O.Z.); (A.A.)
- Department of Biomedical and Neuromotor Sciences, University of Bologna, 40123 Bologna, Italy
| | - Simone Ottavio Zielli
- IRCCS Istituto Ortopedico Rizzoli, 1st Orthopaedics and Traumatology Clinic, University of Bologna, 40136 Bologna, Italy; (A.R.); (M.T.); (G.V.); (M.M.); (M.I.); (M.M.G.); (S.O.Z.); (A.A.)
| | - Alberto Arceri
- IRCCS Istituto Ortopedico Rizzoli, 1st Orthopaedics and Traumatology Clinic, University of Bologna, 40136 Bologna, Italy; (A.R.); (M.T.); (G.V.); (M.M.); (M.I.); (M.M.G.); (S.O.Z.); (A.A.)
| | - Cesare Faldini
- IRCCS Istituto Ortopedico Rizzoli, 1st Orthopaedics and Traumatology Clinic, University of Bologna, 40136 Bologna, Italy; (A.R.); (M.T.); (G.V.); (M.M.); (M.I.); (M.M.G.); (S.O.Z.); (A.A.)
- Department of Biomedical and Neuromotor Sciences, University of Bologna, 40123 Bologna, Italy
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Haapala H, Heiskanen S, Syvänen J, Raitio A, Helenius L, Ahonen M, Diarbakerli E, Gerdhem P, Helenius I. Surgical and Health-related Quality of life Outcomes in Children With Congenital Scoliosis During 5-year Follow-up. Comparison to Age and Sex-matched Healthy Controls. J Pediatr Orthop 2023; 43:e451-e457. [PMID: 36998176 DOI: 10.1097/bpo.0000000000002408] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
BACKGROUND Congenital spinal anomalies represent a heterogeneous group of spinal deformities, of which only progressive or severe curves warrant surgical management. Only a limited number of studies have investigated the impact of surgery on the health-related quality of life and very limited data exists comparing these outcomes to healthy controls. METHODS A single surgeon series of 67 consecutive children with congenital scoliosis (mean age at surgery 8.0 y, range: 1.0 to 18.3 y, 28 girls) undergoing hemivertebrectomy (n = 34), instrumented spinal fusion (n = 20), or vertical expandable prosthetic titanium rib procedure (n = 13) with a mean follow-up of 5.8 years (range: 2 to 13 y). The comparison was made to age and sex-matched healthy controls. Outcome measures included the Scoliosis Research Society questionnaire both pre and postoperatively, radiographic outcomes, and complications. RESULTS The average major curve correction was significantly better in the hemivertebrectomy (60%) and instrumented spinal fusion (51%) than in the vertical expandable prosthetic titanium rib group (24%), respectively ( P < 0.001). Complications were noted in 8 of 67 (12%) children, but all patients recovered fully during follow-up. Pain, self-image, and function domains improved numerically from preoperative to final follow-up, but the pain score was the only one with a statistically significant change ( P = 0.033). The Scoliosis Research Society pain, self-image, and function domain scores remained at a significantly lower level at the final follow-up than in the healthy controls ( P ≤ 0.05), while activity scores improved to a similar level. CONCLUSIONS Surgery for congenital scoliosis improved angular spinal deformities with a reasonable risk of complications. Health-related quality of life outcomes improved from preoperative to final follow-up, but especially pain and function domains remained at a significantly lower level than in the age and sex-matched healthy controls. LEVEL OF EVIDENCE Level III, therapeutic.
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Affiliation(s)
- Hermanni Haapala
- Department of Pediatric Surgery, Pediatric Orthopaedics, and Traumatology
- Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki
| | | | | | | | - Linda Helenius
- Department of Anesthesia and Intensive Care, University of Turku and Turku University Hospital, Turku, Finland
| | - Matti Ahonen
- Department of Pediatric Surgery, Pediatric Orthopaedics, and Traumatology
| | - Elias Diarbakerli
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute
- Department of Reconstructive Orthopaedics, Karolinska University Hospital, Stockholm
| | - Paul Gerdhem
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute
- Department of Hand Surgery and Orthopaedics, Uppsala University Hospital, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Ilkka Helenius
- Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki
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Perioperative Risk Factors for Bleeding in Adolescents Undergoing Pedicle Screw Instrumentation for Scoliosis. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020381. [PMID: 36832510 PMCID: PMC9955766 DOI: 10.3390/children10020381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023]
Abstract
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.
