Retrospective multicenter review.
Determine the definition, indications, results, and outcomes, focusing on complications of vertebral column resection (VCR) for severe pediatric spinal deformity.
...The strict definition of the VCR procedure, indications, results, outcomes, and the numerous, potentially serious complications are unknown or controversial, and a large multicenter review has never been performed.
A total of 147 patients treated by 7 pediatric spinal deformity surgeons were reviewed-seventy-four females and 73 males, with an average age of 13.7 years, an average of 1.6 (range, 1-5) vertebrae resected, and an average follow-up of 17 months (range, 0.5-64 mo). The strict definition of VCR used was a "3-column circumferential vertebral osteotomy creating a segmental defect with sufficient instability to require provisional instrumentation."
Indications for a VCR were divided into 5 diagnostic categories: kyphoscoliosis (n = 52), severe scoliosis (n = 37), congenital deformity (n = 28), global kyphosis (n = 17), and angular kyphosis (n = 13). Eighty-four primary and 63 revision patients with 174 operative procedures, 127 posterior-only (17 staged), and 20 patients combined anterior-posterior (10 staged) were reviewed. Average preoperative upright, flexibility, and postoperative Cobb measures (% correction or average kyphosis decrease) were kyphoscoliosis: 91°, 65°, 44° (51% coronal), 104°, 81°, and 47° (decrease, 57° sagittal); severe scoliosis: 104°, 78°, and 33° (67%); congenital deformity: 47°, 38°, 22° (46% coronal), 56°, 48°, and 32° (decrease, 24° sagittal); global kyphosis: 101°, 79°, and 47° (decrease, 54°); and angular kyphosis: 88°, 90°, and 38° (decrease, 50°), respectively. Operative time averaged 545 minutes (range, 204-1355 min) and estimated blood loss averaged 1610 mL (range, 50-8244 mL) for an average 65% blood volume loss (range, 6%-316%). Eighty-six patients (59%) developed a complication, 39 patients (27%) having an intraoperative neurological event (spinal cord monitoring change or failed wake-up test); however, no patient had complete permanent paraplegia.
A total of 147 consecutive pediatric VCRs performed by 7 surgeons demonstrated excellent radiographical correction. However, these complex reconstructions were associated with a 59% complication rate, thus emphasizing the challenging nature of these patients and procedures.
Retrospective review.
To compare the incidence of and risk factors for proximal junctional kyphosis (PJK) in adolescent idiopathic scoliosis (AIS) following posterior spinal fusion using hook, ...pedicle screw, or hybrid constructs.
Proximal junctional kyphosis is a recently recognized phenomenon in adults and adolescents after AIS surgery. The postoperative effect on PJK with the use of hooks, hybrid constructs, or screws has not been compared in a multicenter study to date.
From a multicenter database, the preoperative and 2-year follow-up radiographic measurements from 283 patients with AIS treated with posterior spinal fusion using hooks (group 1, n = 51), hybrid constructs (group 2, n = 177), pedicle screws (group 3, n = 37), and pedicle screws with hooks only at the top level (group 4, n = 18) were compared.
The average proximal level kyphosis at 2 years after surgery was 8.2 degrees (range -1 to 18) in the all screw constructs, representing a significant increase when compared with hybrid and all hook constructs, 5.7 degrees (P = 0.02) and 5.0 degrees (P = 0.014), respectively. Conversely, average postoperative T5-T12 kyphosis was significantly less (P = 0.016) in the screw group compared with the all hook group. Of potential interest, but currently not statistically significant, was the trend towards a decrease in proximal kyphosis in constructs with all pedicle screws except hooks at the most cephalad segment, 6.4 degrees . The incidence of PJK (assuming PJK is a kyphotic deformity greater than 15 degrees ) was 0% in group 1, 2.3% in group 2, 8.1% in group 3, and 5.6% in group 4 (P = 0.18). Patients with PJK had an increased body mass index compared with those who did not meet criteria for PJK (P = 0.013).
Adjacent level proximal kyphosis was significantly increased with pedicle screws, but the clinical significance of this is unclear. A potential solution is the substitution of hooks at the upper-instrumented vertebrae, but further investigation is required.
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.
