Spinal Deformity Surgery In Patients Research Articles

Spinal deformity surgery in patients for whom blood transfusion is not an option: a single-center experience.

Spinal deformity surgery is associated with significant blood loss, often requiring the transfusion of blood and/or blood products. For patients declining blood or blood products, even in the face of life-threatening blood loss, spinal deformity surgery has been associated with high rates of morbidity and mortality. For these reasons, patients for whom blood transfusion is not an option have historically been denied spinal deformity surgery. The authors retrospectively reviewed a prospectively collected data set. All patients declining blood transfusion who underwent spinal deformity surgery at a single institution between January 2002 and September 2021 were identified. Demographics collected included age, sex, diagnosis, details of any prior surgery, and medical comorbidities. Perioperative variables included levels decompressed and instrumented, estimated blood loss, blood conservation techniques used, length of surgery, length of hospital stay, and complications from surgery. Radiographic measurements included, where appropriate, sagittal vertical axis correction, Cobb angle correction, and regional angular correction. Spinal deformity surgery was performed in 31 patients (18 male, 13 female) over 37 admissions. The median age at surgery was 41.2 years (range 10.9-70.1 years), and 64.5% had significant medical comorbidities. A median of 9 levels (range 5-16 levels) were instrumented per surgery, and the median estimated blood loss was 800 mL (range 200-3000 mL). Posterior column osteotomies were performed in all surgeries, and pedicle subtraction osteotomies in 6 cases. Multiple blood conservation techniques were used in all patients. Preoperative erythropoietin was administered prior to 23 surgeries, intraoperative cell salvage was used in all, acute normovolemic hemodilution was performed in 20, and perioperative administration of antifibrinolytic agents was performed in 28 surgeries. No allogenic blood transfusions were administered. Surgery was staged intentionally in 5 cases, and there was 1 unintended staging due to intraoperative blood loss from a vascular injury. There was 1 readmission for a pulmonary embolus. There were 2 minor postoperative complications. The median length of stay was 6 days (range 3-28 days). Deformity correction and the goals of surgery were achieved in all patients. Two patients underwent revision surgery during the follow-up period: one for pseudarthrosis and the other for proximal junctional kyphosis. With proper preoperative planning and judicious use of blood conservation techniques, spinal deformity surgery may be performed safely in patients for whom blood transfusion is not an option. The same techniques can be applied widely to the general population in order to minimize blood loss and the need for allogeneic blood transfusion.

Canadian Spine Society

# Abstract 57. Radiographic reporting in adolescent idiopathic scoliosis: Is there a discrepancy comparing radiologists’ reports and surgeons’ assessments? {#article-title-2} Cobb angle measurement is the standard method for quantification of scoliosis in adolescent idiopathic scoliosis (AIS),

Importance of physiological age in determining indications for adult spinal deformity surgery in patients over 75years of age: a propensity score matching analysis.