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Soini V, Raitio A, Helenius I, Helenius L, Syvänen J. A retrospective cohort study of bleeding characteristics and hidden blood loss after segmental pedicle screw instrumentation in neuromuscular scoliosis as compared with adolescent idiopathic scoliosis. NORTH AMERICAN SPINE SOCIETY JOURNAL 2022; 12:100190. [PMID: 36561891 PMCID: PMC9763505 DOI: 10.1016/j.xnsj.2022.100190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/28/2022] [Accepted: 11/30/2022] [Indexed: 12/09/2022]
Abstract
Background Progressive scoliosis in neuromuscular patients often requires a long instrumented spinal fusion. Previous studies have shown larger intraoperative blood loss in these patients than those with adolescent idiopathic scoliosis (AIS), but the total blood loss composed of visible and hidden blood loss has not been described in this patient population. The aim of our study was to investigate the bleeding characteristics and hidden blood loss related to spinal fusion in neuromuscular scoliosis (NMS) as compared to AIS patients. Methods A retrospective cohort study with prospective data collection of NMS patients undergoing segmental pedicle screw instrumentation at a university hospital between 2009 and 2021. A comprehensive statistical analysis was performed regarding intra- and postoperative blood loss compared to patient characteristics such as age and diagnosis. Hidden blood loss was estimated and compared to the total blood loss. We standardized amount of bleeding with patient weight and fusion level for further analysis. Consecutive AIS patients served as a control population. Eighty-one consecutive patients with NMS (mean age 15.2 years, 37 females) were included and their bleeding characters were compared with 199 AIS patients (mean age 15.8 years, 143 females). The primary outcome was total blood loss including intraoperative, 24-hour drain output and hidden blood loss. Secondary outcome measures included requirement for blood transfusion. Results Neuromuscular patients had a significantly larger total blood loss with mean values of 1914 mL in the NMS and 1357 mL in the AIS groups, respectively (p<0.001). The hidden blood loss was also significantly larger in NMS than in AIS group (566 ± 533 mL vs. 398 ±411 mL, p=0.0332). Neuromuscular scoliosis was also associated with significantly greater weight and levels of fused adjusted intraoperative bleeding (1.79 ml/kg/fused level in NMS vs. 0.87 ml/kg/fused level in AIS vs. p< 0.0001) and hidden blood loss (1.00 ml/kg/levels fused vs. 0.65 ml/kg/fused levels, p=0.053). NMS diagnosis was also a risk factor for greater hidden blood loss in multivariable analysis (p=0.0011). 24-hour drain output was similar in the NMS and AIS groups. Male gender was a risk factor for greater hidden blood loss in the NMS group (p=0.0429). Fifty-nine (73%) NMS and 27 (14%) AIS patients received allogenic red blood cell infusions perioperatively (p<0.001). Conclusions Hidden blood loss constitutes one-third of total blood loss in children undergoing segmental pedicle screw instrumentation for neuromuscular scoliosis. Hidden blood loss is significantly greater in the neuromuscular as compared with idiopathic scoliosis. Hidden blood loss should be considered in the perioperative management of NMS.
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Affiliation(s)
- Venla Soini
- Department of Paediatric Surgery and Paediatric Orthopaedic Surgery, University of Turku, and Turku University Hospital, Savitehtaankatu 5, 20520, Turku, Finland,Department of Surgery, Vaasa Central Hospital, Wellbeing Services County of Ostrobothnia, Vaasa, Finland
| | - Arimatias Raitio
- Department of Paediatric Surgery and Paediatric Orthopaedic Surgery, University of Turku, and Turku University Hospital, Savitehtaankatu 5, 20520, Turku, Finland
| | - Ilkka Helenius
- Department of Orthopaedics and Traumatology, University of Helsinki, and Helsinki University Hospital, Finland,Department of Paediatric Orthopaedic Surgery, Helsinki New Children's Hospital, Helsinki, Finland
| | - Linda Helenius
- Department of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Turku, Finland
| | - Johanna Syvänen
- Department of Paediatric Surgery and Paediatric Orthopaedic Surgery, University of Turku, and Turku University Hospital, Savitehtaankatu 5, 20520, Turku, Finland,Corresponding author at: Department of Paediatric Surgery and Paediatric Orthopaedic Surgery, University of Turku, and Turku University Hospital, Savitehtaankatu 5, FI-20520 Turku, Finland.
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