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Welborn MC, Redding G, Evers P, Nicol L, Bauer DF, Iyer RR, Poon S, Hwang S. Pre-op considerations in neuromuscular scoliosis deformity surgery: proceedings of the half day course at the 58th annual meeting of the Scoliosis Research Society. Spine Deform 2024; 12:867-876. [PMID: 38634998 DOI: 10.1007/s43390-024-00865-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/16/2024] [Indexed: 04/19/2024]
Abstract
Scoliosis is a common complication of neuromuscular disorders. These patients are frequently recalcitrant to nonoperative treatment. When treated surgically, they have the highest risk of complications of all forms of scoliosis. While recent studies have shown an improvement in the rate of complications, they still remain high ranging from 6.3 to 75% depending upon the underlying etiology and the treatment center (Mohamad et al. in J Pediatr Orthop 27:392-397, 2007; McElroy et al. in Spine, 2012; Toll et al. in J Neurosurg Pediatr 22:207-213, 2018; Cognetti et al. in Neurosurg Focus 43:E10, 2017). For those patients who are able to recover from the perioperative period without major complications, several recent studies have shown decreased long-term mortality and improved health-related quality of life in neuromuscular patients who have undergone spine fusion (Bohtz et al. in J Pediatr Orthop 31:668-673, 2011; Ahonen et al. in Neurology 101:e1787-e1792, 2023; Jain et al. in JBJS 98:1821-1828, 2016). It is critically important to optimize patients preoperatively to minimize the risk of post-operative complications and maximize long-term outcomes. In order to do so, one must familiarize themselves with the common complications and their treatment. The most common complications are pulmonary in nature. With reported rates as high as 23-29%, pre-operative optimization should be employed for these patients to minimize the risk of post-operative complications (Sharma et al. in Eur Spine J 22:1230-1249, 2013; Rumalla et al. in J Neurosurg Spine 25:500-508, 2016). The next most common cause of complications are implant related, with 13-23% of patients experiencing an implant-related complication that may require a second procedure (Toll et al. in J Neurosurg Pediatr 22:207-213, 2018; Sharma et al. in Eur Spine J 22:1230-1249, 2013) Therefore optimization of bone quality prior to surgical intervention is important to help minimize the risk of instrumentation failure. Optimization of muscle tone and spasticity may help to decrease the risk of instrumentation complications, but may also contribute to the progression of scoliosis. While only 3% of patients have neurologic complication, significant equipoise remains regarding whether or not patients should undergo prophylactic detethering procedures to minimize those risks (Sharma et al. in Eur Spine J 22:1230-1249, 2013). Although only 1.8% of complications are classified as cardiac related, they can be among the most devastating (Rumalla et al. in J Neurosurg Spine 25:500-508, 2016). Simply understanding the underlying etiology and the potential risks associated with each condition (i.e., conduction abnormalities in a patient with Rett syndrome or cardiomyopathies patients with muscular dystrophy) can be lifesaving. The following article is a summation of the half day course on neuromuscular scoliosis from the 58th annual SRS annual meeting, summarizing the recommendations from some of the world's experts on medical considerations in surgical treatment of neuromuscular scoliosis.
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Affiliation(s)
- Michelle C Welborn
- Shriners Children's Portland, 3101 SW Sam Jackson Park Road, Portland, OR, 97229, USA.
