Abstract Background context Spine surgery is usually associated with large amount of blood loss, necessitating blood transfusions. Blood loss-associated morbidity can be because of direct risks, such ...as hypotension and organ damage, or as a result of blood transfusions. The antifibrinolytic, tranexamic acid (TXA), is a lysine analog that inhibits activation of plasminogen and has shown to be beneficial in reducing surgical blood loss. Purpose To consolidate the findings of randomized controlled trials (RCTs) investigating the use of TXA on surgical bleeding in spine surgery. Study design A metaanalysis. Study sample Randomized controlled trials investigating the effectiveness of intravenous TXA in reducing blood loss in spine surgery, compared with a placebo/no treatment group. Methods MEDLINE, Embase, Cochrane controlled trials register, and Google Scholar were used to identify RCTs published before January 2014 that examined the effectiveness of intravenous TXA on reduction of blood loss and blood transfusions, compared with a placebo/no treatment group in spine surgery. Metaanalysis was performed using RevMan 5. Weighted mean difference with 95% confidence intervals was used to summarize the findings across the trials for continuous outcomes. Dichotomous data were expressed as risk ratios with 95% confidence intervals. A p<.05 was considered statistically significant. Results Eleven RCTs were included for TXA (644 total patients). Tranexamic acid reduced intraoperative, postoperative, and total blood loss by an average of 219 mL (−322, −116, p<.05), 119 mL (−141, −98, p<.05), and 202 mL (−299, −105, p<.05), respectively. Tranexamic acid led to a reduction in proportion of patients who received a blood transfusion (risk ratio 0.67 0.54, 0.83, p<.05) relative to placebo. There was one myocardial infarction (MI) in the TXA group and one deep vein thrombosis (DVT) in placebo. Conclusions Tranexamic acid reduces surgical bleeding and transfusion requirements in patients undergoing spine surgery. Tranexamic acid does not appear to be associated with an increased incidence of pulmonary embolism, DVT, or MI.
Brace treatment is the most common nonoperative treatment for the prevention of curve progression in adolescent idiopathic scoliosis. The success reported in level 1 and 2 clinical trials is ...approximately 75%. The aim of this review was to identify the main risk factors that significantly reduce success rate of brace treatment.
A literature search using the MEDLINE and Embase databases was conducted. Studies were included if they identified specific risk factor(s) for curve progression. Studies that looked at nighttime braces, superiority of one type of brace over another, the effect of physical therapy on brace performance, cadaver or nonhuman studies were excluded. A total of 1,022 articles were identified of which 25 met all of the inclusion criteria. Seven risk factors were identified: Poor brace compliance (eight studies), lack of skeletal maturity (six studies), Cobb angle over a certain threshold (six studies), poor in-brace correction (three studies), vertebral rotation (four studies), osteopenia (two studies), and thoracic curve type (two studies). Three risk factors were highly repeated in the literature which identified specific subgroups of patients who have a much higher risk to fail brace treatment and to progress to fusion. This data demonstrates that 60% to 70% of the patients referred to bracing are Risser 0 and 30% to 70% of this group will not wear the brace enough to ensure treatment efficacy. Furthermore, Risser 0 patients who reach the accelerated growth phase with a curve ≥40° are at 70% to 100% risk of curve progression to the fusion surgical threshold despite proper brace wear. Skeletally immature patients with relatively large magnitude scoliosis who are noncompliant are at a higher risk of failing brace treatment.
Fusion is the current standard of care for AIS. Anterior vertebral body tethering (AVBT) is a motion-sparing alternative gaining interest. As a novel procedure, there is a paucity of literature on ...safety. Here, we report 90-day complication rates in 184 patients who underwent AVBT by a single surgeon. Patients were retrospectively reviewed. Approaches included 71 thoracic, 45 thoracolumbar, 68 double. Major complications were those requiring readmittance or reoperation, prolonged use of invasive materials such as chest tubes, or resulted in spinal cord or nerve root injury. Minor complications resolved without invasive intervention. Mean operative time and blood loss were 186.5 ± 60.3 min and 167.2 ± 105.0 ml, respectively. No patient required allogenic blood transfusion. 6 patients experienced major (3.3%), and 6 had minor complications (3.3%). Major complications included 3 chylothoracies, 2 hemothoracies, and 1 lumbar radiculopathy secondary to screw placement requiring re-operation. Minor complications included 1 patient with respiratory distress requiring supplementary oxygen, 1 superficial wound infection, 2 cases of prolonged nausea, and 1 Raynaud phenomenon. In 184 patients who underwent AVBT for AIS, major and minor complication rates were both 3.3%.