Physiologically, people age at different rates, which leads to a discrepancy between physiological and chronological age. Physiological age should be a priority when considering the indications for adult spinal deformity (ASD) surgery. The primary objective of this study was to determine the characteristics of the postoperative course, surgical outcomes, and complication rates to extend the healthy life expectancy of older ASD patients (≥ 75years). The secondary objective was to clarify the importance of physiological age in the surgical treatment of older ASD patients, considering frailty. A retrospective review of 109 consecutive patients aged ≥ 65years with symptomatic ASD who underwent a corrective long fusion with lateral interbody fusion from the lower thoracic spine to the pelvis from 2015 to 2019 was conducted. Patients were classified into two groups according to age (group Y [65-74years], group O [≥ 75years]) and further divided into four groups according to the ASD-frailty index score (Y-F, Y-NF, O-F, and O-NF groups). To account for potential risk factors for perioperative course characteristics, complication rates, and surgical outcomes, patients from the database were subjected to propensity score matching based on sex, BMI, and preoperative sagittal spinal alignment (C7 sagittal vertical axis, pelvic incidence-lumbar lordosis, and pelvic tilt). Clinical outcomes were evaluated 2years postoperatively, using three patient-reported outcome measures of health-related quality of life: the Oswestry Disability Index, Scoliosis Research Society questionnaire (SRS-22), and Short Form 36 (SF-36). Additionally, the postoperative time-to-first ambulation, as well as minor, major, and mechanical complications, were evaluated. In the comparison between Y and O groups, patients in group O were at a higher risk of minor complications (delirium and urinary tract infection). In contrast, other surgical outcomes of group O were comparable to those of group Y, except for SRS-22 (satisfaction) and time to ambulation after surgery, with better outcomes in Group O. Patients in the O-NF group had better postoperative outcomes (time to ambulation after surgery, SRS-22 (function, self-image, satisfaction), SF-36 [PCS]) than those in the Y-F group. Older age warrants monitoring of minor complications in the postoperative management of patients. However, the outcomes of ASD surgery depended more on frailty than on chronological age. Older ASD patients without frailty might tolerate corrective surgery and have satisfactory outcomes when minimally invasive techniques are used. Physiological age is more important than chronological age when determining the indications for surgery in older patients with ASD.

Marfan syndrome and adolescent idiopathic scoliosis patients have similar 90-day postoperative outcomes and 5-year reoperation rates after spinal deformity surgery.

Outcomes after spinal deformity surgery in patients with Marfan syndrome (MFS) are poorly characterized given the rarity of the condition. Updated analyses from nationally representative samples, and comparison to outcomes after more commonly performed procedures for conditions such as adolescent idiopathic scoliosis (AIS) could help define the relative risks. Using the 2010-2020 PearlDiver administrative databases, patients who underwent posterior spinal fusion for > 7 segments were extracted. MFS patients were matched 1:4 to AIS patients based on age, sex, and Elixhauer comorbidity index (ECI). Ninety-day outcomes and 5-year reoperation rates were compared. Significance was set at p < 0.05. In total, 206 MFS patients were matched to 825 AIS patients. After adjusting for age, sex, and ECI, multivariate odds ratios (OR) for 90-day any, serious, and minor adverse events, as well as readmissions, were not significantly different for those with MFS compared to those with AIS (p > 0.05 for each). Five-year reoperation rates were also not significantly different (13.1% for the MFS cohort and 13.0% for the AIS cohort (no difference by log-rank, p = 0.9). While deformity surgery is much less commonly performed for MFS than AIS, it is not uncommonly considered for patients with this condition. Despite some known technical challenges for MFS deformity surgery, the current study leveraged a large, national database to find that 90-day adverse events and 5-year reoperations were not different for matched MFS and AIS patients undergoing deformity surgery. For select patients, these findings should be useful for surgical planning and patient counseling.

Safe and effective performance of pediatric spinal deformity surgery in patients unwilling to accept blood transfusion: a clinical study and review of literature

BackgroundPediatric deformity surgery traditionally involves major blood loss. Patients refusing blood transfusion add extra clinical and medicolegal challenges; specifically the Jehovah’s witnesses population. The objective of this study is to review the safety and effectiveness of blood conservation techniques in patients undergoing pediatric spine deformity surgery who refuse blood transfusion.MethodsAfter obtaining institutional review board approval, we retrospectively reviewed 20 consecutive patients who underwent spinal deformity surgery and refused blood transfusion at a single institution between 2014 and 2018. We collected pertinent preoperative, intraoperative and most recent clinical and radiological data with latest follow-up (minimum two-year follow-up).ResultsTwenty patients (13 females) with a mean age of 14.1 years were identified. The type of scoliotic deformities were adolescent idiopathic (14), juvenile idiopathic (1), neuromuscular (3) and congenital (2). The major coronal Cobb angle was corrected from 55.4° to 11.2° (80% correction, p < 0.001) at the latest follow-up. A mean of 11.4 levels were fused and 5.6 levels of Pontes osteotomies were performed. One patient underwent L1 hemivertebra resection and three patients had fusion to pelvis. Estimated blood loss, percent estimated blood volume loss, and cell saver returned averaged 307.9 mL, 8.5%, and 80 mL, respectively. Average operative time was 214 min. The average drop in hemoglobin after surgery was 2.9 g/dL. The length of hospital stay averaged 5.1 days. There were no intraoperative complications. Three postoperative complications were identified, none related to their refusal of transfusion. One patient had in-hospital respiratory complication, one patient developed a late infection, and one patient developed asymptomatic radiographic distal junctional kyphosis.ConclusionsBlood conservation techniques allow for safe and effective spine deformity surgery in pediatric patients refusing blood transfusion without major anesthetic or medical complications, when performed by an experienced multidisciplinary team.Level of evidenceLevel IV.

