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.
A cross-sectional study.
The purpose of this study was to assess intervertebral segmental and cumulative motion in the distal unfused segments of the spine in patients with adolescent idiopathic ...scoliosis after instrumentation as a function of the lowest instrumented level.
The implications of hyper- or hypomobility in the unfused segments of the spine after instrumentation are poorly understood. There is little research on changes in functional movement capabilities of the spine after thoracolumbar spinal fusion.
Patients were prospectively offered inclusion into this institutional review board-approved cross-sectional study at their routine 2-, 3-, 4-, or 5-year postoperative visits at 1 of the 5 participating centers. Motion was assessed by standardized radiographs acquired in maximum right, left and forwarding bending positions. The intervertebral angles were measured via digital radiographic measuring software at each level from T12 to S1. The relationship of the vertebral segmental motion for each interspace to the lowest instrumented vertebrae was evaluated with an analysis of variance. The relationship between the cumulative preserved motion and each domain of the Scoliosis Research Society questionnaire were evaluated using a Pearson correlation coefficient.
The data for 100 patients are included. The lowest instrumented vertebrae ranged from T10 to L4. In lateral bending, an association was detected between the lowest fused vertebral level and the degree of motion at the distal unfused segments. With a more distal instrumented vertebrae, there was significantly greater L2-L3, L3-L4, and L4-L5 segment motion (P = 0.002, 0.009, and 0.001, respectively). A similar trend was noticed at L5-S1 level. In addition, the summed motion from L3 to S1 also increased with a more distal fusion (P = 0.001). Similar results were not found in forward bending. None of the domains of the Scoliosis Research Society questionnaire correlated with the preserved L3-S1 motion.
In a group of postoperative patients with adolescent idiopathic scoliosis, evaluation of the distal unfused intervertebral motion showed that preservation of vertebral motion segments allowed greater distribution of functional motion across more levels. With each distal fusion level, motion was significantly increased at the L2-L3, L3-L4, and L4-L5 segmental levels in lateral bending. The relationship between the increased motion and subsequent disc degeneration with a more distal fusion is unknown, but suspected.
Background
Traditionally, adolescent idiopathic scoliosis (AIS) has not been associated with back pain, but the increasing literature has linked varying factors between pain and AIS and suggested ...that it is likely underreported.
Purpose
Our objective was to investigate factors associated with post-op pain in AIS.
Methods
A prospectively collected multicenter registry was retrospectively queried. Pediatric patients with AIS having undergone a fusion with at least 2 years of follow-up were divided into two groups: (1) patients with a postoperative SRS pain score ≤ 3 or patients having a reported complication specifically of pain, and (2) patients with no pain. Patients with other complications associated with pain were excluded.
Results
Of 1744 patients, 215 (12%) experienced back pain after postoperative recovery. A total of 1529 patients (88%) had no complaints of pain, and 171 patients (10%) had pain as a complication, with 44 (2%) having an SRS pain score ≤ 3. The mean time from date of surgery to the first complaint of back pain was 25.6 ± 21.6 months. In multivariate analysis, curve type (16% of Lenke 1 and 2 curves vs. 10% of Lenke 5 and 6,
p
= 0.002) and a low preoperative SRS pain score (no pain 4.15 ± 0.67 vs. pain 3.75 ± 0.79,
p
< 0.001) were significant. When comparing T2–4 as the upper instrumented vertebrae in a subgroup of Lenke 1 and 2 curves, 9% of patients had pain when fused to T2, 13% when fused to T3, and 18% when fused to T4 (
p
= 0.002).
Conclusion
12% of all AIS patients who underwent fusion had back pain after postoperative recovery. The most consistent predictive factor of increased postoperative pain across all curve types was a low preoperative SRS pain score.
Graphic abstract
These slides can be retrieved under Electronic Supplementary Material.
Purpose
To evaluate changes in pulmonary function tests (PFT) at 5 years post-operatively in patients with adolescent idiopathic scoliosis (AIS) and to determine whether these changes are progressive ...or static after 2 years.
