Posterior Spinal Fusion For Scoliosis Research Articles

More Than a Flesh Wound: Trisomy 21 Patients Undergoing Posterior Spinal Fusion for Scoliosis Have High Odds of Wound Complications.

Retrospective cohort study. Patients with trisomy 21 (T21) often have soft tissue differences that lead to greater risk of postoperative wound complications. Our aim was to use a matched cohort of adolescent idiopathic scoliosis (AIS) patients with >2year outcomes to determine odds of specific wound complications when comparing T21 and AIS patients. 14 T21 and 544 AIS patients were available for matching. Propensity score matching was conducted using logistic regression models and yielded a 1:5 match of 14 T21 patients and 70 AIS patients. Bivariate analyses were conducted across both patient groups. The proportion of wound complications was estimated along with a 95% confidence interval. Multivariable logistic regression analysis was utilized to determine if there was a significant association between T21 patients and wound outcomes. 64% of T21 patients experienced a wound complication (9/14; 95% CI = 35.63-86.02) while only 3% of the AIS patients experienced a wound complication (2/70; 95% CI = .50-10.86). Patients with T21 had 56.6 times the odds of having a wound complication compared to matched AIS patients (OR = 56.57; 95% CI = 8.12-394.35; P < .001), controlling for age at surgery, BMI percentile, and propensity score. T21 patients had 10.4 times the odds of reoperation compared to AIS patients (OR = 10.36; 95% CI = 1.62-66.02; P = .01). T21 patients have 10.4× the odds of reoperation and 56.6× the odds of overall wound complication when compared to AIS patients in a 1:5 matched cohort with appropriate controls. This is important for surgical planning, surgeon awareness, and communication with families preoperatively.

The machine-vision image guided surgery system reduces fluoroscopy time, ionizing radiation and intraoperative blood loss in posterior spinal fusion for scoliosis

PurposeTo determine if the novel 3D Machine-Vision Image Guided Surgery (MvIGS) (FLASH™) system can reduce intraoperative radiation exposure, while improving surgical outcomes when compared to 2D fluoroscopic navigation.MethodsClinical and radiographic records of 128 patients (≤ 18 years of age) who underwent posterior spinal fusion (PSF), utilising either MvIGS or 2D fluoroscopy, for severe idiopathic scoliosis were retrospectively reviewed. Operative time was analysed using the cumulative sum (CUSUM) method to evaluate the learning curve for MvIGS.ResultsBetween 2017 and 2021, 64 patients underwent PSF using pedicle screws with 2D fluoroscopy and another 64 with the MvIGS. Age, gender, BMI, and scoliosis aetiology were comparable between the two groups. The CUSUM method estimated that the MvIGS learning curve with respect to operative time was 9 cases. This curve consisted of 2 phases: Phase 1 comprises the first 9 cases and Phase 2 the remaining 55 cases. Compared to 2D fluoroscopy, MvIGS reduced intraoperative fluoroscopy time, radiation exposure, estimated blood loss and length of stay by 53%, 62% 44%, and 21% respectively. Scoliosis curve correction was 4% higher in the MvIGS group, without any increase in operative time.ConclusionMvIGS for screw insertion in PSF contributed to a significant reduction in intraoperative radiation exposure and fluoroscopy time, as well as blood loss and length of stay. The real-time feedback and ability to visualize the pedicle in 3D with MvIGS enabled greater curve correction without increasing the operative time.

Hospital Burdens of Patients With Cerebral Palsy Undergoing Posterior Spinal Fusion for Scoliosis.