Canadian Spine SocietyPresentation CPSS1: Spinal insufficiency fracture in the geriatric pediatric spinePresentation CPSS2: The clinical significance of tether breakages in anterior vertebral body growth modulation: a 2-year postoperative analysisPresentation CPSS3: Anterior vertebral body growth modulation for idiopathic scoliosis: early, mid-term and late complicationsPresentation CPSS4: Ovine model of congenital chest wall and spine deformity with alterations of respiratory mechanics: follow-up from

Canadian Spine SocietyPresentation CPSS1: Spinal insufficiency fracture in the geriatric pediatric spinePresentation CPSS2: The clinical significance of tether breakages in anterior vertebral body growth modulation: a 2-year postoperative analysisPresentation CPSS3: Anterior vertebral body growth modulation for idiopathic scoliosis: early, mid-term and late complicationsPresentation CPSS4: Ovine model of congenital chest wall and spine deformity with alterations of respiratory mechanics: follow-up from

Adult Spinal Deformity Surgery in Patients With Movement Disorders: A Propensity-matched Analysis of Outcomes and Cost.

This was a retrospective study using national administrative data from the MarketScan database. To investigate the complication rates, quality outcomes, and costs in a nationwide cohort of patients with movement disorders (MD) who undergo spinal deformity surgery. Patients with MD often present with spinal deformities, but their tolerance for surgical intervention is unknown. The MarketScan administrative claims database was queried to identify adult patients with MD who underwent spinal deformity surgery. A propensity-score match was conducted to create two uniform cohorts and mitigate interpopulation confounders. Perioperative complication rates, 90-day postoperative outcomes, and total costs were compared between patients with MD and controls. A total of 316 patients with MD (1.7%) were identified from the 18,970 undergoing spinal deformity surgery. The complication rate for MD patients was 44.6% and for the controls 35.6% (P = 0.009). The two most common perioperative complications were more likely to occur in MD patients, acute-posthemorrhagic anemia (26.9% vs. 20.8%, P < 0.05) and deficiency anemia (15.5% vs. 8.5%, P < 0.05). At 90 days, MD patients were more likely to be readmitted (17.4% vs. 13.2%, P < 0.05) and have a higher total cost ($94,672 vs. $85,190, P < 0.05). After propensity-score match, the overall complication rate remained higher in the MD group (44.6% vs. 37.6%, P < 0.05). 90-day readmissions and costs also remained significantly higher in the MD cohort. Multivariate modeling revealed MD was an independent predictor of postoperative complication and inpatient readmission. Subgroup analysis revealed that Parkinson disease was an independent predictor of inpatient readmission, reoperation, and increased length of stay. Patients with MD who undergo spinal deformity surgery may be at risk of higher rate of perioperative complications and 90-day readmissions compared with patients without these disorders. 3.