| | - Gregory Redding
- Pulmonary and Sleep Medicine Division, Seattle Children's Hospital, Room O.C. 7.730, 4800 Sand Point Way N E, Seattle, WA, 98105, USA
| | - Patrick Evers
- Doernbecher Children's Hospital, 700 SW Campus Dr, Portland, OR, 97239, USA
| | - Lindsey Nicol
- Shriners Children's Portland, 3101 SW Sam Jackson Park Road, Portland, OR, 97229, USA
- Doernbecher Children's Hospital, 700 SW Campus Dr, Portland, OR, 97239, USA
| | - David F Bauer
- Texas Children's Hospital, 6701 Fannin St., Suite 1230.01, Houston, TX, USA
| | - Rajiv R Iyer
- , 100 N. Mario Capecchi Drive, Suite 3850, Salt Lake City, UT, 84113, USA
| | - Selina Poon
- Shriners Children's Southern California, 909 S. Fair Oaks Ave, Pasadena, CA, 91105, USA
| | - Steven Hwang
- Shriners Children's Philadelphia, 3551 N Broad St., Philadelphia, PA, 19140, USA
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Sferra SR, Donnelly S, Kabagambe S, Fallon EM. Modifiable Preoperative Risk Factors to Mitigate Postoperative Site Infection Following Pediatric Gastrostomy. J Pediatr Surg 2024; 59:1094-1100. [PMID: 38402131 DOI: 10.1016/j.jpedsurg.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 02/01/2024] [Accepted: 02/07/2024] [Indexed: 02/26/2024]
Abstract
PURPOSE There are limited studies assessing modifiable preoperative risk factors for pediatric laparoscopic gastrostomy tubes (LGT) and percutaneous endoscopic gastrostomy (PEG) tubes. We sought to evaluate the effect of demographics and surgical/infectious history on the superficial infection rate following gastrostomy tube (GT) placement. METHODS After IRB approval, we conducted a single-institution retrospective cohort study from 2015 to 2021 of pediatric patients undergoing LGT or PEG tube. The primary outcome was cellulitis or abscess formation within 30-days and 90-days postoperatively. Statistical analyses were performed with t-tests, Chi-squared, and logistic regression(p ≤ 0.05). RESULTS There were 382 patients, with 181 (47%) LGT and 201 (53%) PEGs. LGT patients were younger (5.9 vs. 12.3 months, p < 0.001) and more likely to be admitted to the neonatal or cardiac intensive care unit prior to their GT. There were similar rates of prior surgical intervention (58% vs. 66%, p = 0.29) and previous infection (37% vs. 38%, p = 0.87) in both LGT and PEG patients. Within 30-days postoperatively, LGT patients had a higher superficial infection rate (12% vs. 6%, p = 0.04). On multivariate regression, Black race (Odds Ratio 0.10, p = 0.03) was protective and prior Staphylococcus colonization (OR 2.35, p = 0.04) increased the odds of infection. In those patients colonized with Staphylococcus, 21% developed a superficial site infection compared to 9% in those not colonized (p = 0.01). CONCLUSION These data suggest prior Staphylococcus colonization is a significant risk factor for superficial infection following GT. Further work into preoperative decolonization strategies may provide an avenue to decrease the high infection rate in this common pediatric procedure. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Shelby R Sferra
- Division of General Pediatric Surgery, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Broadway New York, NY, 10032, United States.
| | - Sara Donnelly
- Division of General Pediatric Surgery, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Broadway New York, NY, 10032, United States
| | - Sandra Kabagambe
- Division of General Pediatric Surgery, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Broadway New York, NY, 10032, United States
| | - Erica M Fallon
- Division of General Pediatric Surgery, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Broadway New York, NY, 10032, United States
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Grush AE, Mohan VE, Roy MG, Burns HR, Monson LA. Plastic surgeon closure is comparable to orthopedic closure when a perioperative optimization protocol is instituted for pediatric patients with neuromuscular scoliosis. Spine J 2024; 24:454-461. [PMID: 37979696 DOI: 10.1016/j.spinee.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 11/02/2023] [Accepted: 11/05/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND CONTEXT Since 2015, plastic multilayer closure (PMC) has been gaining attraction due to improved wound healing outcomes for medically complex patients. Plastic multilayer closure has been readily used for complex spine surgery closures in patients susceptible to wound healing issues (ie, dehiscence, surgical site infection [SSI]). However, PMC requires extensive soft tissue manipulation compared with standard orthopedic spine surgeon closure (SOC) and can result in extended operative times, increased transfusion rates, and more frequent returns to the operating room. PURPOSE From 2016 to 2019, our institution implemented a perioperative protocol designed to decrease postoperative complication rates in NMS patients. A retrospective cohort study was performed to determine if PMC imparted advantages over SOC above and beyond that from the perioperative protocol. STUDY DESIGN/SETTING Retrospective study at a single academic institution. PATIENT SAMPLE Eighty-one pediatric patients with neuromuscular scoliosis undergoing spinal fixation surgery. OUTCOME MEASURES Postoperative wound complications such as surgical site infection, hematoma, and superficial/deep dehiscence were the main outcome measures. Respiratory and neuromuscular complications along with duration of surgery were also recorded. METHODS A retrospective review was conducted of NMS patients undergoing spinal fixation at a single academic pediatric hospital over 4 years. Cases were labeled as SOC (n=41) or PMC (n=40) based on the closure technique applied. Reported 90-day complications were evaluated as the primary outcome. RESULTS Of the 81 reviewed patients, 45 reported complications, roughly equal between the study groups. While we found no statistically significant differences in rates of postoperative complications or SSIs, SOC cases were 30 minutes shorter on average with fewer returns to the operating room for additional surgery. CONCLUSIONS With the implementation of our perioperative protocol for NMS patients, PMC did not result in fewer complications than SOC but the surgeries did take longer.