Study Design:Retrospective cohort study.Objectives:Many patients undergoing posterior spinal fusion (PSF) for scoliosis have concurrent cerebral palsy (CP), which is associated with many medical comorbidities and inherent operative risk. We aimed to quantify the contribution of CP to increased cost, length of stay (LOS), and complication rates in patients with scoliosis undergoing PSF.Methods:Using the National Inpatient Sample database, we collected data regarding patient demographics, hospital characteristics, comorbidities, in-hospital complications, and mortality. Primary outcomes included complications, hospital LOS, and total hospital costs. Multivariate regression models assessed the contribution of CP to in-hospital complications, discharge status, and mortality. Linear regression identified the contribution of a diagnosis of CP on hospital LOS and inflation-adjusted cost.Results:Cerebral palsy was an independent predictor of several complications. The most striking differences were seen for mortality (odds ratio [OR]: 3.40, P < .001), a postoperative requirement for total parenteral nutrition (OR: 3.16, P < .001), urinary tract infection (OR: 2.75, P < .001), surgical site infection (OR: 2.67, P < .001), and pneumonia (2.21, P < .001). Patients with CP ultimately cost an additional $13 482 (P < .001) with a 2.07-day greater LOS (P < .001) than patients without CP.Conclusion:Most complications were seen in higher rates in the CP cohort, with higher cost and LOS in patients with CP versus those with idiopathic scoliosis (IS). Our findings represent important areas of emphasis during preoperative consultations with patients with CP and their families. Extra care in patient selection and multifaceted treatment protocols should continue to be implemented with further investigation on how to mitigate common complications.

Delayed quadriparesis after posterior spinal fusion for scoliosis: a case series.

A multicenter retrospective IRB exempt case series analyzing clinical and radiographical data of patients treated by three surgeons over the past two decades was conducted. To examine the factors involved in the development of quadriparesis in patients who underwent posterior spinal fusion for scoliosis. Delayed spinal cord infarcts usually present at the region of instrumentation according to reports from the Scoliosis Research Society. Nonetheless, there is a lack of data regarding factors associated with delayed quadriparesis following posterior spinal fusion METHODS: Evaluated variables were age, Cobb angle, blood loss, and curve correction percentage. Postoperative imaging was also evaluated to determine factors indicative of the etiology of the quadriparesis. Eight patients presented delayed postoperative quadriparesis. All patients had a postoperative examination equal to that of baseline. The first patient deteriorated at 6h postoperatively and the most delayed patient presented 4days postoperatively. Six patients had neuromuscular disorders and 2 had adolescent idiopathic scoliosis. Mean age was 13.7, mean curve magnitude was 78.7°, mean percent curve correction was 71% and the mean estimated blood loss was 1185cc. Seven of eight patients had documented peri- or postoperative hypotension. Cervical infarction is the likely cause of delayed quadriparesis after posterior spinal fusion. Even though the underlying etiology continues to be unclear, postoperative hypotension, curve magnitude, percent curve correction, and the presence of cervical kyphosis/stenosis may be contributory and need to be closely evaluated. IV, Case Series.

Reduction of Surgical Invasion in Posterior Spinal Fusion for Scoliosis

Reduction of Surgical Invasion in Posterior Spinal Fusion for Scoliosis

Preoperative Pulmonary Function Test Results Are Not Associated With Postoperative Intubation in Children Undergoing Posterior Spinal Fusion for Scoliosis: A Retrospective Observational Study

