Scoliosis Research Society Morbidity Research Articles

Comparative Analysis of Early Outcomes and Complications of PSO Among Neurosurgeons and Orthopedic Surgeons.

Retrospective comparative cohort study using the National Surgical Quality Improvement Program. The aim of this study was to evaluate trends in the annual number of PSOs performed, describe the patient populations associated with each cohort, and compare outcomes between specialties.Summary of Background Data:Pedicle subtraction osteotomies (PSO) are complex and advanced spine deformity surgical procedures performed by neurosurgeons and orthopedic surgeons. Though both sets of surgeons can be equally qualified and credentialed to perform a PSO, it is possible that differences in training and exposure could translate into differences in patient management and outcomes. Patients that underwent lumbar PSO from 2005 to 2014 in the American College of Surgeons-National Surgical Quality Improvement Program registry were identified. Relevant demographic, preoperative comorbidity, and postoperative 30-day complications were queried and analyzed. The data was divided into 2 cohorts consisting of those patients who were treated by neurosurgeons versus orthopedic surgeons. Additional data from the Scoliosis Research Society Morbidity and Mortality database was queried and analyzed for comparison. Demographic and comorbidity factors were similar between the neurosurgery and orthopedic surgery cohorts, except there were higher rates of hypertension among orthopedic surgeon-performed PSOs (65.66% vs. 48.67%, P =0.004). Except for 2012, in every year queried, orthopedic surgeons reported more PSOs than neurosurgeons. In patients who underwent lumbar fusion surgery, there was a higher rate of PSOs if the surgery was performed by an orthopedic surgeon (OR 1.7824, 95% CI: 1.4017-2.2665). The incidence of deep vein thrombosis after PSOs was higher for neurosurgery compared with orthopedic surgery (8.85% vs. 1.20%, P =0.004). However, besides deep vein thrombosis, there were no salient differences in surgical complication rates between neurosurgeon-performed PSOs and orthopedic surgeon-performed PSOs. The number of PSO procedures performed by neurosurgeons and orthopedic surgeons has increased annually. Differences in outcomes between neurosurgeons and orthopedic surgeons suggest an opportunity for wider assessment and alignment of adult spinal deformity surgery exposure and training across specialties.

131. Risk factors that decrease complete recovery in idiopathic scoliosis surgery associated neurological injuries

<h3>BACKGROUND CONTEXT</h3> Neurological injuries (NI) are devastating complications of idiopathic scoliosis (IS) surgeries. The risk factors for these injuries have been well studied in the literature. However, the prognosis and the factors that impact the prognosis of NIs have been poorly studied. <h3>PURPOSE</h3> The purpose of this study was to summarize the prognosis of the documented 8-year NIs associated with IS surgeries from the Scoliosis Research Society Morbidity and Mortality (SRS M&M) database. <h3>STUDY DESIGN/SETTING</h3> Retrospective study conducted querying the SRS M&M database between 2009 and 2017 for idiopathic scoliosis population who had perioperative neurological deficits from scoliosis surgery. <h3>PATIENT SAMPLE</h3> n= 418; males (n=93; 22.4%), females (n=322, 77.6%), 3 unknown. <h3>OUTCOME MEASURES</h3> To determine the risk factors that decrease the complete recovery of neurological injuries. <h3>Methods</h3> Analyses were made to compare the correlation between the extent of neurological recovery (complete, partial and no change) and time of event occurrence (intraoperative, acute postoperative (<24hrs) and delayed postoperative >24hrs), intraoperative neurophysiological monitoring (IONM) used (yes/no), intra- and postoperative hypotension (yes/no), type of neurological injury (cord, root or both), type of cord injury (complete or incomplete). Chi-square and ANOVA tests were used for analyses. <h3>Results</h3> Data showed: EOIS (n=30), adolescent IS (n=244) and adult IS (n=144); average estimated blood loss, 1.9L; and average follow-up: 180 days. Intraoperative neuromonitoring (IONM) was used in 351 (84%), intraoperative hypotension observed in 73 (18%), and postoperative hypotension observed in 32 (8%). The majority of the NIs were intraoperative 168 (40.2%); postoperative (<24hrs.) 159 (38%); delayed (> 24 hrs) 91 (21.8%). Incomplete cord injuries were 178 (47.7%), complete cord injuries 53 (14.2%), root injuries 142 (38.1%) and no information for 45 patients. Injury level noticed at: cervical=20 (4.8%); thoracic=181 (43.3%), lumbar=187 (44.7%), sacrum=5 (1.2%) and unknown in 25 (6.0%) patients. Complete recovery was noticed in 269 patients (64.4%), partial recovery in 125 patients (29.9%), no recovery in 24 patients (5.7%). Average follow-up length was no different among recovery types: complete=190 days; partial=174 days; and no change=174 days, p=0.35. Complete NI recovery rate was significantly lower for adult IS patients (n= 67, 46.5%) vs EOIS (n=24, 80%) and AIS (n=178, 73%), (p<0.001). There was a significant increase in no recovery NIs status rates for complete cord injuries (n=13, 24.5%) vs incomplete cord (n=4, 2.2%) and root injuries (n=4, 2.8%), p<0.001), IONM abnormalities decreased complete recovery rates for intraoperative NIs (n=4, 33% vs n=109, (76.8%), p=0.001. There was a trend toward lower complete recovery rates in patients who did not use IONM for intraoperative NIs (p=0.06). <h3>Conclusions</h3> Lower complete NI recovery rates were observed in adult IS patients. Complete cord injuries reduced NIs complete recovery rate. IONM signal abnormalities have a potential effect on intraoperative NI prognosis, but not on postoperative or delayed NI prognosis. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Complications following surgery for adolescent idiopathic scoliosis over a 13-year period.