Spinal fusion in children with osteogenesis imperfecta: A nationwide retrospective comparative cohort study over a 12-year period

Background: Osteogenesis imperfecta (OI) is an uncommon disorder frequently associated with spinal deformity. Relatively little is known about the effect this disorder has on the outcomes of spinal fusion for spinal deformity. The purpose of this study was to evaluate the differences in treatment and outcomes of this unique patient population. Methods: The nationwide HCUP Kids’ Inpatient Database (KID) from 2000 to 2012 was queried to identify patients with OI who underwent spinal fusion surgery for treatment of scoliosis. Demographic variables were obtained along with length of stay, mortality, length of fusion, transfusion rates, and hospital charges. Control data consisting of pediatric patients who underwent spinal fusion for adolescent idiopathic scoliosis (AIS) were acquired and compared. Results: A total of 60 patients (average age of 13.2 yr) with OI underwent spinal fusion during the study period. Of the patients who underwent fusions, 63.3% had involvement of nine or more vertebrae, which was significantly higher than patients with AIS (35.7%: P&lt;0.001). Patients with OI also had a higher average length of stay (8.1 vs. 5.7 days: P&lt;0.001). Nearly half of the patients with OI required blood transfusions, which was significantly more than patients with AIS (43.3% vs. 30.4%; P=0.029). Patients with OI also experienced significantly higher hospital charges versus controls ($173,652 vs. $46,953; P&lt;0.0001). Conclusions: Spinal deformity surgery in patients with OI is a technically demanding procedure with high morbidity and high cost. In this nationwide series, a higher rate of blood transfusions, longer hospital stays, and significantly higher hospital charges were identified compared to patients with AIS. Level of Evidence: Level III, Retrospective comparative cohort study

Validation of a previously published risk severity score predicting surgical site infection after spinal deformity surgery in patients with cerebral palsy utilizing a large, separate cohort

Validation of a previously published risk severity score predicting surgical site infection after spinal deformity surgery in patients with cerebral palsy utilizing a large, separate cohort

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P77. Adult spinal deformity surgery in patients 75years and older: how do the outcomes compare with younger patients?

BACKGROUND CONTEXT Up to 68% of the elderly population has spinal deformity which is a growing concern given that average lifespan is increasing. Adult spinal deformity surgeries are generally very taxing and come with significant morbidity. It is of interest to see how adult spinal surgery outcomes compare between the age groups of 65-74.9 and 75+ years of age. PURPOSE Compare outcomes and complications between 65-74.9 and 75+ year olds undergoing surgery for spinal deformity. STUDY DESIGN/SETTING Retrospective study of a prospectively collected database at one center. PATIENT SAMPLE All patients 65years and older who underwent deformity surgery of the thoracolumbar spine with a minimum of 24 months' follow-up (range 25–186 months). OUTCOME MEASURES Visual Analog Scale (VAS) and Oswestry Disability Index (ODI), radiographic outcomes, postoperative complications and need for additional surgery. METHODS Patients were divided based on age into 65-74.9 or 75+ groups. Radiographic parameters were measured preop, postop, and at 2years. VAS and ODI were collected preop, 1 year, and 2years. Comorbidities included were based on the Charlson Comorbidity Index (CCI) and compared to the incidence of complications and need for further surgery. RESULTS A total of 176 patients were included in this study. A total of 130 were aged 65-74.9 and 46 were older than 75. Average follow-up was 69.1 months (25–186 months). No demographic differences other than age and BMI (65–74.9:BMI 27.3, 75+:BMI 23.0, p=.003) were of significance. Both age groups had improvements in their radiographic parameters postop which was maintained at 2years except that there was an overall increase in thoracic kyphosis. In the 65-74.9 group, 47.9% with 0-2 comorbidities had a complication whereas 54.5% with ≥3 comorbidities had a complication. In the 0-2 group, 37.8% required additional surgery compared to 45.5% in the ≥3 comorbidities group. In the 75+ group 61.9% with 0-2 comorbidities had a complication whereas 50.0% with ≥3 comorbidities had a complication. In the 0-2 group, 38.1% required additional surgery compared to 50.0% in the ≥3 comorbidities group. Comparing the different age groups with similar comorbidity burden in regards to complications and need for additional surgery yielded no statistically significant difference between groups. The 65-74.9 group had a 2.6 decrease in their VAS at 2years whereas the 75+ group had a 2.5 decrease. A 15.4 improvement in the preop ODI was seen at 2years in the 65-74.9 group whereas the 75+ group also had a 15.4 improvement. The preop and 2-year VAS and ODI scores were not found to have a statistically significant difference between groups. CONCLUSIONS Analysis of our study population indicates that there is not a statistically significant difference between the outcomes and complications of deformity surgery in patients 75 years and older when compared to a younger elderly population. It also does not appear that a ≥3 comorbidity burden has a significant impact on the complications or need for additional surgery in our elderly spinal deformity surgery population.