Preoperative pulmonary function tests are routinely obtained in children with scoliosis undergoing posterior spinal fusion despite unclear benefits as a perioperative risk assessment tool and frequent inability of patients to provide acceptable results. The goal of this study was to determine whether preoperative pulmonary function test results are associated with the need for postoperative intubation or intensive care unit admission after posterior spinal fusion. The electronic medical records of patients who underwent posterior spinal fusion at a pediatric tertiary hospital between June 2012 and August 2017 were reviewed. Pulmonary function tests were consistently ordered for all patients, unless the patient was deemed unable to perform the test due to cognitive disability. Cases were categorized as primary or secondary scoliosis.Demographic data, preoperative bilevel positive airway pressure use, Cobb angle, intraoperative allogeneic blood transfusion, and ability to produce acceptable pulmonary function test results were collected for each patient. In patients with satisfactory pulmonary function test results, forced vital capacity and maximum inspiratory pressure were collected. Primary outcomes for analysis were postoperative intubation and intensive care unit admission. Univariable logistic regression models were used to assess the association between each variable of interest and the primary outcomes. The study sample included 433 patients, 288 with primary scoliosis and 145 with secondary scoliosis. Among patients with primary scoliosis, 90% were able to produce acceptable pulmonary function test results, zero remained intubated postoperatively, and 6 were admitted to the intensive care unit. Among patients with secondary scoliosis, 44% could not attempt pulmonary function tests. Among those who did attempt the test, 30% were unable to produce meaningful results. Forced vital capacity and maximum inspiratory pressure were not found to be associated with postoperative intubation or intensive care unit admission. Weight, Cobb angle, intraoperative blood transfusion, American Society of Anesthesiologists physical status classification, and preoperative bilevel positive airway pressure use were associated with patient outcomes. Among 357 total patients who attempted pulmonary function tests, 37 had high-risk results. Only 1 of these 37 patients remained intubated postoperatively. Patients undergoing posterior spinal fusion, especially those with secondary scoliosis, are frequently unable to adequately perform pulmonary function tests. Among patients with interpretable pulmonary function tests, there was no association between results and postoperative intubation or intensive care unit admission. Routine pulmonary function testing for all patients with scoliosis may not be indicated for purposes of risk assessment before posterior spinal fusion. Clinicians should consider a targeted approach and limit pulmonary function tests to patients for whom results may guide preoperative optimization as this may improve outcomes and reduce inefficiencies and costs.

Outcomes of Primary Posterior Spinal Fusion for Scoliosis in Spinal Muscular Atrophy: Clinical, Radiographic, and Pulmonary Outcomes and Complications.

Spinal muscular atrophy (SMA) is a progressive neuromuscular disease commonly including progressive scoliosis resulting in severe deformity and negatively affecting pulmonary function. Surgical correction and stabilization of this progressive deformity is generally recommended; however, the timing and method of surgical fixation remains controversial. Retrospective review of clinical, radiographic, and pulmonary function data from 16 children with SMA and surgically treated scoliosis between 1985 and 2013. Radiographic data included direct measures of major curve, coronal balance, pelvic obliquity, T1-T12 height, T1-S1 height, and T1-rod length. Estimations of rib collapse, thoracic cavity shape, and space-available-for-lung (T6:T12, width ratio; T6:T10, rib-vertebral-angle difference ratios; and lung height) were determined. Eleven patients were able to complete pulmonary function testing. Results were compared with published outcomes for growing rod constructs. Posterior spinal fusion was performed at an average age of 9.8±3.6 years. The mean age at most recent follow-up was 19.4 years (range, 10 to 37 y), with a mean follow-up of 10.1 years (range, 3.1 to 26 y). Radiographic measurements improved from preoperative to latest follow-up as follows: major curve, 78±20 degrees to 27±24 degrees; coronal balance, 4.1±4.0 cm to 1.9±2.2 cm; pelvic obliquity (median), 23 to 5 degrees; T1-T12 height, 19±3 cm to 22±3 cm; T1-S1 height, 31±7 cm to 36±6 cm; T1-rod length, 0.8±1.1 cm (postop) to 2.8±1.6 cm (final); and space-available-for-lung ratio, 0.88±0.26 to 0.95±0.25. Rib collapse continued throughout the follow-up period in all but 1 patient. Pulmonary function testing demonstrated a decrease in rate of decline in forced vital capacity and forced expiratory volume when comparing preoperative with postoperative rates. Mean length of stay was 7.8±4.4 days. Complications included reintubation for low tidal volumes (n=1), pneumonia (n=1), superficial wound breakdown (n=1), and superficial infection (n=1). Definitive posterior spinal fusion for treatment of scoliosis associated with SMA is effective at controlling curve progression and pelvic obliquity without negatively impacting the space-available-for-lung ratio, trunk height, or pulmonary function at 10 years follow-up. Therapeutic Level IV.