Idiopathic scoliosis is a complex three-dimensional deformity of the spine with anterior overgrowth (hypokyphosis), coronal curvature, and axial rotation. Scoliosis treatment in the skeletally ...immature spine is therapeutically challenging because of growth and was commonly limited to observation, bracing treatment, or fusion. Fusion accomplishes powerful deformity correction at the expense of future growth and mobility of the involved segments, increasing the risk of adjacent segment degeneration and intervertebral disk disease later in life. Anterior vertebral body tethering is a motion-preserving technique that exploits the Hueter-Volkmann principle by applying compression at the anterior and convex aspects of the curve to stimulate differential vertebral growth for gradual deformity reduction without fusion. The appropriate timing, curve magnitude, tensioning, growth prediction, indications, and limitations of tethering are being refined as this technique becomes more prevalent. Early outcome studies show that growth modulation with vertebral body tethering is safe, can achieve good results, and preserve motion in select patients.
A retrospective multicenter study.
To evaluate the effect of repeated surgical lengthenings and time on spinal growth and Cobb angle in children with early onset scoliosis and dual growing rods.
...Previous studies have established the effectiveness of dual growing rods for controlling spinal deformity and promoting spinal "growth." Although anecdotal experience suggests that the effectiveness of repeated lengthenings decreases over time, this has not been previously studied.
Medical records from five different centers were reviewed to identify children treated with dual growing rods for early onset scoliosis who had a minimum of 2-year follow-up and at least three lengthening procedures. Initial radiographs, postimplantation radiographs, and radiographs from before and after each lengthening were measured for T1-S1 distance and Cobb angle. Linear regression and analysis of variance were used for statistical analysis.
Thirty-eight patients from five centers met the inclusion criteria. The average age of our patients was 5.7 years (range 1.7-8.9 years); mean follow-up was 3.3 years (range 2-7 years). The average interval between lengthenings was 6.8 months. Cobb angle decreased from a mean value of 74° preoperatively to 36° after the primary implantation and did not change significantly with repeated lengthenings (P = 0.96). After initial implantation, the average annual T1-S1 gain was 1.76 ± 0.71 cm/year. The T1-S1 gain after a given lengthening, however, decreased significantly with repeated lengthenings (P = 0.007). When the effect of time was considered, there was also a significant decrease in T1-S1 gain over time (P = 0.014).
There seems to be a "law of diminishing returns" with repeated lengthenings of dual growing rods. Repeated lengthenings still result in a net T1-S1 increase; however, this gain tends to decrease with each subsequent lengthening and over time. This phenomenon may be due to autofusion of the spine from prolonged immobilization by a rigid device.
As we navigate to provide the best patient care and outcomes, the patient experience has shown to be a driver that improves quality. Patient experience surveys are the primary means of measuring the ...perception of the care received. Positive patient experience has been linked to better patient compliance, decreased health care costs, decreased liability, and improved outcomes. Physician wellbeing and improved job satisfaction is a recognized additional benefit. Strategies have been developed to achieve these goals, enhance our practice and improve our work satisfaction and the patient experience.
Serial casting is favored for the initial treatment of early onset scoliosis (EOS), but there is concern about significant morbidity and caregiver burden. Studies have examined the utility of bracing ...as an alternative to casting, but little is known about differences in health-related quality of life (HRQoL) between treatments. We hypothesized that patients with a diagnosis of idiopathic EOS experience an improvement in HRQoL when transitioning from serial casting to bracing as measured by the 24-Item Early Onset Scoliosis Questionnaire (EOSQ).
Subjects with idiopathic EOS were retrospectively identified from a multicenter database. EOSQ scores were compared before treatment, after index casting, after transition out of cast to brace, and at the most recent follow-up. Available major curve magnitudes were also compared during these time points. Data were compared using repeated-measures ANOVA with post hoc Bonferroni correction.