Surgical Correction of Scoliosis in Patients With Duchenne Muscular Dystrophy: 30-Year Experience.

The natural history of scoliosis in Duchenne muscular dystrophy (DMD) is progressive and debilitating if neglected. The purpose of this study was to evaluate outcomes related to spinal deformity surgery in patients with DMD over a 30-year period. This was a single center retrospective study of all operatively treated scoliosis in DMD patients over 30 years. Minimum follow-up was 2 years. Owing to changes in instrumentation over time, patients were divided into 2 groups: Luque or pedicle screws (PS) constructs. Radiographic, perioperative variables, pulmonary function test (preoperatively and postoperatively), and complication data were evaluated. There were 60 subjects (Luque: 47, PS: 13). The Luque group was on average 13 years old, 53 kg, and had 7 years of follow-up. Coronal Cobb was 31±12 degrees preoperatively, 16±11 degrees at first postoperatively, and 21±15 degrees at final follow-up (P≤0.001). Pelvic obliquity was 7±6 degrees preoperatively, 5±5 degrees at first postoperatively (P=0.43), and 5±4 degrees at final follow-up (P=0.77). The majority of this group was fused to L5 (45%) or the sacrum (49%). The PS group was on average 14 years old, 65 kg, and had 4 years of follow-up. Coronal Cobb was 43±19 degrees preoperatively, 12±9 degrees at first postoperatively (P≤0.001), and 12±8 degrees at final follow-up. Pelvic obliquity was 6±5 degrees preoperatively, 3±3 degrees at first postoperatively (P=0.06), and 2±2 degrees at final follow-up (P=0.053). The majority were fused to the pelvis (92%). Both groups' pulmonary function declined with time. Both groups had high complication rates (Luque 68%; PS group 54%). The Luque group had more implant-related complications (26%); the PS group had a higher rate of early postoperative infections (23%). Over a 30-year period of operative treatment of scoliosis in DMD, both PS constructs and Luque instrumentation improved coronal Cobb. The PS group had improved and maintained pelvic obliquity. Both groups had high complication rates. Level IV-therapeutic.

Inpatient morbidity after spinal deformity surgery in patients with movement disorders.

To investigate the inpatient perioperative morbidity rate of patients with movement disorders (MD) after spinal deformity surgery. The Nationwide Inpatient Sample database from 2002 to 2011 was queried to identify adult patients with MD who underwent spinal deformity surgery. Complication rates were compared between patients with MD and controls. A multiple logistic regression analysis was conducted to assess the effect of MD on outcome. A total of 365 patients with MD (3.3%) were identified among 11,043 patients undergoing surgery for spinal deformity. Patients with MD were on average 8 years older than the control group (67 vs. 59 years of age, P<0.001). The complication rate was 55.1% for patients with MD and 43.7% for patients without MD (P<0.001). The most common complication was acute post-hemorrhagic anemia, which occurred in 31.9% of all patients (41.6% in MD patients and 31.5% in the control group, P<0.001). Other complications that were more common in patients with MD included delirium (P<0.001), acute kidney injury (P=0.032), and pulmonary embolism (P=0.014). After controlling for patient age, sex, osteoporosis, complex procedures, fusion to the lumbosacral spine, use of bone morphogenetic protein, and use of blood transfusion, patients with MD were 1.3 times more likely to develop a complication compared to patients without MD [odds ratio (OR), 1.27; 95% confidence interval (CI), 1.02-1.59; P=0.032] on multiple logistic regression analysis. No significant difference in hospital stay was observed. Patients with MD who undergo spinal deformity surgery may be at risk of higher rate of complications compared to patients without these disorders.