Posterior spinal fusion for scoliosis after Fontan procedure: Acaseseries.

As the surgical treatment of scoliosis after a Fontan procedure is very challenging due to the risk of various perioperative complications, case reports are scarce. We herein describe three patients who were successfully treated for scoliosis following a Fontan procedure and discuss their clinical and radiological outcomes. We retrospectively reviewed three cases of scoliosis treated by posterior spinal fusion after a Fontan procedure. Mean preoperative major curve Cobb angle was 83.7°, mean surgical time was 233.0min, and mean blood loss was 1167g. The mean correction rate of the major curve was 48.0%. Surgical outcome as evaluated by Scoliosis Research Society-22 patient questionnaires revealed acceptable results without any severe complications. Corrective surgery for scoliosis after a Fontan procedure becomes a stronger option if cardiac insufficiency is prevented during the perioperative period and a conservative plan is carried out with minimal invasiveness and operation time.

Pediatric Return to Sports After Spinal Surgery.

Context:Pediatric patients who undergo spinal surgery are frequently involved in sporting activities. Return to play is often an important postoperative concern for the patient and family.Evidence Acquisition:A PubMed search was conducted for articles in the English language on return to play after treatment of pediatric acute disc herniation, degenerative disc disease, spondylolysis, spondylolisthesis, and scoliosis from 1980 to 2015. Reference lists were reviewed for additional pertinent articles. We included articles that focused on return to sports after surgical treatment of these conditions in this review.Study Design:Clinical review.Level of Evidence:Level 4.Results:There are no published guidelines, and most of the literature in this area has focused on return to play after spinal injury rather than after spinal surgery. Most children and adolescents have excellent outcomes with minimal pain at 1 year after lumbar discectomy. The majority of surgeons allow return to full activity once pain-free range of motion and strength are regained, typically at 8 to 12 weeks postoperatively. Pediatric patients with spondylolysis have good outcomes after direct pars repair. Satisfactory outcomes have been demonstrated after fusion for low- and high-grade spondylolisthesis. Most surgeons allow return to noncontact sports by 6 months after surgical treatment of spondylolysis and spondylolisthesis. Return to contact and collision sports is controversial. After posterior spinal fusion for scoliosis, most surgeons allow return to noncontact sports by 3 months and return to contact sports between 6 months and 1 year. Return to collision sports is controversial.Conclusion:There is little evidence to guide practitioners on return to sports after pediatric spinal surgery. Ultimately, the decision to allow any young athlete to resume sports participation after spinal injury or surgery must be individualized.

The Use of Chewing Gum Postoperatively in Pediatric Scoliosis Patients Facilitates an Earlier Return to Normal Bowel Function

PurposeIn surgical correction of scoliosis in pediatric patients, gastrointestinal complications including postoperative ileus can result in extended hospital stays, poorer pain management, slower progression with physical therapy, and overall decreased patient satisfaction. In patients undergoing gastrointestinal, gynecological, and urological surgery, gum chewing has been shown to reduce time to flatus and passage of feces. The authors hypothesized that chewing gum could also speed return to normal bowel function in pediatric patients undergoing surgical correction of scoliosis. MethodsThe researchers obtained institutional review board approval for a prospective, randomized, controlled trial. Eligible patients included all adolescent idiopathic scoliosis patients undergoing posterior spinal fusion. Exclusion criteria included previous gastrointestinal surgery or preexisting gastrointestinal disease. Patients were randomized by coin flip. The treatment group chewed sugar-free bubble gum 5 times a day for 20 to 30 minutes beginning on postoperative day 1; the control group did not chew gum. Patients were asked a series of questions regarding subjective gastrointestinal symptoms each day. Time to flatus and first passage of feces were recorded as indicators of return to normal bowel function. Normality of data was assessed using normal probability plots. ResultsA total of 83 patients completed the study (69 females and 14 males; mean age, 14.4 years). Of the 42 patients in the chewing gum group, 8 elected to stop chewing gum regularly before discharge for to a variety of reasons. Patients who chewed gum experienced first bowel movement on average 145.9 hours after surgery, 30.9 hours before those who did not chew gum (p = .04). Gum-chewing patients first experienced flatus an average of 55.2 hours after surgery, compared with 62.3 hours for controls. This trend did not reach statistical significance (p = .12). No difference was noted in duration of hospital stay, medications administered as required, or subjective symptoms. ConclusionChewing gum after posterior spinal fusion for scoliosis is safe and may speed return of normal bowel function. Chewing gum after surgical correction of scoliosis facilitates an earlier return to normal bowel function, which may improve patient satisfaction in the early postoperative period.