Sixty-six subjects met the inclusion criteria. Thirty-seven (56%) subjects were male and the average age at the time of index treatment was 1.9 (0.37-6.4) years. The average follow-up was 3.2 (0.90-6.8) years. In 57 subjects, the major curve magnitude improved from a mean of 33 (CI 28-37) degrees before treatment initiation to 27 (CI 23-30) degrees after casting and to 24 (CI 20-29) degrees at the most recent follow-up. The HRQoL subdomain showed a significant decrease in HRQoL during casting treatment 75.7 (CI 72.9-78.5) from pre-index treatment 84.9 (CI 81.4-88.5), during brace treatment 84.8 (CI 81.8-88.0) and at most recent follow-up 87.0 (CI 83.6-90.3) ( P <0.001). The parental impact subdomain improved from the beginning to the end of treatment (77.7 to 87.7, P =0.001) (n=64). Satisfaction improved from casting to bracing (73.4 to 86.7, P <0.001) (n=63) and to the most recent follow-up (73.4 to 87.9, P <0.001).
Patients treated with casting for EOS experience reversible declines in HRQoL. After patients transition from casting to bracing, EOSQ scores recover to pretreatment baseline levels and are maintained at follow-up. This information must be balanced with the effectiveness of treatment for EOS with either method and customized for each patient.
Level III-retrospective comparative study.
Although traditionally it has been accepted that back pain in young children and adolescents most often has an organic etiology, nonorganic back pain in this population is becoming more common. The ...most common identifiable clinical entities responsible for such pain are spondylolysis, spondylolisthesis, Scheuermann kyphosis, overuse syndromes, disk herniation, apophyseal ring fracture, spondylodiscitis, vertebral osteomyelitis, and neoplasm. Appropriate clinical workup leads to earlier diagnosis and management of back pain and avoids unnecessary cost. Knowledge of the most common diagnoses associated with back pain in children and adolescents and the use of a systematic method to select the appropriate diagnostic tests can help the clinician to minimize costs and maximize the likelihood of making the correct diagnosis and providing appropriate treatment.
The development of new technologies and an enhanced understanding of the three-dimensional deformity in adolescent idiopathic scoliosis has led to advances in surgical management of adolescent ...idiopathic scoliosis. Posterior spinal approaches with pedicle screw constructs are now standard of care because they allow for powerful rotation maneuvers with three-column deformity correction. Selective fusion of the main curve while allowing for spontaneous correction of compensatory curves should be attempted whenever possible in the interest of limiting fusion size and preserving spinal mobility. Recent research provides updated criteria to determine optimal candidates for selective fusion. These criteria must be weighed against patient goals and patient-specific factors to limit complications and maximize chances of successful deformity correction.
Retrospective cohort.
To examine SRS-Self Image scores at up to 10 years after surgery for adolescent idiopathic scoliosis (AIS).
Self-image is complex with implications for surgical and ...patient-reported outcomes after AIS surgery. Surgically modifiable factors that impact self-image are inconsistently reported in the literature with few longer-term reports. We examined the rate and durability of self-image improvement.
An AIS registry was queried for patients with up to 10 years of follow-up after AIS surgery. A mixed effects model estimated change in SRS-22 Self Image from baseline to 6 weeks, 1 year, 2 years, 5 years, and 10 years. All enrolled patients contributed data to the mixed effects models. A sub-analysis of patients with 1-year and 10-year follow-up evaluated worsening/static/improved SRS-22 Self Image scores examined stability of scores over that timeline. Baseline demographic data and 1-year deformity magnitude data were compared between groups using parametric and nonparametric tests as appropriate.
Data from 4608 patients contributed data to the longitudinal model; 162 had 1-year and 10-year data. Mean SRS-Self Image improvement at 10-year follow-up was 1.0 (95% CI: 0.9-1.1) point. No significant changes in Self-Image domain scores were estimated from 1-year to 10-year (all P >0.05) postoperative. Forty (25%) patients had SRS-Self Image worsening from 1 year to 10 years, 36 (22%) improved, and 86 (53%) were unchanged. Patients who worsened over 10 years had lower SRS-Self Image at baseline than those unchanged at enrollment (3.3 vs. 3.7, P =0.007). Neither radiographic parameters nor SRS-Mental Health were different at baseline for the enrolled patients.
Ten years after surgery, 75% of patients reported similar or better SRS-Self Image scores than one year after surgery. Nearly 25% of patients reported worsening self-image at 10 years. Patients who worsened had lower baseline SRS-Self Image scores, without radiographic or mental health differences at baseline or follow-up.