Acute Complications After Adult Spinal Deformity Surgery in Patients Aged 70 Years and Older

This report is a retrospective case series that examined the acute complications of patients aged 70 years and older undergoing spinal deformity surgery that required fusion of at least 6 levels. To determine the acute complications that patients in the eighth decade of their life experience after spinal reconstructive surgery, and how these complication rates compare with other patient populations undergoing similar procedures. As the mean age of the United States population rises, more older patients with painful spinal deformities can be expected. Although there are similar studies in the literature examining acute complications of patients undergoing major spinal deformity surgery, the complication rates of this unique patient population have not been adequately studied. Twenty patients had complete medical records with at least 6 months of follow-up. All the 20 patients underwent instrumented posterior spinal fusions performed by the same surgeon. Comorbidities, weighted comorbidity index, duration, number of hospital days, estimated blood loss, intensive care unit days, American Society of Anesthesiologist score, and intraoperative and postoperative complications were recorded. The mean age of our patient cohort was 76.6 years (range, 70-84 y). Patients had an average of 4 comorbidities and an American Society of Anesthesiologist score of 2.7. Although the group of patients had a large number of comorbidities, their weighted comorbidity index, according to Charlson and colleagues, was fairly low at 1.05 (range, 0-4). All of the patients were fused at least 6 levels, with the average being 10.75 (range, 6-15). Ninety-five percent of patients experienced a complication of some type. Nine major complications occurred in 7 patients. Spinal deformity surgery in patients at any age has associated risks. These risks are believed to increase with age and the complexity of the procedure. Our results show that, although the risks of major complications are significant, the risk is not greater than in a younger population undergoing the similar procedures. We feel that age alone should not be a contraindication for patients in their eighth decade of life who are incapacitated by their painful spinal deformity.

Risk factors for revision surgery following primary adult spinal deformity surgery in patients 65 years and older.

OBJECTIVE Surgical correction of adult spinal deformity (ASD) is a complex undertaking with high revision rates. The elderly population is poorly studied with regard to revision surgery, yet senior citizens constitute a rapidly expanding surgical demographic. Previous studies aimed at elucidating appropriate risk factors for revision surgery have been limited by small cohort sizes. The purpose of this study was to assess factors that modify the risk of revision surgery in elderly patients with ASD. METHODS The PearlDiver database (2005-2012) was used to determine revision rates in elderly ASD patients treated with a primary thoracolumbar posterolateral fusion of 8 or more levels. Analyzed risk factors included demographics, comorbid conditions, and surgical factors. Significant univariate predictors were further analyzed with multivariate analysis. The causes of revision at each year of follow-up were determined. RESULTS A total of 2293 patients who had been treated with posterolateral fusion of 8 or more levels were identified. At the 1-year follow-up, 241 (10.5%) patients had been treated with revision surgery, while 424 (18.5%) had revision surgery within 5 years. On univariate analysis, obesity was found to be a significant predictor of revision surgery at 1 year, while bone morphogenetic protein (BMP) use was found to significantly decrease revision surgery at 4 and 5 years of followup. Diabetes mellitus, osteoporosis, and smoking history were all significant univariate predictors of increased revision risk at multiple years of follow-up. Multivariate analysis at 5 years of follow-up revealed that osteoporosis (OR 1.98, 95% CI 1.60-2.46, p < 0.0001) and BMP use (OR 0.70, 95% CI 0.56-0.88, p = 0.002) were significantly associated with an increased and decreased revision risk, respectively. Smoking history trended toward significance (OR 1.37, 95% CI 1.10-1.70, p = 0.005). Instrument failure was consistently the most commonly cited reason for revision. Five years following surgery, it was estimated that the cohort had 68.8% survivorship. CONCLUSIONS For elderly patients with ASD, osteoporosis increases the risk of revision surgery, while BMP use decreases the risk. Other comorbidities were not found to be significant predictors of long-term revision rates. It is expected that within 5 years following the index procedure, over 30% of patients will require revision surgery.