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Affiliation(s)
- Andrew E Grush
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, 6701 Fannin St, Suite 610, TX, USA; Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, 6701 Fannin St, Suite 610, TX, USA
| | - Vamsi E Mohan
- Texas Tech University Health Sciences Center El Paso, 5001 El Paso Drive, El Paso, TX 79905, USA
| | - Michelle G Roy
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, 6701 Fannin St, Suite 610, TX, USA; Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, 6701 Fannin St, Suite 610, TX, USA
| | - Heather R Burns
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, 6701 Fannin St, Suite 610, TX, USA; Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, 6701 Fannin St, Suite 610, TX, USA
| | - Laura A Monson
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, 6701 Fannin St, Suite 610, TX, USA; Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, 6701 Fannin St, Suite 610, TX, USA.
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Badin D, Baldwin KD, Cahill PJ, Spiegel DA, Shah SA, Yaszay B, Newton PO, Sponseller PD. When to Perform Fusion Short of the Pelvis in Patients with Cerebral Palsy?: Indications and Outcomes. JB JS Open Access 2023; 8:JBJSOA-D-22-00123. [PMID: 37073271 PMCID: PMC10106181 DOI: 10.2106/jbjs.oa.22.00123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2023] Open
Abstract
Patients with scoliosis secondary to cerebral palsy (CP) are often treated with posterior spinal fusion (PSF) with or without pelvic fixation. We sought to establish criteria to guide the decision of whether or not to perform fusion "short of the pelvis" in this population, and to assess differences in outcomes. Methods Using 2 prospective databases, we analyzed 87 pediatric patients who underwent PSF short of the pelvis from 2008 to 2015 to treat CP-related scoliosis and who had ≥2 years of follow-up. Preoperative radiographic and clinical variables were analyzed for associations with unsatisfactory correction (defined as pelvic obliquity of ≥10°, distal implant dislodgement, and/or reoperation for increasing deformity at 2- or 5-year follow-up). Continuous variables were dichotomized using the Youden index, and a multivariable model of predictors of unsatisfactory correction was created using backward stepwise selection. Finally, radiographic, health-related quality-of-life, and clinical outcomes of patients with fusion short of the pelvis who had neither of the 2 factors associated with unsatisfactory outcomes were compared with those of 2 matched-control groups. Results Deformity correction was unsatisfactory in 29 of 87 patients with fusion short of the pelvis. The final model included preoperative pelvic obliquity of ≥17° (odds ratio [OR], 6.8; 95% confidence interval [CI], 2.3 to 19.7; p < 0.01) and dependent sitting status (OR, 3.2; 95% CI, 1.1 to 9.9; p = 0.04) as predictors of unsatisfactory correction. The predicted probability of unsatisfactory correction increased from 10% when neither of these factors was present to a predicated probability of 27% to 44% when 1 was present and to 72% when both were present. Among matched patients with these factors who had fusion to the pelvis, there was no association with unsatisfactory correction. Patients with independent sitting status and pelvic obliquity of <17° who had fusion short of the pelvis had significantly lower blood loss and hospital length of stay, and better 2-year health-related quality-of-life scores compared with matched controls with fusion to the pelvis. Conclusions In patients with scoliosis secondary to CP, pelvic obliquity of <17° and independent sitting status are associated with a low risk of unsatisfactory correction and better 2-year outcomes when fusion short of the pelvis is performed. These may be used as preoperative criteria to guide the decision of whether to perform fusion short of the pelvis in patients with CP. Level of Evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Daniel Badin
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Keith D. Baldwin
- Division of Orthopedic Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Patrick J. Cahill
- Division of Orthopedic Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David A. Spiegel
- Division of Orthopedic Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Suken A. Shah
- Department of Orthopedic Surgery, Nemours Children’s Hospital, Wilmington, Delaware
| | - Burt Yaszay
- Department of Orthopedics and Sports Medicine, Seattle Children’s Hospital and University of Washington, Seattle, Washington
| | - Peter O. Newton
- Department of Orthopedics, Rady Children’s Hospital and University of California-San Diego Medical Center, San Diego, California
| | - Paul D. Sponseller
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland
- Email for corresponding author:
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Severyns M, Hostalrich FX, Flurin L, Vendeuvre T, Germaneau A, Turmel JM, Cabié A, Benchikh El-Fegoun A. Surgical Site Infections after Spinal Surgery in a Tropical Area: A Prospective Monocentric Observational Study. Am J Trop Med Hyg 2022; 107:457-462. [PMID: 35895422 PMCID: PMC9393452 DOI: 10.4269/ajtmh.21-1329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 01/24/2022] [Indexed: 08/03/2023] Open
Abstract
To date, no study has described the microbiological profile of surgical site infections (SSIs) after spine surgery in a tropical environment. The main objective of this study is to describe the microbiology and the risk factors of SSI after spinal surgery in a tropical climate. Our hypothesis is that the microbiology of SSIs in tropical areas is different to what is mainly described in temperate countries. As a consequence, the recommendation for antibiotic prophylaxis administered in the operative room, which mainly relays on the literature, might not be adequate in such countries. We included 323 consecutive patients who underwent a spinal intervention between 2017 and 2019, with a 2-year minimum follow-up. Objective ISO criteria were established in accordance with the criteria accepted by the Center of Disease Control in Atlanta. The identification of risk factors for SSI was carried out by uni- and multivariate analysis with a significance threshold of P < 0.05. The incidence of SSI was 7.7%. A total of 54.8% were in favor of a predominantly digestive origin of germs with an average of 1.68 bacteria found by ISO. Inadequate antibiotic prophylaxis was found in 54.8%. Age and body mass index were found to be independent risk factors for SSI. We report here an unusual microbiological profile of SSI with a predominance of gram-negative bacteria and a low proportion of Staphylococcus aureus and Staphylococcus epidermidis.