Surgical Management of Scoliosis in JehovahÂ’s Witness Patients: One InstitutionÂ’s Experience

Introduction: Blood loss is a major cause of morbidity in scoliosis surgery. Jehovah’s Witnesses pose a unique challenge, as their religious convictions restrict them from receiving blood products. There is a paucity of literature regarding blood conservation protocols in pediatric Jehovah’s Witness patients undergoing scoliosis surgery. Methods: Ten consecutive Jehovah’s Witness patients under 21 years of age, who underwent posterior spinal fusion for scoliosis between 1995 and 2013, were retrospectively evaluated. Medical charts were used to assess curve type and magnitude, blood conservation techniques used, operative time, estimated blood loss (EBL), hemoglobin levels and postoperative complications. Results: Diagnoses included 5 idiopathic, 3 syndromic, and 2 neuromuscular scoliosis. An average of 11.5 levels were fused with 58% curve correction. The mean operative time was 325 minutes. Commonly employed blood conservation techniques were electrocautery (100%), cell saver (70%), supplemental iron (70%), and epinephrinesoaked gauze (60%). Anti-fibrinolytics were consistently used in 4 cases since 2010, and the bipolar sealer device in 5 cases since 2007. Hemodilution and hypotensive anesthesia were used in 2 and one case, respectively. EBL was 544 ml. No surgery was aborted due to blood loss. The preoperative and nadir postoperative hemoglobin levels averaged 14.1 and 9.8 g/dL, respectively. There were 4 postoperative complications, which were unrelated to blood loss. At a mean 4-year follow-up, all patients were stable. Conclusion: Posterior spinal fusion can be safely performed in standard fashion in the pediatric Jehovah’s Witness population. The variety of blood conservation techniques has increased over recent years. More aggressive techniques such as hemodilution and hypotensive anesthesia are not always imperative for efficacious surgery. Our institution is currently establishing a blood conservation protocol for spinal deformity surgery.

Prolonged perioperative infusion of low-dose ketamine does not alter opioid use after pediatric scoliosis surgery.

Opioid consumption after posterior spinal fusion is known to be high and often exceeds those reported in other major surgical procedures. A number of clinical trials provide evidence that the perioperative use of subanesthetic doses of ketamine reduces pain and opioid requirements in some surgical procedures, but the effect of prolonged perioperative low-dose ketamine infusion in patients undergoing posterior spinal fusion for pediatric scoliosis surgery is unknown. To test the hypothesis that a 72-h perioperative low-dose ketamine infusion would decrease opioid use in pediatric patients undergoing posterior spinal fusion. In a double-blind prospective controlled trial, patients undergoing posterior spinal fusion for scoliosis were randomized to receive perioperative low-dose ketamine or placebo control. Patients received general anesthesia, intraoperative remifentanil, and morphine patient-controlled analgesia postoperatively. Daily opioid consumption, self-reported pain scores, and sedation scores were measured. Fifty-four patients were enrolled and 50 completed the study. Contrary to our hypothesis, ketamine- and control-treated patients had similar postoperative opioid use, pain scores, and sedation scores measurements. In contrast, ketamine-treated patients required less intraoperative remifentanil compared with control (mean 2.9mg vs. 4mg, P=0.0415). Number of vertebrae instrumented, time between end-of-surgery and 24h assessment, or remifentanil doses did not impact on postoperative opioid use. Over 96-h postoperatively, morphine-equivalent consumption was lower (-0.40, P=0.006) and sedation score was higher (0.47, P=0.0211) in male patients, compared with female patients. These findings do not support the use of perioperative low-dose ketamine to decrease opioid use in children with scoliosis undergoing posterior spinal fusion.