The purpose of this study was to evaluate the incidence and analyze the trends of surgeon-reported complications following surgery for adolescent idiopathic scoliosis (AIS) over a 13-year period from the Scoliosis Research Society (SRS) Morbidity and Mortality database. All patients with AIS between ten and 18 years of age, entered into the SRS Morbidity and Mortality database between 2004 and 2016, were analyzed. All perioperative complications were evaluated for correlations with associated factors. Complication trends were analyzed by comparing the cohorts between 2004 to 2007 and 2013 to 2016. Between 2004 and 2016, a total of 84,320 patients were entered into the database. There were 1,268 patients associated with complications, giving an overall complication rate of 1.5%. Death occurred in 12 patients (0.014%). The three most commonly reported complications were surgical site infection (SSI) (441 patients; 0.52%), new neurological deficit (293; 0.35%), and implant-related complications (172; 0.20%). There was a statistically significant but weak correlation between the occurrence of a SSI and the magnitude of the primary curve (r = 0.227; p < 0.001), and blood loss in surgery (r = 0.111; p = 0.038), while the occurrence of a new neurological deficit was correlated statistically significantly but weakly with age at surgery (r = 0.147; p = 0.004) and magnitude of the primary curve (r = 0.258; p < 0.001). The overall complication rate decreased from 4.95% during 2004 to 2007 to 0.98% during 2013 to 2016 (p = 0.023). An overall complication rate of 1.5% was found in our series after surgery for AIS, with a reduction of complication rates found in the second period of the analysis. Cite this article: Bone Joint J 2020;102-B(4):519-523.

Instrumentation complication rates following spine surgery: a report from the Scoliosis Research Society (SRS) morbidity and mortality database.

Objective of this study is to evaluate demographics, risk factors, and incidence of instrumentation related complications (IRC) in spinal surgeries from 2009-2012. The Scoliosis Research Society (SRS) morbidity and mortality (M&M) database has tremendous value in orthopaedic surgery. SRS gathers surgeon-reported complications, including instrumentation failure, visual complications, neurological deficits, infections, and death. Limited literature exists on the incidence of perioperative instrumentation complications in deformity surgery. We utilized the SRS database to evaluate demographics, risk factors, and incidence of IRC in spinal surgeries from 2009-2012. The SRS M&M database was queried for IRC in patients undergoing surgery for scoliosis, spondylolisthesis, and kyphosis from 2009-2012. Demographics, comorbidities, diagnoses, curve magnitude, and intraoperative characteristics were analyzed. Intraoperative characteristics included surgical approach, performance of fusion or osteotomy, operative times, blood loss, instrumentation used, and documented instrumentation complication. A total of 167,972 patients were identified, including 311 IRC. The overall IRC rate was 0.19% (18.5 per 10,000 patients), which decreased significantly from 2009-2012 (0.37% vs. 0.19%, P<0.001). The mean age of patients with IRC was 38.5±25.5 years. Most common comorbidities included hypertension (23.5%), pulmonary disease (13.5%), diabetes (10.6%), smoking (8.7%), and vascular disease (7.1%). IRC occurred in 206 (66.2%) patients with scoliosis, 58 (18.6%) with spondylolisthesis, and 45 (14.5%) with kyphosis. Compared to patients with spondylolisthesis, patients with kyphosis (0.27% vs. 0.11%, P<0.001) and scoliosis (0.21% vs. 0.11%, P<0.001), experienced significantly more IRC. IRC included implant failure (23.3%), migration (28.3%), and malpositioned implants (48.6%). New perioperative neurologic deficits were reported in 146 (46.9%) patients, and 84 (27%) of these implants were removed. IRC occur in approximately 18.5 per 10,000 deformity patients, with a rate significantly higher in patients with kyphosis. The potentially avoidable occurrence of implant malpositioning represents nearly 50% of these complications. Closer attention to posterior bony anatomy, improved intraoperative imaging with utilization of navigation or robotic guidance may decrease these complications.