Methods
AIS surgical patients with pre-operative and 5 year post-operative forced expiratory volume (FEV) and forced vital capacity (FVC) were included. The percentage of patients with pulmonary impairment at 5 years was calculated. Repeated measures ANOVA was used to evaluate changes between pre-operative PFT and 5 years post-operative PFT and to determine whether the changes differed between curve types and approach. A sub-analysis of patients with 2 year data was performed to determine whether PFT changes were static or progressive.
Results
Two hundred and sixty-two patients had undergone pre-operative and 5 year post-operative PFTs. At 5 years, 42% were normal, 41% had mild impairment, and 17% had moderate-severe impairment. Overall, there was a decline in % predicted FVC (
p
< 0.05); FEV remained stable. There was no difference based on major curve type (
p
> 0.05). Anterior instrumentation cases declined significantly between pre-operative PFT and 5 years post-operative PFT (FEV: − 10% open, − 6% thoracoscopic; FVC: − 13% open, − 8% thoracoscopic) (
p
≤ 0.02). The posterior cases remained stable (2% FEV,
p
= 0.7; − 0.6% FVC,
p
= 0.06). A subgroup of 90 patients with 2 year post-operative PFTs demonstrated that changes were progressive between 2 and 5 years post-operatively. The average change in FVC from 2 to 5 years was significantly different between the anterior open (− 9%) and posterior-only (0.7%) groups (
p
= 0.015).
Conclusion
In patients who underwent anterior instrumentation, PFTs declined from the pre-operative to the 5 years post-operative time point. There was a progressive decline of 4–10% beyond 2 years post-operatively. Patients who underwent posterior instrumentation remained stable.
Graphical abstract
These slides can be retrieved under Electronic Supplementary Material.
Purpose
To assess the following hypotheses related to vertebral body tethering (VBT): 1. VBT is associated with asymmetric (concave > convex) increases in height over the instrumented vertebra. 2. ...The instrumented Cobb angle improves following VBT surgery with growth.
Methods
This is a retrospective case series of pediatric patients from a multicenter scoliosis registry treated with VBT between 2013 to 2021. Inclusion criteria: patients with standing radiographs at < 4 months and ≥ 2 years after surgery. Distances between the superior endplate of the UIV and the inferior endplate of the LIV were measured at the concave corner, mid-point, and convex corner of the endplates. The UIV-LIV angle was recorded. Subgroup analyses included comparing different Risser scores and tri-radiate cartilage (TRC) closed versus open using student t-tests.
Results
83 patients met inclusion criteria (92% female; age at time of surgery 12.5 ± 1.4 years) with mean follow-up time of 3.8 ± 1.4 years. Risser scores at surgery were: 0 (n = 33), 1 (n = 12), 2 (n = 10), 3 (n = 11), 4 (n = 12), and 5 (n = 5). Of the 33 Risser 0 patients, 17 had an open TRC, 16 had a closed TRC. The UIV-LIV distance at concave, middle, and convex points significantly increased from immediate post-op to final-follow-up for Risser 0 patients, but not for Risser 1–5 patients. Increases in UIV-LIV distance were not significantly different between concave, middle, and convex points for all groups. There was no significant improvement or worsening in UIV-LIV angle for any group.
Conclusion
At a mean of 3.8 years following VBT, 33 Risser 0 patients demonstrated significant growth in the instrumented segment, though there was no difference between concave or convex growth, even for patients with open TRC.
Purpose
To determine the mid-term clinical and radiographic impact of pedicle screw fixation in patients with adolescent idiopathic scoliosis (AIS).
Methods
A multicenter AIS database was ...retrospectively queried to identify 99 consecutive patients who underwent posterior spinal fusion using an all pedicle screw construct with a minimum of 5-year follow-up. Radiographic and clinical parameters were reviewed at regular intervals up to 5 years.