BACKGROUND:Reporting accurate surgical complication rates to patients and their families is important in the management of adolescent idiopathic scoliosis (AIS). In this study, we report the rate of ...major complications following the surgical treatment of AIS both in the perioperative period and among patients with a minimum of 2 years of follow-up.
METHODS:We reviewed the prospectively collected data of a multicenter registry of patients who underwent surgical treatment of AIS during the period of 1995 to 2014 in order to identify all complications. A complication was defined as “major” if it resulted in reoperation or in spinal cord or nerve root injury, or was life-threatening. A total of 3,582 patients with preoperative and early postoperative data (4 to 6 weeks of follow-up) were included. A subset of 2,220 patients with a minimum of 2 years of follow-up comprised the cohort for delayed complications. Overall complication rates were calculated, as was the percentage of complications according to the year of the index surgery and type of surgical approach.
RESULTS:The mean age of the 3,582 patients at the time of surgery was 14.8 ± 2.2 years. The average major curve magnitude was 56° ± 13° for thoracic curves and 51° ± 11° for lumbar. In 365 patients, anterior spinal fusion (ASF) with instrumentation was performed, and in 3,217 patients, posterior spinal fusion (PSF) with instrumentation was performed; 142 patients in the PSF group underwent concomitant anterior release. There were 192 major complications, with 93 (2.6%) occurring perioperatively. Perioperative complications included wound-related (1.0% of the patients), neurologic (0.5%), pulmonary (0.4%), instrumentation-related (0.4%), and gastrointestinal (0.2%) complications. One patient died. The mean annual perioperative major complication rate based on the year of surgery ranged from 0% to 10.5%. The complication rate by surgical approach was 3.0% for ASF and 2.6% for PSF (2.4% for PSF only and 5.6% for PSF with anterior release). The major complication rate for the 2,220 patients with at least 2 years of follow-up was 4.1%; all but 1 had a reoperation (4.1%). The majority of these major complications were wound and instrumentation-related (1.9% and 0.8%, respectively).
CONCLUSIONS:After surgery for AIS, a 2.6% rate of perioperative major complications and a 4.1% rate of major complications at 2 or more years after surgery can be anticipated. The complication rate decreased over the period of study.
LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Correct identification of fusion levels in surgical planning for the management of adolescent idiopathic scoliosis is a complex task. Several classification systems and algorithms exist to assist ...surgeons in determining the appropriate levels to be instrumented. The Lenke classification is the benchmark system. Among the many factors and measurements that are taken into account when selecting the proper upper instrumented vertebra and lower instrumented vertebra are planning for selective fusion; preserving motion segments; preventing proximal and/or distal junctional kyphosis, shoulder imbalance, and neck pain; and maintaining short fusion lengths. Existing treatment algorithms do not account for every exception, and further research is required to improve long-term surgical outcomes.
Correct identification of fusion levels in surgical planning for the management of adolescent idiopathic scoliosis is a complex task. Several classification systems and algorithms exist to assist ...surgeons in determining the appropriate levels to be instrumented. The Lenke classification is the benchmark system. Among the many factors and measurements that are taken into account when selecting the proper upper instrumented vertebra and lower instrumented vertebra are planning for selective fusion; preserving motion segments; preventing proximal and/or distal junctional kyphosis, shoulder imbalance, and neck pain; and maintaining short fusion lengths. Existing treatment algorithms do not account for every exception, and further research is required to improve long-term surgical outcomes.