Postoperative Surgical Site Infection After Spine Surgery: An Update From the Scoliosis Research Society (SRS) Morbidity and Mortality Database*

Retrospective review of prospectively collected data. Analyze the Scoliosis Research Society (SRS) Morbidity & Mortality (M&M) database to assess the incidence and characteristics related to postoperative surgical site infection (SSI) after spinal deformity surgery. Infections involving spinal instrumentation are associated with greater rates of disability. Rates of postoperative SSI after spinal deformity surgery range from 1.9% to 4.4%. Postoperative SSI rates of 4.2% for adult kyphosis, 2.1% for adult spondylolisthesis, and 3.7% for adult scoliosis have been reported. The SRS M&M database was evaluated to define patient demographics, perioperative factors, and infection characteristics of spinal deformity patients with postoperative spine infections after deformity surgery in2012. Of the 47,755 procedures reported to the SRS in 2012, there were 578 (1.2%) diagnosed SSIs. Infection rates for patients with kyphosis were significantly higher compared with patients with scoliosis (2.4% vs. 1.1%, p < .0001) or spondylolisthesis (2.4% vs. 1.1%, p < .0001). Spinal fusions were performed in 86.3% of patients, 75.1% of which were performed posteriorly. Osteotomies were performed in 30.1% of patients. Deep infections below the fascia accounted for 68.0% of infections. Methicillin-sensitive (41.9%) and methicillin-resistant (17.0%) Staphylococcus aureus were the most commonly isolated pathogens, whereas gram-negative bacteria accounted for 25.4% of cases. Long-term antibiotic suppression was required in 18.9% of patients, and overall complications from antibiotics occurred in 4.5% of patients. Operative treatment was required in 81.8% of SSI cases. SSIs occur in 1.2% of spine deformity patients, with a rate significantly higher in patients with kyphosis. Approximately 25% of these infections are secondary to gram-negative species. Antibiotic complications occur in 4.5% of patients being treated for SSI. Despite advancements in surgical technique and infection prophylaxis, postoperative SSI remains one of the most common complications in spinal deformity surgery. Level III.

Visual Loss Following Spine Surgery

A retrospective review of the Scoliosis Research Society (SRS) morbidity and mortality (M&M) database. The aim of this study was to investigate visual related complications in spinal deformity patients undergoing spine surgery. The SRS compiles surgeon-reported complications into an M&M database, tracking postoperative complications including visual loss, neurological deficits, infections, and death. Limited literature exists on postoperative visual complications, a rare but devastating complication following spine surgery. We utilized the SRS M&M database to determine demographics, perioperative risk factors, and prognosis for visual related complications in spinal deformity patients undergoing corrective spine surgery from 2009 to 2012. A total of 167,972 spinal deformity patients from 2009 to 2012 were identified with a visual acuity complication (VAC) rate of 0.01%, or 12.5 per 100,000 patients. VAC rates for patients with kyphosis were significantly higher than patients with scoliosis (0.049% vs. 0.010%, P = 0.002) and spondylolisthesis (0.049% vs. 0.005%, P = 0.001). Postoperative visual loss rates significantly decreased from 2010 to 2012 (0.022% vs. 0.004%, P = 0.029). Twenty-one patients identified with VACs had a mean age of 34.8 ± 24.3 years. Two (9.5%) patients had preoperative vision changes, two (9.5%) were diabetic, two (9.5%) had vascular disease, one (4.8%) had a history of thromboembolic disease, and five (23.8%) had hypertension. Extent of VAC was bilateral-partial in four (19.0%), bilateral-total in five (23.8%), unilateral-partial in eight (38.1%), and unilateral-total in three (14.3%) patients. Four (19.0%) patients developed anterior ischemic optic neuropathy, four (19.0%) had posterior ischemic optic neuropathy (PION), five (23.8%) had central retinal artery occlusion, and five (23.8%) developed cortical blindness (CB). Greater than 50% of the VACs occurred on, or before, the first postoperative day. Ten (47.6%) patients recovered complete vision and four (19.0%) improved. All patients with CB and 50% with posterior ischemic optic neuropathy experienced complete resolution. VACs occur in approximately 12.5 per 100,000 deformity patients, with a rate five times higher in patients with kyphosis. More than 50% of these complications occur within 24 hours postoperatively. Nearly half of these complications resolve completely, and another 19% improve postoperatively. 4.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P23. Trends in complications in operative adolescent and adult idiopathic scoliosis from the SRS morbidity and mortality database