Results
The mean age was 14.4 ± 2.0 years with 79 % being female. The mean preoperative major curve was 51.7 ± 14.2° with a mean correction of 66 and 64 % at 2 and 5 years (
p
= 0.16). Pre-op thoracic kyphosis averaged 22.3 ± 12.9° and was 18.4 ± 10.6° at 5 years with no significant change from 2 years (
p
= 0.33). SRS total and domain scores demonstrated significant improvements at 2 years, which were slightly decreased at 5 years (
p
= 0.06). SRS scores of self-image (
p
= 0.99) and satisfaction (
p
= 0.18) were significantly improved after surgery with minimal change by 5 years. The change in SRS total scores from 2 to 5 years was attributed to differences in SRS scores of pain and mental health (
p
< 0.05).
Conclusions
Intermediate follow-up of patients with AIS treated with an all pedicle screw construct demonstrates maintenance of their coronal, and sagittal plane correction between 2- and 5-year follow-up. At 5 years, improvements in SRS scores were consistent with 2-year values, except for a decline in pain and mental health scores.
Background: The routine use of intraoperative vancomycin powder to prevent postoperative wound infections has not been borne out in the literature in the pediatric spine population. The goal of this ...study is to determine the impact of vancomycin powder on postoperative wound infection rates and determine its potential impact on microbiology. Methods: A retrospective analysis of 1269 adolescent idiopathic scoliosis patients in the Harms Study Group was performed. Patients who underwent a posterior fusion from 2004 to 2018 were analyzed. A comparative analysis of postoperative infection rates was done between patients who received vancomycin powder and those who did not. Statistical significance was determined using X2 tests. Additionally, the microbiology of infected patients was examined. Results: A total of 765 patients in the vancomycin group (VG) were compared with 504 patients in the nonvancomycin group (NVG). NVG had a significantly higher rate of deep wound infection (p < 0.001) and reoperation rate compared with VG (p < 0.001). The groups were compared for age, sex, race, weight, surgical time, blood loss, number of levels instrumented and preoperative curve magnitude. There were significant differences between the groups for race (p < 0.001), surgical time (p = 0.003) and blood loss (p = 0.002). In terms of microbiology, VG grew Propionibacterium acnes (n = 2) and serratia (n = 1), whereas NVG grew P. acnes (n = 1) and gram-positive bacilli (n = 1). The remaining cultures were negative. Conclusion: Intraoperative vancomycin powder use in adolescent idiopathic scoliosis appears to contribute significantly to deep wound infection prevention and reduction in associated reoperations. On the basis of the limited culture data obtained, vancomycin does not seem to alter the microbiology of deep wound infections.
In vitro biomechanical investigation using human cadaveric cervical spines.
Evaluate differences in biomechanical stability between typical lateral mass screw + rod constructs compared to transfacet ...screw fixation with and without rods.
Lateral mass screw + rod constructs have reported efficacious arthrodesis rates/quality but risk damaging the lateral neurovascular structures. Transfacet screw fixation has been studied in the lumbar spine, but little data exists regarding its potential utility in the cervical spine.
Sixteen human cadaveric cervical spines were stripped of soft tissue leaving the occiput and ligamentous structures intact. Spines were randomized to lateral mass or transfacet groups (n = 8/group). Spines were prepared in typical surgical fashion and instrumented with the appropriate devices. In the case of the transfacet constructs, the occiput was left intact to simulate the potential surgical difficulty of screw insertion. The transfacet screw group was initially instrumented with rods. Once instrumented (C3-C6) for each group, spines were further dissected to isolate the instrumented levels. End vertebral bodies were rigidly fixed and constructs biomechanically tested in flexion/extension, lateral bending, and axial torsion between +/-2 Nm. After testing for the transfacet screw + rod group, rods were removed and spines retested. All instrumentation was then removed and spines tested in their destabilized state as would occur with surgical preparation. Stiffness data were calculated for each test direction for all groups. Raw and normalized data were each compared across techniques with a 1-way ANOVA (P < 0.05).
The transfacet screw groups (with and without rods) were found to have statistically similar biomechanical stability to lateral mass screw + rod constructs for each test direction.
Transfacet screws (without rods) were found to have similar biomechanical stability compared to typical lateral mass screw + rod constructs. However, transfacet fixation eliminates the risk to the neurovascular structures and lowers the overall implant profile.