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Affiliation(s)
- Mathieu Severyns
- Orthopaedic and Traumatologic Department, CHU Martinique, Fort-de-France, France
- Pprime Institute, University of Poitiers, Poitiers, France
| | | | - Laure Flurin
- Divisions of Clinical Microbiology and Infectious Diseases, Mayo Clinic, Rochester, Minnesota
| | | | | | - Jean-Marie Turmel
- Infectious Diseases Department, CHU Martinique, Fort-de-France, France
| | - André Cabié
- Infectious Diseases Department, CHU Martinique, Fort-de-France, France
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Matsumoto H, Larson EL, Warren SI, Hammoor BT, Bonsignore-Opp L, Troy MJ, Barrett KK, Striano BM, Li G, Terry MB, Roye BD, Lenke LG, Skaggs DL, Glotzbecker MP, Flynn JM, Roye DP, Vitale MG. A Clinical Risk Model for Surgical Site Infection Following Pediatric Spine Deformity Surgery. J Bone Joint Surg Am 2022; 104:364-375. [PMID: 34851324 DOI: 10.2106/jbjs.21.00751] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite tremendous efforts, the incidence of surgical site infection (SSI) following the surgical treatment of pediatric spinal deformity remains a concern. Although previous studies have reported some risk factors for SSI, these studies have been limited by not being able to investigate multiple risk factors at the same time. The aim of the present study was to evaluate a wide range of preoperative and intraoperative factors in predicting SSI and to develop and validate a prediction model that quantifies the risk of SSI for individual pediatric spinal deformity patients. METHODS Pediatric patients with spinal deformity who underwent primary, revision, or definitive spinal fusion at 1 of 7 institutions were included. Candidate predictors were known preoperatively and were not modifiable in most cases; these included 31 patient, 12 surgical, and 4 hospital factors. The Centers for Disease Control and Prevention definition of SSI within 90 days of surgery was utilized. Following multiple imputation and multicollinearity testing, predictor selection was conducted with use of logistic regression to develop multiple models. The data set was randomly split into training and testing sets, and fivefold cross-validation was performed to compare discrimination, calibration, and overfitting of each model and to determine the final model. A risk probability calculator and a mobile device application were developed from the model in order to calculate the probability of SSI in individual patients. RESULTS A total of 3,092 spinal deformity surgeries were included, in which there were 132 cases of SSI (4.3%). The final model achieved adequate discrimination (area under the receiver operating characteristic curve: 0.76), as well as calibration and no overfitting. Predictors included in the model were nonambulatory status, neuromuscular etiology, pelvic instrumentation, procedure time ≥7 hours, American Society of Anesthesiologists grade >2, revision procedure, hospital spine surgical cases <100/year, abnormal hemoglobin level, and overweight or obese body mass index. CONCLUSIONS The risk probability calculator encompassing patient, surgical, and hospital factors developed in the present study predicts the probability of 90-day SSI in pediatric spinal deformity surgery. This validated calculator can be utilized to improve informed consent and shared decision-making and may allow the deployment of additional resources and strategies selectively in high-risk patients. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Hiroko Matsumoto
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Elaine L Larson
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY.,School of Nursing, Columbia University Irving Medical Center, New York, NY
| | - Shay I Warren
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Bradley T Hammoor
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Lisa Bonsignore-Opp
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Michael J Troy
- Department of Orthopedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Kody K Barrett
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, California
| | - Brendan M Striano
- Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Gen Li
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Mary Beth Terry
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Benjamin D Roye
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Lawrence G Lenke
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY
| | - David L Skaggs
- Spine Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael P Glotzbecker
- Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospital Cleveland Medical Center, Cleveland, Ohio
| | - John M Flynn
- Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David P Roye
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Michael G Vitale
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY
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