Abstract Background context Thoracic pedicle screw (TPS) constructs have improved curve correction measurements compared with hook and hybrid constructs in the treatment of adolescent idiopathic ...scoliosis (AIS), but the optimal implant density, or the number of screws per level, remains unknown in the treatment of flexible thoracic curves. Purpose To determine how implant density affects clinical outcome, radiographic outcome, and cost in the treatment of Lenke Curve Type I AIS. Study design A retrospective clinical study. Patient sample Ninety-one consecutive AIS patients with Lenke Type I curves who underwent surgical correction with a minimum follow-up of 24 months. Outcome measures Radiographic outcomes included assessment of preoperative and 2-year postoperative thoracic Cobb angle, T5–T12 kyphosis, and curve flexibility. We also assessed SRS-22 outcome measures and thoracic angle of trunk rotation (ATR) before surgery and at the 2-year postoperative time point. The cost of each construct was also evaluated. Methods Bivariate analysis was conducted between implant density and the following factors: percent correction of the major curve, ATR, and change in kyphosis. The correlation between curve flexibility and percent correction of the major curve was determined. Patients were then divided into two groups: the low-density (LD) TPS group defined by implant density below the mean number of screws per level for the entire cohort (less than 1.3 screws per level) and the high-density (HD) TPS group defined by implant density above the mean number of screws per level (more than 1.3 screws per level). Independent sample t tests were used to compare demographic data as well as radiographic and clinical outcomes at baseline and at follow-up between the two groups. Results Sixty-one female and 30 male patients met inclusion criteria. No significant correlations were found between implant density and the following parameters: percent correction of the major curve (p=.25), ATR (p=.75), and change in T5–T12 kyphosis (p=.40). No correlation was found between curve flexibility and percent correction of the major curve (p=.54). The LD group consisted of 57 patients, whereas the HD group had 34 patients. There were no differences between the HD group and the LD group in regard to major curve correction, change in T5–T12 kyphosis, or change in ATR. Total implant costs were significantly higher in the HD group ($13,272 vs. $10,819; p<.01). The SRS-22 image domain and overall score improved at 2 years within both groups, but there were no group differences in any of the SRS-22 domains or the overall score. Conclusions We identified no clinical, radiographic, perioperative, or complication-related advantage of constructs with higher TPS implant density in this patient cohort with flexible idiopathic scoliosis. Cost was significantly higher with HD constructs in comparison with LD constructs. Optimal implant density chosen by the surgeon should rely on a number of factors including curve magnitude and rigidity, bone density, and desired correction.
STUDY DESIGN.Retrospective analysis of a prospectively collected, national inpatient hospital database.
OBJECTIVE.We aimed to investigate comorbid psychiatric disorders in the ASD population. We ...hypothesized that a high incidence of comorbid psychiatric disorders in ASD would negatively impact perioperative outcomes.
SUMMARY OF BACKGROUND DATA.Adult spinal fusion (ASF) patients suffer from severe back pain and often depression. Psychiatric comorbidities in the adult spinal deformity (ASD) population are not well understood, despite the apparent psychological effects of spinal deformity-related self-image.
METHODS.The Nationwide Inpatient Sample databases from 2001–2009 were queried for patients age ≥18 with in-hospital stays including a spine arthrodesis. Patients were divided into two groupsASD (diagnosis of scoliosis, excluding neuromuscular & congenital) and all other ASF. Subjects were further stratified by presence of a comorbid psychiatric diagnosis. Differences between each surgical group in psychiatric frequency and complications were calculated using ANOVA, adjusted for operative complexity. A binary logistic regression analyzed the association between psychiatric diagnoses and likelihood of complications.
RESULTS.3,366,352 ASF and 219,975 ASD patients were identified. The rate of comorbid psychiatric diagnoses in ASD was significantly higher (23.5%) compared to ASF patients (19.4%, p < 0.001). Complication rates were higher for ASD compared to ASF; patients without a psychiatric diagnosis had lower (or comparable) complication rates than psychiatric patients, across all disorder categories. Patients with psychotic disorders and dementia showed more complications than controls; patients with mood, anxiety and alcohol disorders showed fewer.