BACKGROUND CONTEXT Surgical techniques in adolescent idiopathic scoliosis (AIS, age=10–18 years) and adult idiopathic scoliosis (ADS, age>18 years) surgery have evolved over the past 10years. PURPOSE To assess trends in complication rates in AIS and ADS patients from the Scoliosis Research Society (SRS) Morbidity and Mortality (MM n=63,574) and ADS (18–30 years; n=27,990) surgeries from one file. A second file contained the demographics, surgical data and types of complications data (2004–2015) of patients who had only complications. There were 1,165 AIS and 139 ADS patients with complications. Neurological deficit, blindness and death rates over 7years (2009–2015), and infection rates over 4years (2012–2015) were analyzed for both populations. In patients with complications data, we analyzed blood loss, number of levels fused, neurological recovery rate, and type of surgeries. Linear regression was used to analyze the trends of changes. P RESULTS In AIS patients (p=.02), the amount of blood loss was significantly reduced from 957 mL to 750 mL (2009–2015), and in ADS patients, blood loss was also significantly reduced (p=.02) from 1438 mL to 904 mL (2009–2015). The number of levels fused in the AIS patients (p=.02) significantly increased from 11 levels to 11.9 levels (2009–2015), and also in ADS patients (p=.04) from 10.4 levels to 12.7 levels (2009–2015). In AIS (p=.052) and ADS (p=.03) fusion levels increased significantly over 7years for Lenke type 1 curves. In the AIS population, posterior fusion rate (p=.002) significantly increased and anterior fusion rate (p=.001) significantly decreased over the 12-year analysis (2004–2015). In the ADS population, posterior fusion rate (p=.002) increased, and combined surgeries (p=.046) and anterior fusion rates (p=.035) decrease over the 12-year analysis. In the AIS population, death, blindness and neurological deficits rates were constant over the 7-year analysis (2009–2015), spinal infections rate was constant over 4years of analysis (2012–2015), neurological deficits recovery rate significantly decreased (p=.05). In ADS population, death rate was constant, blindness (p=.04) and neurological deficit (p=.04) rates significantly increased over the 7years of analysis (2009–2015), and spinal infections rate was constant from 2012–2015. CONCLUSIONS Over 12years, the amount of blood loss and anterior surgery rates significantly decreased in both populations. Posterior fusion rates and number of fused levels significantly increased in both populations. Neurological deficit and blindness rates were constant in AIS patients, but significantly increased in the ADS patients. Complications rates in ADS patients increased even with the evolution of surgical techniques compared to AIS population.

Neuromuscular scoliosis complication rates from 2004 to 2015: a report from the Scoliosis Research Society Morbidity and Mortality database.

OBJECTIVE Postoperative complications are one of the most significant concerns in surgeries of the spine, especially in higher-risk cases such as neuromuscular scoliosis. Neuromuscular scoliosis is a classification of multiple diseases affecting the neuromotor system or musculature of patients leading to severe degrees of spinal deformation, disability, and comorbidity, all likely contributing to higher rates of postoperative complications. The objective of this study was to evaluate deformity correction of patients with neuromuscular scoliosis over a 12-year period (2004-2015) by looking at changes in postsurgical complications and management. METHODS The authors queried the Scoliosis Research Society (SRS) Morbidity and Mortality (M&M) database for neuromuscular scoliosis cases from 2004 to 2015. The SRS M&M database is an international database with thousands of self-reported cases by fellowship-trained surgeons. The database has previously been validated, but reorganization in 2008 created less-robust data sets from 2008 to 2011. Consequently, the majority of analysis in this report was performed using cohorts that bookend the 12-year period (2004-2007 and 2012-2015). Of the 312 individual fields recorded per patient, demographic analysis was completed for age, sex, diagnosis, and preoperative curvature. Analysis of complications included infection, bleeding, mortality, respiratory, neurological deficit, and management practices. RESULTS From 2004 to 2015, a total of 29,019 cases of neuromuscular scoliosis were reported with 1385 complications, equating to a 6.3% complication rate when excluding the less-robust data from 2008 to 2011. This study shows a 3.5-fold decrease in overall complication rates from 2004 to 2015. A closer look at complications shows a significant decrease in wound infections (superficial and deep), respiratory complications, and implant-associated complications. The overall complication rate decreased by approximately 10% from 2004-2007 to 2012-2015. CONCLUSIONS This study demonstrates a substantial decrease in complication rates from 2004 to 2015 for patients with neuromuscular scoliosis undergoing spine surgery. Decreases in specific complications, such as surgical site infection, allow us to gauge our progress while observing how trends in management affect outcomes. Further study is needed to validate this report, but these results are encouraging, helping to reinforce efforts toward continual improvement in patient care.