A case who underwent posterior spinal fusion for scoliosis caused by Fontan operation for pulmonary atresia

A case who underwent posterior spinal fusion for scoliosis caused by Fontan operation for pulmonary atresia

Airport metal detector activation is rare after posterior spinal fusion in children with scoliosis

Since the September 11, 2001 terrorist attacks on the World Trade Center in New York City, travel security has become an ever-increasing priority in the United States. Frequent parent and patient inquiry and recent literature reports have generated interest in the impact of heightened security measures on patients with orthopaedic implants, and have indicated increasing rates of metal detector triggering. There are no reports to date, however, evaluating children and adolescents who have undergone posterior spinal fusion for scoliosis, so responses to patient and parent inquiries are not data-driven. The purpose of this study is to determine the frequency of airport metal detector triggering by patients who have had posterior-only spinal fusion and to characterise any potential predictors of metal detector activation. A cross-sectional study was performed by interviewing 90 patients who underwent posterior-only spinal fusion for a diagnosis of juvenile or adolescent idiopathic scoliosis and have travelled by air in the past year. Demographic, clinical and surgical instrumentation data were collected and evaluated, along with patients' reports of airport metal detector triggering and subsequent screening procedures. Five patients with stainless steel instrumentation (5.6% of the cohort) triggered an airport walkthrough metal detector, and an additional five patients who did not trigger an airport detector triggered a handheld detector at a different venue. All patients who triggered an airport metal detector had stainless steel instrumentation implanted prior to 2008, and no patient with titanium instrumentation triggered any detector in any venue. All trigger events required subsequent screening procedures, even when an implant card was presented. In this cohort of children and adolescents with posterior spinal instrumentation, airport walkthrough metal detector triggering was a rare event. Therefore, we advise patients and families with planned posterior scoliosis fusions using titanium instrumentation that airport detection risk is essentially non-existent, and only rare for those with planned stainless steel instrumentation. We no longer issue implant cards postoperatively, as these did not prevent further screening procedures in this cohort. Prognostic level 2. cross-sectional.

Successful Manubriosternal Fusion Following Failure of Open Reduction and Internal Fixation of a Traumatic Manubriosternal Dislocation

Manubriosternal joint dislocations are rare clinical entities that may occur secondary to trauma1-4, inflammatory arthropathy5-7, or infection8. When they occur in a traumatic setting, concomitant cardiac contusions, pulmonary contusions, and spine fractures or dislocations may be observed9,10, and they must be treated appropriately. Manubriosternal dislocations may be classified as type-1 injuries, in which the sternal body is dislocated posteriorly with respect to the manubrium, or as type-2 injuries, in which the sternal body is dislocated anteriorly11. It is felt that most posterior dislocations are the result of direct impact to the anterior chest wall, while anterior dislocations are uniformly the result of an indirect flexion-compression mechanism12. Both operative1-4 and nonoperative8,10,11,13 strategies have been employed, but because of the relative rarity of this injury, a consensus regarding optimal management has not been established. To our knowledge, few reports of this injury exist in the literature, and we are unaware of any cases of operative fixation that have required revision surgery. We report the failure of an open reduction and internal fixation (ORIF) of a type-2 dislocation, which was salvaged with a successful manubriosternal fusion. The patient was informed that data concerning the case would be submitted for publication, and she provided consent. A fifty-year-old woman presented to the emergency department after a fall from an all-terrain vehicle onto her anterior chest wall. She had a history of posterior spinal fusion for scoliosis thirty-seven years prior to presentation, but was otherwise healthy. Chief symptoms were anterior chest pain and midthoracic back pain. On physical examination, she had an obvious sternal deformity with associated tenderness and was tender throughout the mid-to-lower thoracic region posteriorly. Radiographs …