Acute Intraoperative Ventriculoperitoneal Shunt Failure in a Child with Myelomeningocele: A Case Report.

Spinal deformity surgery in patients with myelomeningocele carries a high rate of complications, including wound infection and fusion pseudarthrosis1,2. Most patients with myelomeningocele have a ventriculoperitoneal (VP) shunt with the potential for malfunction either during surgery or in the immediate postoperative period3. Death from shunt malfunction in the early postoperative period also can occur1. In this report, we present a patient with myelomeningocele and severe spinal deformity whose initial spinal surgery was aborted secondary to acute VP shunt malfunction. Subsequent spinal surgery was completed with the aid of continuous intracranial pressure (ICP) monitoring with use of an external shunt tap. The importance of recognizing this potentially lethal complication and a suggested management protocol are presented. The patient and his family were informed that data concerning the case would be submitted for publication, and they provided consent. A fifteen-year-old boy with a thoracic-level myelomeningocele presented to our institution with a severe scoliosis measuring 120° (Figs. 1-A and 1-B). A VP shunt that had been placed at birth had never required any shunt revisions. A preoperative neurosurgical evaluation, including a stable head computed tomography (CT) scan, revealed no evidence of shunt malfunction. He was scheduled for a spinal fusion from T2 to the pelvis in a planned two-stage surgical approach. Stage one included a halo ring application, exposure of the posterior spine with placement of spinal anchors, and multiple Ponte osteotomies (bilateral excision of facets and removal of the ligamentum flavum to improve spinal flexibility), followed by six weeks of halo-gravity traction. Stage two consisted of an apical vertebral column resection as well as completion of the posterior spinal fusion and instrumentation. Fig. 1-A Fig. 1-B Anteroposterior ( Fig. 1-A ) and lateral supine ( Fig. 1-B ) radiographs of a fifteen-year-old boy with myelomeningocele. He has severe scoliosis measuring 120°, thoracolumbar …

Morbidity and mortality after spinal deformity surgery in patients 75 years and older: complications and predictive factors

As the population continues to age, relatively older geriatric patients will present more frequently with complex spinal deformities that may require surgical intervention. To the authors' knowledge, no study has analyzed factors predictive of complications after major spinal deformity surgery in the very elderly (75 years and older). The authors' objective was to determine the rate of minor and major complications and predictive factors in patients 75 years of age and older who underwent major spinal deformity surgery requiring a minimum 5-level arthrodesis procedure. Twenty-one patients who were 75 years of age or older and underwent thoracic and/or lumbar fixation and arthrodesis across 5 or more levels for spinal deformity were analyzed retrospectively. The medical and surgical records were reviewed in detail. Age, diagnosis, comorbidities, operative data, hospital data, major and minor complications, and deaths were recorded. Factors predictive of perioperative complications were identified by logistic regression analysis. The mean patient age was 77 years old (range 75-83 years). There were 14 women and 7 men. The mean follow-up was 41.2 months (range 24-81 months). Fifteen patients (71%) had at least 1 comorbidity. A mean of 10.5 levels were fused (range 5-15 levels). Thirteen patients (62%) had at least 1 perioperative complication, and 8 (38%) had at least one major complication for a total of 17 complications. There were no perioperative deaths. Increasing age was predictive of any perioperative complication (p = 0.03). However, major complications were not predicted by age or comorbidities as a whole. In a subset analysis of comorbidities, only hypertension was predictive of a major complication (OR 10, 95% CI 1.3-78; p = 0.02). Long-term postoperative complications occurred in 11 patients (52%), and revision fusion surgery was necessary in 3 (14%). Patients 75 years and older undergoing major spinal deformity surgery have an overall perioperative complication rate of 62%, with older age increasing the likelihood of a complication, and a long-term postoperative complication rate of 52%. Patients in this age group with a history of hypertension are 10 times more likely to incur a major perioperative complication. However, the mortality risk for these patients is not increased.