A Comparative Analysis Among the SRS M&M, NIS, and KID Databases for the Adolescent Idiopathic Scoliosis

Study DesignRetrospective cohort analysis. ObjectivesA growing number of publications have utilized the Scoliosis Research Society (SRS) Morbidity and Mortality (M&M) database, but none have compared it to other large databases. The objective of this study was to compare SRS complications with those in administrative databases. Summary of Background DataThe Nationwide Inpatient Sample (NIS) and Kid's Inpatient Database (KID) captured a greater number of overall complications while the SRS M&M data provided a greater incidence of spine-related complications following adolescent idiopathic scoliosis (AIS) surgery. Chi-square was used to obtain statistical significance, with p < .05 considered significant. MethodsThe SRS 2004–2007 (9,904 patients), NIS 2004–2007 (20,441 patients) and KID 2003–2006 (10,184 patients) databases were analyzed for AIS patients who underwent fusion. Comparable variables were queried in all three databases, including patient demographics, surgical variables, and complications. ResultsPatients undergoing AIS in the SRS database were slightly older (SRS 14.4 years vs. NIS 13.8 years, p < .0001; KID 13.9 years, p < .0001) and less likely to be male (SRS 18.5% vs. NIS 26.3%, p < .0001; KID 24.8%, p < .0001). Revision surgery (SRS 3.3% vs. NIS 2.4%, p < .0001; KID 0.9%, p < .0001) and osteotomy (SRS 8% vs. NIS 2.3%, p < .0001; KID 2.4%, p < .0001) were more commonly reported in the SRS database. The SRS database reported fewer overall complications (SRS 3.9% vs. NIS 7.3%, p < .0001; KID 6.6%, p < .0001). However, when respiratory complications (SRS 0.5% vs. NIS 3.7%, p < .0001; KID 4.4%, p < .0001) were excluded, medical complication rates were similar across databases. In contrast, SRS reported higher spine-specific complication rates. Mortality rates were similar between SRS versus NIS (p = .280) and SRS versus KID (p = .08) databases. ConclusionsThere are similarities and differences between the three databases. These discrepancies are likely due to the varying data-gathering methods each organization uses to collect their morbidity data. Level of EvidenceLevel IV.

Results of the Scoliosis Research Society Morbidity and Mortality Database 2009–2012: A Report From the Morbidity and Mortality Committee

IntroductionMembers of the Scoliosis Research Society are required to annually submit complication data regarding deaths, visual acuity loss, neurological deficit and infection (2012-1st year for this measure) for all deformity operations performed. The purpose of this study is to report the 2012 results and the differences in these complications from the years 2009-2012. MethodsThe SRS M&M database is a self-reported complications registry of deformity operations performed by the members. The data from 2009-2012, inclusive, was tabulated and analyzed. Differences in frequency distribution between years were analyzed with Fisher's exact test. Significance was set at α = 0.05. ResultsThe total number of cases reported increased from 34,332 in 2009 to 47,755 in 2012. Overall mortality ranged from 0.07% in 2011 to 0.12% in 2009. The neuromuscular scoliosis group had the highest mortality rate (0.44%) in 2010. The combined groups' neurological deficit rate increased from 0.44% in 2009 to 0.79% in 2012. Neurological deficits were significantly lower in 2009 compared to 2012 for idiopathic scoliosis >18 years, other scoliosis, degenerative and isthmic spondylolisthesis and other groups. The groups with the highest neurological deficit rates were dysplastic spondylolisthesis and congenital kyphosis. There were no differences in vision loss rates between years. The overall 2012 infection rate was 1.14% with neuromuscular scoliosis having the highest group rate at 2.97%. ConclusionNeuromuscular scoliosis has the highest complication rates of mortality and infection. The neurological deficit rates of all groups combined have slightly increased from 2009 to 2012 with the highest rates consistently being in the dysplastic spondylolisthesis and congenital kyphosis groups. This could be due to a number of factors, including more rigorous reporting.

Association Between Age and Complications in Adult Scoliosis Surgery: An Analysis of the Scoliosis Research Society Morbidity and Mortality Database.