Migration of Laminar Hook Causing Thoracic Myelopathy Eight Years Post Scoliosis Surgery

Case report. A case report describing late presentation of neurologic injury with latent infection following scoliosis surgery. Neurologic injury is a well described complication of scoliosis surgery. Late presentations of neurologic injury are rare but have been reported. To our knowledge, there are no reports of late presenting thoracic cord compression from a Cotrel-Dubousset type hook and rod instrumentation associated with latent indolent infection. A 23-year-old man, 8 years status post T3-L3 posterior spinal fusion for scoliosis, presented with approximately a 6-month history of progressive leg numbness and mild weakness. Computed tomography myelogram showed cord compression from a laminar hook at T10 on the left side. The patient's neurologic status improved after device removal. Intraoperative tissue cultures grew coagulase-negative Staphylococci despite having normal preoperative laboratory data for infection. We report a case of late presenting neurologic injury from migration of a laminar hook causing thoracic cord compression and myelopathy. Removal of device resulted in discovery of a latent infection and satisfactory neurologic recovery.

Thromboemboli, Acute Right Heart Failure and Disseminated Intravascular Coagulation After Intraoperative Application of a Topical Hemostatic Matrix

Topical hemostatic agents are frequently used in spine surgeries to control or reduce bleeding. Although there are a number of commercially available products, at our institution, an absorbable gelatin powder (Surgifoam) is mixed with bovine thrombin and used for this purpose. We report the case of a patient undergoing a posterior spinal fusion for scoliosis who developed acute right heart failure, cardiac arrest, and disseminated intravascular coagulation after probable intravascular hemostatic agent-induced emboli. Clinicians need to be aware of this potentially deadly complication associated with topical hemostatic agents.

Tranexamic Acid Diminishes Intraoperative Blood Loss and Transfusion in Spinal Fusions for Duchenne Muscular Dystrophy Scoliosis

Retrospective review of intraoperative blood loss and blood replacement. We compared intraoperative blood loss and blood replacement during spinal fusion surgery for scoliosis in Duchenne muscular dystrophy (DMD) performed with and without the synthetic antifibrinolytic agent tranexamic acid (TXA). High levels of intraoperative blood loss are widely documented in DMD patients undergoing posterior spinal fusion for scoliosis. The effect of the antifibrinolytic agent tranexamic acid on decreasing the blood loss has not been studied in a large group of DMD patients. All 56 DMD patients underwent posterior spinal fusion with the same technique using 2 rods and multiple sublaminar wires. TXA was not used in 36 patients and was used in 20. In the respective groups, the age at surgery (14 vs. 13.9 years), the preoperative deformity (45 degrees vs. 51 degrees ), the mean number of levels fused (14.3 vs. 14.7), and the mean surgical times (446 minutes vs. 459 minutes) were similar. TXA dose was 100 mg/kg in solution over 15 minutes before incision followed by an infusion of 10 mg/kg per hour during surgery. Standardized measurements of intraoperative blood loss were used and calculated to compare total amount of blood loss in milliliters per patient and blood loss as a percentage in relation to estimated blood volume [estimated blood loss (EBL)/estimated blood volume (EBV) x 100]. The EBV was calculated to be 70 mL/kg (body weight). Mean blood loss with TXA was 1944 +/- 789 mL (range, 760-4000 mL) and without TXA was 3382 +/- 1795 mL (range, 600-9580 mL) (P < 0.001). Blood loss with TXA decreased by 42% compared with those not treated with TXA. Accounting for patient weight and estimated blood volume, mean % blood loss with and without TXA was 47% +/- 28% versus 112% +/- 67% (P < 0.001). This physiologic indicator shows that blood loss with TXA decreased by 58% compared with those patients not treated with TXA. TXA was also found to reduce blood loss after accounting for surgical time. No hypercoagulation or other complications from TXA therapy were observed. The reduced blood loss in TXA-treated patients translated into decreased blood transfusions. Transfusion of homologous whole blood and packed red blood cells in the TXA group was decreased by 46% compared with the no TXA group (mean levels, 512 +/- 470 mL vs. 955 +/- 718 mL), and transfusion of autologous cell saver blood was decreased by 42% in the TXA group (mean levels, 419 +/- 235 mL vs. 728 +/- 416 mL). TXA significantly reduces both intraoperative blood loss and the need for homologous transfusion of whole blood and packed red blood cells in DMD patients undergoing posterior spinal fusion for scoliosis.