Surgical correction of spinal deformity in patients with congenital muscular dystrophy

BackgroundCongenital muscular dystrophy (CMD), among the myopathic disorders is one form of flaccid neuromuscular disorder (NMD). Patients with NMD frequently develop progressive spinal deformity. For NMD patients who have a severe spinal deformity, sitting is often difficult and is accompanied by pain and breakdown of the skin. Spinal deformity surgery in these patients has been highly effective in stabilizing the spine, maintaining upright, comfortable sitting balance, and improving patients’ quality of life. However, many studies have reported significant rates of peri/postoperative complications in these patients. To our knowledge, there has been no study on the results of spinal deformity surgery in patients with CMD. The purpose of this study was to review the clinical and radiological results of spinal deformity surgery in this group of patients with CMD. MethodsBetween 2004 and 2007, a total of 10 CMD patients underwent scoliosis surgery. There were three patients with Fukuyama CMD, three with Ullrich CMD, and 4 with nonsyndromic CMD (merosin-negative). They were nonambulatory. All the patients had standard posterior spinal fusion and pedicle-screw-alone fixation from T3 or T4 to L5 for spinal deformity. Our inclusion criteria required that each patient (1) had considerable difficulty with sitting balance and pain or breakdown of the skin due to scoliosis; (2) was able to ventilate his or her lung autonomously; (3) was not ventilator-dependent; and (4) did not have cardiac failure. Sufficient informed consent was important, and the decision to perform surgery was made by the patient/family with sufficient preoperative informed consent. Patients were trained with inspiratory muscle training (IMT) using an inspiratory muscle trainer (Threshold IMT) for 6 weeks prior to surgery Cardiac function was assessed preoperatively. Pulmonary function tests were performed preoperatively and postoperatively. Radiographic assessments were performed on sitting anteroposterior (AP) and lateral radiographs. These assessments were made periodically. The Cobb angles of the curves and spinal pelvic obliquity (SPO) on the coronal plane, thoracic kyphosis, and lumbar lordosis were measured. The preoperative AP radiograph and side-bending films were examined to determine flexibility. Patients’ and parents’ satisfaction were surveyed by a self-completed questionnaire at the last follow-up. ResultsPercent forced vital capacity (%FVC) increased from a mean of 30% before IMT to a mean of 34% the day before surgery. The preoperative scoliosis was 75° (range 61°–95°). The scoliotic curvature on preoperative side-bending films was 19° (range 11°–28°). All patients were extubated on the day of surgery. No patients developed cardiac or respiratory complications. The scoliotic curvature was 18° (range 10°–25°) immediately after surgery, and 19° (range 12°–27°) at the last follow-up. The pelvic obliquity improved from a mean of 17° (range 14°–20°) preoperatively to a mean of 6° (range 4°–9°) postoperatively and to 7° (range 4°–10°) at the last follow-up. Balanced sitting posture was achieved and maintained. On the sagittal plane, good reconstruction of sagittal plane alignment was recreated and maintained. There were no major complications or deaths. All patients/parents completed the outcome satisfaction questionnaire. Eight patients/parents were very satisfied and two were satisfied. ConclusionsPedicle-screw-alone fixation and fusion to L5 was safe and effective in CMD patients with scoliosis of <95° and pelvic obliquity of <20°. Scoliosis curves were flexible (75% correction) on side-bending films preoperatively. Curve correction and maintenance of correction in the coronal and sagittal plane was excellent. The pelvic obliquity significantly improved. Balanced sitting posture was achieved and maintained in all patients. Our patients with CMD spinal deformity and a moderately and severely decreased FVC could be operated on safely and successfully with general anesthesia. All patients were extubated in the operating room. There were no major complications or deaths. We believe a FVC of <30% alone is not a predisposition to pulmonary complications. However, cardiomyopathy might be a determining risk of mortality, and we believe surgery for these patients should be avoided. Patients’ and parents’ satisfaction was high.