Retrospective review. To assess the relationship between age and complications, and report age-stratified complication rates for the surgical treatment of adult scoliosis. Literature examining age and complication rates for adult scoliosis surgery is conflicting. The Scoliosis Research Society (SRS) morbidity and mortality (M&M) database contains a large series of adult scoliosis patients that can be utilized to investigate this relationship. The SRS M&M database was queried from 2004 to 2007 to identify all cases of adult scoliosis. Data pertaining to patient age, complications, scoliosis, and surgery type were extracted from the database. Age-based analyses of clinical parameters were conducted using age as both a stratified categorical variable and as a continuous variable. In our cohort of 5470 adult scoliosis patients, the overall complication rate was 13.5% and there was a 0.3% mortality rate. Patients who experienced complications were significantly older than those without complications (55.9 ± 16.5 yrs vs. 51.2 ± 18.7 yrs, P < 0.001). When complications were stratified according to decade of age, there was also a statistically significant trend of increasing complication rates with each decade of life (P < 0.001). Dural tears were the most common complication in patients over 50 years, whereas implant-related complications were the most common in patients less than 50 years. There was a clear association between increasing age and higher rates of major short-term complications, a factor that ought to be taken into account during treatment decision making and patient counseling.

Association Between Surgeon Experience and Complication Rates in Adult Scoliosis Surgery: A Review of 5117 Cases From the Scoliosis Research Society Database 2004-2007.

Retrospective review of a multicenter database. To evaluate whether surgeon experience is associated with complication rates in adult spinal deformity (ASD) surgery. Multiple patient- and surgery-related factors have been shown to increase the risk of complications in ASD. No study exists evaluating surgeon experience as an associated factor with complications in ASD. The Scoliosis Research Society Morbidity and Mortality database was queried for patients older than 18 years who underwent ASD from 2004 to 2007. Patient demographics, surgical characteristics, complications, and surgeon membership status were analyzed. Two-tailed t test and χ tests were performed, with P value of less than 0.05 considered significant. A total of 5117 patients underwent ASD surgery. The average patient age was 51.8 years. Patients operated by candidate members were older than those operated by active members (53.1 vs. 51.4, P = 0.003). Active members performed 3836 (75%) cases whereas candidate members performed 1281 cases. There were 1110 (21.7%) revisions. A total of 681 (13.3%) complications were recorded, 498 (13.0%) for active and 183 (14.3%) for candidate members, respectively (P = 0.24). Mortality rate was 0.29%. Spinal cord complications accounted for 0.68% of all cases. Active members had 21 (0.55%) spinal cord complications, whereas candidates had 14 (1.1%) (P = 0.049). There were a total of 174 (3.4%) surgical site infections (SSI). Active members had 82 (2.1%) deep SSI, whereas candidate members had 36 (2.8%) deep SSI (P = 0.164). Active members had 33 (0.9%) superficial SSI whereas candidate members had 23 (1.8%) superficial SSI (P = 0.008). There was a statistically significant, 2-fold increase in the rate of spinal cord complications and superficial SSI among candidate compared with active members. Overall complication rates were similar between candidate and active members. 4.

Funnel plots and spine surgery: unit level and surgeon level outcome data

Funnel plots and spine surgery: unit level and surgeon level outcome data

Comparative Analysis of Osteotomies During Adult Spinal Fusions: A Retrospective Review of 3,990 Cases from the Scoliosis Research Society Morbidity and Mortality Database

Comparative Analysis of Osteotomies During Adult Spinal Fusions: A Retrospective Review of 3,990 Cases from the Scoliosis Research Society Morbidity and Mortality Database

Reporting Surgical Outcomes

he treatment of spinal fractures is one of the fundamental clinical competencies of neurosurgical and T orthopedic spine training. For surgeons working at tertiary referral centers, these injuries constitute a significant component of trauma calls. Traumatic spinal fractures are frequently accompanied by other visceral injuries, making their management complex at times. Spinal reconstruction is performed to decompress neural elements in an effort to maintain or improve neurologic function and alleviate pain and restore biomechanical stability to the spine when necessary. These patients often require complex medical and surgical care, and it is vital to be comfortable with the treatment of such injuries, particularly when surgery is required. In this issue of WORLD NEUROSURGERY, Williams et al. examined all surgical cases from 2004e2007 from the Scoliosis Research Society Morbidity and Mortality database. All cases of traumatic spinal fractures were identified and assessed for complication rates associated with surgical treatment. In addition, the authors evaluated cases for factors associated with the occurrence of complications. With 6706 cases, this likely represents the largest retrospective analysis of surgically treated traumatic spinal fractures in the literature.