CONCLUSIONS.Psychiatric comorbidities are more common in the adult spinal deformity population than in adult fusion patients. ASD and ASF patients with the most common psychiatric disorders (mood, anxiety and alcohol abuse) are not at increased risk for complications compared to controls. Those patients with psychotic disorders and dementia are at a significant risk for increased complications and surgeons should be aware of these specific risks.Level of Evidence2
BACKGROUND:Patient and surgical factors are known to influence operative blood loss in spinal fusion for adolescent idiopathic scoliosis (AIS), but have only been loosely identified. To date, there ...are no established recommendations to guide decisions to predonate autologous blood, and the current practice is based primarily on surgeon preference. This study is designed to determine which patient and surgical factors are correlated with, and predictive of, blood loss during spinal fusion for AIS.
METHODS:Retrospective analysis of 340 (81 males, 259 females; mean age, 15.2 y) consecutive AIS patients treated by a single surgeon from 2000 to 2008. Demographic (sex, age, height, weight, and associated comorbidities), laboratory (hematocrit, platelet, PT/PTT/INR), standard radiographic, and perioperative data including complications were analyzed with a linear stepwise regression to develop a predictive model of blood loss.
RESULTS:Estimated blood loss was 907±775 mL for posterior spinal fusion (PSF, n=188), 323±171 mL for anterior spinal fusion (ASF, n=124), and 1277±821 mL for combined procedures (n=28). For patients undergoing PSF, stepwise analysis identified sex, preoperative kyphosis, and operative time to be the most important predictors of increased blood loss (P<0.05). For ASF, the mean arterial pressure at incision and the operative time were predictive (P<0.05). The following formula was developed to estimate blood loss in PSFblood loss (mL)=C+Op-time (min)×(6.4)−pre-op T2-T12 kyphosis (degrees)×(8.7), C=233 if male and −270 if female.
CONCLUSION:We find sex, operative time, and preoperative kyphosis to be the most important predictors of increased blood loss in PSF for AIS. Mean arterial pressure and operative time were predictive of estimated blood loss in ASF. For posterior fusions, we also present a model that estimates blood loss preoperatively and can be used to guide decisions regarding predonation of blood and the use of antifibrinolytic agents.
LEVEL OF EVIDENCE:Retrospective studyLevel II.
Thoracic spinal deformities may reduce chest wall compliance, leading to respiratory complications. The first SARS-CoV-2 (L-variant) strain caused critical respiratory illness, especially in ...vulnerable patients. This study investigates the association between scoliosis and SARS-CoV-2 (COVID-19) disease course severity.
Clinical data of 129 patients treated between March 2020 to June 2021 who received a positive COVID-19 polymerase chain reaction result from Mount Sinai and had a scoliosis ICD-10 code (M41.0–M41.9) was retrospectively analyzed. Degree of coronal plane scoliosis on imaging was confirmed by 2 independent measurers and grouped into no scoliosis (Cobb angle <10°), mild (10°–24°), moderate (25°–39°), and severe (>40°) cohorts. Baseline characteristics were compared, and a multivariable logistic regression controlling for clinically significant comorbidities examined the significance of scoliosis as an independent risk factor for hospitalization, intensive care unit (ICU) admission, acute respiratory distress syndrome (ARDS), mechanical ventilation, and mortality.
The no (n = 42), mild (n = 14), moderate (n = 44), and severe scoliosis (n = 29) cohorts differed significantly only in age (P = 0.026). The percentage of patients hospitalized (P = 0.59), admitted to the ICU (P = 0.33), developing ARDS (P = 0.77), requiring mechanical ventilation (P = 1.0), or who expired (P = 0.77) did not significantly differ between cohorts. The scoliosis cohorts did not have a significantly higher likelihood of hospital admission (mild P = 0.19, moderate P = 0.67, severe P = 0.98), ICU admission (P = 0.97, P = 0.94, P = 0.22), ARDS (P = 0.87, P = 0.74, P = 0.94), mechanical ventilation (P = 0.73, P = 0.69, P = 0.70), or mortality (P = 0.74, P = 0.87, P = 0.66) than the no scoliosis cohort.
Scoliosis was not an independent risk factor for critical COVID-19 illness. No trends indicated any consistent effect of degree of scoliosis on increased adverse outcome likelihood.
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