Use of Wound V.A.C. Therapy in Pediatric Patients With Infected Spinal Wounds

Deep wound infection in patients that have had a posterior spinal fusion for scoliosis is a major complication in pediatric spine surgery. To explore characteristics of pediatric patients who had a posterior spinal fusion with segmental spinal instrumentation and bone graft and subsequently developed deep spinal wound infections that were treated with wound vacuum-assisted closure (V.A.C.) therapy Retrospective Chart Review. Characteristics of patients' age, gender, comorbid illnesses, identified bacteria, antibiotics, time on V.A.C. device, infection recurrence, any instrumentation removal, and additional surgical intervention was collected. There were 249 patients who had spinal fusions from December 2002 through January 2006, and 11 developed an infection after their spinal fusion and had the use of the V.A.C. device. Those who developed infection within 1 year of their fusion had instrument retention. Wound closure occurred in all cases that used V.A.C. therapy.

Posterior Spinal Fusion for Scoliosis in Duchenne Muscular Dystrophy Diminishes the Rate of Respiratory Decline

To assess the rate of decline in pulmonary function in Duchenne muscular dystrophy (DMD) before and after posterior spinal fusion for scoliosis. To compare the rate of respiratory decline using percent normal forced vital capacity (%FVC) measurements before and after posterior spinal fusion. Posterior spinal fusion for scoliosis is used widely in DMD, although the long-term pulmonary effects have not been well established. Fifty-six patients were assessed. Percent forced vital capacity was the outcome parameter with data analysis using a mixed-model repeated-measures ANOVA and paired t tests. Group 1: Inclusion criteria were a diagnosis of DMD, 2 or more pulmonary function tests presurgery, and 2 or more postsurgery. Group 2: The rates of respiratory decline before and after spinal fusion for the whole study population were determined by within-subjects mixed-model regression analysis to account for the varying number of FVC studies between patients and unequal spacing between tests. Group 1: 20 patients. Mean length of time of respiratory value determination was 2.5 +/- 1.0 years presurgery and 5.6 +/- 2.8 years postsurgery. Mean rate of decline presurgery was 8.0% +/- 4.1% per year, which decreased to 3.9% +/- 1.9% per year postsurgery (paired t test = 4.58, P < 0.0001). Group 2: 56 patients. The respiratory value determinations ranged from 4 years presurgery to 8 years postsurgery. The rates of respiratory decline based on the whole study population were 4% per year presurgery, which decreased to 1.75% per year postsurgery (F-test comparison of slopes = 19.71, P < 0.0001). Posterior spinal fusion for scoliosis in DMD is associated with a significant decrease in the rate of respiratory decline postsurgery compared with presurgery rates.