Rates and Causes of Mortality Associated With Spine Surgery Based on 108,419 Procedures

A retrospective review of a prospectively collected database. To assess rates and causes of mortality associated with spine surgery. Despite the best of care, all surgical procedures have inherent risks of complications, including mortality. Defining these risks is important for patient counseling and quality improvement. The Scoliosis Research Society Morbidity and Mortality database was queried for spinal surgery cases complicated by death from 2004 to 2007, including pediatric (younger than 21 yr) and adult (21 yr or older) patients. Deaths occurring within 60 days and complications within 60 days of surgery that resulted in death were assessed. A total of 197 mortalities were reported among 108,419 patients (1.8 deaths per 1000 patients). Based on age, rates of death per 1000 patients for adult and pediatric patients were 2.0 and 1.3, respectively. Based on primary diagnosis (available for 107,996 patients), rates of death per 1000 patients were as follows: 0.9 for degenerative (n = 47,393), 1.8 for scoliosis (n = 26,421), 0.9 for spondylolisthesis (n = 11,421), 5.7 for fracture (n = 6706), 4.4 for kyphosis (n = 3600), and 3.3 for other (n = 12,455). The most common causes of mortality included: respiratory/pulmonary causes (n = 83), cardiac causes (n = 41), sepsis (n = 35), stroke (n = 15), and intraoperative blood loss (n = 8). Death occurred prior to hospital discharge for 109 (79%) of 138 deaths for which this information was reported. The specific postoperative day (POD) of death was reported for 94 (48%) patients and included POD 0 (n = 23), POD 1-3 (n = 17), POD 4-14 (n = 30), and POD >14 (n = 24). Increased mortality rates were associated with higher American Society of Anesthesiologists score, spinal fusion, and implants (P < 0.001). Mortality rates increased with age, ranging from 0.9 per 1000 to 34.3 per 1000 for patients aged 20 to 39 years and 90 years or older, respectively. This study provides rates and causes of mortality associated with spine surgery for a broad range of diagnoses and includes assessments for adult and pediatric patients. These findings may prove valuable for patient counseling and efforts to improve the safety of patient care.

Short-term Complications Associated With Surgery for High-Grade Spondylolisthesis in Adults and Pediatric Patients

Although it is generally agreed upon that surgery for high-grade spondylolisthesis (HGS) is associated with more complications than low-grade spondylolisthesis, its description is primarily based on case reports and relatively small case series. To assess short-term complication rates associated with the surgical treatment of HGS in pediatric and adult patients and to identify factors associated with increased complication rates. All cases of HGS from the Scoliosis Research Society Morbidity and Mortality database for the year 2007 were reviewed. Patients were classified as pediatric (≤18 years) or adult (>18 years). Complications were tabulated, and the rates were compared between the patient groups and based on clinical and surgical factors. 165 cases of HGS were reported (88 pediatric, 77 adult). There were 49 complications (29.7%) in 41 patients (24.8%), with no difference in the proportions of pediatric vs adult patients with a complication (P = .86). Occurrence of new neurological deficit after surgery was the most common complication, seen in 19 (11.5%) patients. Performance of an osteotomy was associated with a higher incidence of new neurological deficits in both adult and pediatric groups (P = .02 and P = .012, respectively). Although most of the new neurological deficits improved over follow-up, 10% had no improvement. This study provides short-term complication rates associated with surgical treatment for HGS in adult and pediatric patients and may prove valuable for patient counseling, surgical planning, and in efforts to improve the safety of patient care.

Complications in the Surgical Treatment of 19,360 Cases of Pediatric Scoliosis

Retrospective review of a multicenter database. To determine the complication rates associated with surgical treatment of pediatric scoliosis and to assess variables associated with increased complication rates. Wide variability is reported for complications associated with the operative treatment of pediatric scoliosis. Limited number of patients, surgeons, and diagnoses occur in most reports. The Scoliosis Research Society Morbidity and Mortality (M&M) database aggregates deidentified data, permitting determination of complication rates from large numbers of patients and surgeons. Cases of pediatric scoliosis (age ≤18 years), entered into the Scoliosis Research Society M&M database between 2004 and 2007, were analyzed. Age, scoliosis type, type of instrumentation used, and complications were assessed. A total of 19,360 cases fulfilled inclusion criteria. Of these, complications occurred in 1971 (10.2%) cases. Overall complication rates differed significantly among idiopathic, congenital, and neuromuscular cases (P < 0.001). Neuromuscular scoliosis had the highest rate of complications (17.9%), followed by congenital scoliosis (10.6%) and idiopathic scoliosis (6.3%). Rates of neurologic deficit also differed significantly based on the etiology of scoliosis (P < 0.001), with the highest rate among congenital cases (2.0%), followed by neuromuscular types (1.1%) and idiopathic scoliosis (0.8%). Neur-omuscular scoliosis and congenital scoliosis had the highest rates of mortality (0.3% each), followed by idiopathic scoliosis (0.02%). Higher rates of new neurologic deficits were associated with revision procedures (P < 0.001) and with the use of corrective osteotomies (P < 0.001). The rates of new neurologic deficit were significantly higher for procedures using anterior screw-only constructs (2.0%) or wire-only constructs (1.7%), compared with pedicle screw-only constructs (0.7%) (P < 0.001). In this review of a large multicenter database of surgically treated pediatric scoliosis, neuromuscular scoliosis had the highest morbidity, but relatively high complication rates occurred in all groups. These data may be useful for preoperative counseling and surgical decision-making in the treatment of pediatric scoliosis.