STUDY DESIGN.A retrospective analysis of a prospectively collected multicenter database.
OBJECTIVE.To identify the radiographical and clinical outcomes in Lenke 3 curves fused selectively (S) versus ...nonselectively (NS).
SUMMARY OF BACKGROUND DATA.Surgical treatment options for Lenke 3 curves include fusion of both curves (NS) or selective thoracic curve fusion (S). Selective fusion of the thoracic curve spares lumbar motion segments; however, it may result in marked residual deformity.
METHODS.A prospectively collected multicenter database was retrospectively reviewed for adolescent idiopathic scoliosis Lenke 3 curves treated with posterior spinal fusion with a minimum of 2 years of follow-up. Patients were divided into 2 groupsNS (nonselective fusion) and S (selective thoracic fusion). Radiographical and clinical data were compared between the groups using the unpaired Student t test and analysis of variance.
RESULTS.A total of 74 patients met our inclusion criteria, with 49 (66.2%) in the NS group and 25 (33.8%) in the S group. Overall, both groups were similar preoperatively except for lumbar Cobb (NS = 56.3°, S = 47.2°, P < 0.001), lumbar lordosis (NS = 56.9°, S = 67.2°, P = 0.001), lumbar rotational prominence (NS = 11.2°, S = 8.2°, P < 0.05), and lumbar apical translation (NS = 3.2 cm, S = 1.9 cm, P < 0.05). Postoperatively, NS fusion demonstrated significantly less coronal imbalance of 2 cm or less (NS = 10.2%, S = 56.0%, P < 0.001), better lumbar curve correction (NS = 68.2%, S = 51.9%, P < 0.001), better lumbar apical translation correction (NS = 1.2 cm, S = 2.1 cm, P < 0.01), and better percent correction of the lumbar prominence (NS = 66.5%, S = 40.4%, P < 0.05). Scoliosis Research Society Questionnaire 22 scores at 2 years were similar between the groups.
CONCLUSION.Despite preoperatively smaller lumbar curves with less apical translation and lumbar prominence, most patients with selective fusions were out of balance postoperatively and had inferior radiographical outcomes as compared with their nonselective comparison cohort with similar patient-reported outcomes. Long-term follow-up is required to determine whether the trade-off of sparing motion segments at the expense of somewhat lessened radiographical outcomes is worthwhile.Level of Evidence2
Retrospective review of prospective data.
To delineate a curve threshold where further delay of surgery significantly increased the risks for patients with cerebral palsy (CP) scoliosis.
Two ...approaches exist in the management of CP scoliosis: a proactive one where surgery is recommended once there is a risk of progression (Cobb > 50°) and a reactive one where surgery is recommended after the patient/caregiver may have significant challenges caused by a large deformity.
A prospectively collected CP scoliosis surgical registry was queried for patients with minimum two years of follow-up. Three groups were delineated based on the distribution of curve magnitudes: <70° (proactive), 70°-90°, and >90° (reactive). Radiographic, surgical, and quality of life outcome data were compared between the groups using analysis of variance and chi-square analyses.
There were 38 patients in the <70° group, 44 in the 70°-90° group, and 42 in the >90° group. They were similar in age. The >90° group had significantly longer operative time (p < .001), a higher percentage of anterior/posterior procedures (31% vs 5%), and a higher infection rate requiring I&D (16.7%) than the other groups (<70°: 5.3%; 70°-90°: 6.8%; p < .05). The percentage blood volume loss was significantly higher in the >90° group compared to <70°. There were no differences in length of hospitalization or intensive care unit stay. Preoperatively, the Caregiver Priorities and Child Health Index of Life with Disabilities (CPchild) QOL score was significantly higher for the <70° group. At two years, the <70° and 70°-90° groups reached similar QOL scores, whereas the >90° trended toward a lower postoperative QOL.
Being proactive (Cobb <70°) has no advantage in terms of decreasing risks or improving outcomes compared to curves 70°-90°. However, delaying surgery to a curve greater than 90° increases the risk of infection, blood loss, and the need for anterior/posterior procedures. Ideally, surgery should be recommended for curves less than 90°.
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