Rates of New Neurological Deficit Associated With Spine Surgery Based on 108,419 Procedures

Retrospective review of a prospectively collected, multicenter database. To assess rates of new neurologic deficit (NND) associated with spine surgery. NND is a potential complication of spine surgery, but previously reported rates are often limited by small sample size and single-surgeon experiences. The Scoliosis Research Society morbidity and mortality database was queried for spinal surgery cases complicated by NND from 2004 to 2007, including nerve root deficit (NRD), cauda equina deficit (CED), and spinal cord deficit (SCD). Use of neuromonitoring was assessed. Recovery was stratified as complete, partial, or none. Rates of NND were stratified based on diagnosis, age (pediatric < 21; adult ≥ 21), and surgical parameters. Of the 108,419 cases reported, NND was documented for 1064 (1.0%), including 662 NRDs, 74 CEDs, and 293 SCDs (deficit not specified for 35 cases). Rates of NND were calculated on the basis of diagnosis. Revision cases had a 41% higher rate of NND (1.25%) compared with primary cases (0.89%; P < 0.001). Pediatric cases had a 59% higher rate of NND (1.32%) compared with adult cases (0.83%; P < 0.001). The rate of NND for cases with implants was more than twice that for cases without implants (1.15% vs. 0.52%, P < 0.001). Neuromonitoring was used for 65% of cases, and for cases with new NRD, CED, and SCD, changes in neuromonitoring were reported in 11%, 8%, and 40%, respectively. The respective percentages of no recovery, partial, and complete recovery for NRD were 4.7%, 46.8%, and 47.1%, respectively; for CED were 9.6%, 45.2%, and 45.2%, respectively; and for SCD were 10.6%, 43%, and 45.7%, respectively. Our data demonstrate that, even among skilled spinal deformity surgeons, new neurologic deficits are inherent potential complications of spine surgery. These data provide general benchmark rates for NND with spine surgery as a basis for patient counseling and for ongoing efforts to improve safety of care.

Short-term Morbidity and Mortality Associated With Correction of Thoracolumbar Fixed Sagittal Plane Deformity

Retrospective review. Our objective was to assess the short-term complication rate in patients undergoing treatment of thoracolumbar fixed sagittal plane deformity (FSPD). The reported morbidity and mortality for the surgical treatment of thoracolumbar FSPD is varied and based on studies with small sample sizes. Further studies are needed to better assess FSPD complication rate, and the factors that influence it. The Scoliosis Research Society (SRS) Morbidity and Mortality Database was queried to identify cases of thoracolumbar FSPD from 2004 to 2007. Complications were analyzed based on correction technique, surgical approach, surgeon experience (SRS membership status used as a surrogate), patient age, and history of prior surgery. Five hundred and seventy-eight cases of FSPD were identified. Osteotomies were performed in 402 cases (70%), including 215 pedicle subtraction osteotomies (PSO), 135 Smith-Petersen osteotomies (SPO), 19 anterior discectomy with corpectomy procedures (ADC), 18 vertebral column resections (VCR), and 15 unspecified osteotomies. There were 170 complications (29.4%) in 132 patients. There were three deaths (0.5%). The most common complications were durotomy (5.9%), wound infection (3.8%), new neurologic deficit (3.8%), implant failure (1.7%), wound hematoma (1.6%), epidural hematoma (1.4%), and pulmonary embolism (1.0%). Procedures including an osteotomy had a higher complication rate (34.8%) than cases not including an osteotomy (17.0%, P < 0.001), and this remained significant after adjusting for the effects of patient age, surgeon experience, and history of prior surgery (P = 0.003, odds ratio = 2.070, 95% CI = 1.291-3.321). Not significantly associated with complication rate were patient age (P = 0.68), surgeon experience (P = 0.18), and history of prior surgery (P = 0.10). Complication rates were progressively higher from no osteotomy (17.0%), to SPO (28.1%), to PSO (39.1%), to VCR (61.1%). The short-term complication rate for treatment of FSPD is 29.4%. The complication rate was significantly higher in patients undergoing osteotomies, and more aggressive osteotomies were associated with progressively higher complication rates.