Spinal Fusion In Pediatric Patients Research Articles

Spinal Fusion in Pediatric Patients With Low Bone Density: Defining the Value of DXA.

Children with medical complexity are at increased risk of low bone mineral density (BMD) and complications after spinal fusion compared with idiopathic scoliosis patients. Our aim was to compare treatments and outcomes of children with medical complexity undergoing spinal fusion in those who had dual-energy x-ray absorptiometry (DXA) scans versus those who did not in an effort to standardize the workup of these patients before undergoing spinal surgery. We conducted a retrospective review of patients with low BMD who underwent spinal fusion at a tertiary care pediatric hospital between 2004 and 2016. We consulted with a pediatric endocrinologist to create standard definitions for low BMD to classify each subject. Regardless of DXA status, all patients were given a clinical diagnosis of osteoporosis [at least 2 long bone or 1 vertebral pathologic fracture(s)], osteopenia (stated on radiograph or by the physician), or clinically low bone density belonging to neither category. The last classification was used for patients whose clinicians had documented low bone density not meeting the criteria for osteoporosis or osteopenia. Fifty-nine patients met the criteria, and 314 were excluded for insufficient follow-up and/or not meeting a diagnosis definition. BMD Z -scores compare bone density ascertained by DXA to an age-matched and sex-matched average. Patients who had a DXA scan were also given a DXA diagnosis of low bone density (≤-2 SD), slightly low bone density (-1.0 to -1.9 SD), or neither (>-1.0 SD) based on the lowest BMD Z -score recorded. Fifty-nine patients were analyzed. Fifty-four percent had at least 1 DXA scan preoperatively. Eighty-one percent of DXA patients received some form of treatment compared with 52% of non-DXA patients ( P =0.03). Patients referred for DXA scans were more likely to be treated for low BMD, although there is no standardized system in place to determine which patients should get scans. Our research highlights the need to implement clinical protocols to optimize bone health preoperatively. Level II-retrospective prognostic study.

Issues With Big Data: Variability in Reported Demographics and Complications Associated With Posterior Spinal Fusion in Pediatric Patients.

Clinical and administrative registries provide large volumes of data that can be used for clinical research. However, there are several limitations relating to the quality, consistency, and generalizability of big data. In this study, we aim to compare reported demographics and certain outcomes in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS), neuromuscular scoliosis (NS), and Scheuermann kyphosis (SK) between 3 commonly utilized databases in pediatric orthopaedic research. We used International Classification of Diseases, Ninth Revision (ICD-9), International Classification of Diseases, 10th Revision (ICD-10), and Current Procedural Terminology (CPT) codes to identify patients in the National Surgical Quality Improvement Program (NSQIP), Healthcare Cost and Utilization Project (HCUP), and Pediatric Health Information System (PHIS) between the ages of 10 to 18 that underwent PSF for AIS, SK, and NS from 2012 to 2015. We compared various demographic factors, such as sex, race/ethnicity, age, and rates of postsurgical infection and 30-day readmissions. Data was analyzed with descriptive and univariate statistics. We identified 9891 patients that underwent PSF in NSQIP, 10,771 patients in PHIS, and 4335 patients in HCUP over the study period. There were significant differences in patient demographics, readmission rates, and infection rates between all patients that underwent PSF across the databases (P<0.01), as well as specifically in patients with AIS (P<0.01). HCUP had the highest proportion of Hispanic patients that underwent PSF (13.5%), as well as patients who had AIS (13.3%) or NS (17.9%). The PHIS database had the highest proportion of patients undergoing PSF for SK. Among patients with NS, there were significant differences in race across the databases (P<0.01), but no significant differences in sex, ethnicity, or readmission (P>0.05). In addition, there were significant differences in race (P=0.04) and readmission (P=0.01) across databases for patients with SK, but no differences in sex or ethnicity (P>0.05). NSQIP reported the highest rate of 30-day readmissions for patients undergoing PSF (17.9%) compared with other databases (HCUP 4.1%, PHIS 12.1%). There are significant differences in patient demographics, sample sizes, and rates of complications for pediatric patients undergoing PSF across 3 commonly utilized US administrative databases. Given the variability in reported outcomes and demographics, generalizability is difficult to extrapolate from these large data sources. In addition, certain databases should be selected to appropriately power studies focusing on particular patient populations or outcomes.

Clinical and health-related quality-of-life outcomes after early and late spinal fusion in pediatric patients with congenital scoliosis at 10-year follow-up.

A retrospective comparative study. This study compares the effect of age at the time of surgery on clinical and health-related quality-of-life (HRQoL) outcomes at 10-year follow-up in pediatric patients with congenital scoliosis (CS). Several studies have evaluated the outcomes of surgical treatments of CS during the growth period; however, age at surgery and its long-term effects have been assessed in only a few case reports. We enrolled patients with CS who underwent spinal fusion at the age of 18years or younger in our study. We evaluated 97 patients (38 males, 59 females; average age 16.5years) who met our inclusion criteria, including the availability of outcome data for a minimum of 10-year post-surgery. We divided patients into two groups in terms of the age at surgery: early fusion (EF) and late fusion (LF) groups. Clinical outcomes included re-operations, major curve corrections immediately and at 10-year follow-up, Scoliosis Research Society (SRS)-22 questionnaire, and percentage forced vital capacity (%FVC). The EF group (33 patients) and the LF group (64 patients) did not differ significantly in terms of demographics. In all domains, the EF group had better HRQoL than the LF group. More patients (52%) in the EF group required re-operation than in the LF group (23%). In addition, patients with short fusion (< 7 segments, p = 0.0011) and greater T1-T12 height (≥ 22cm, p = 0.0088) had better %FVC than their counterparts. Age at surgery might have some non-negligible impacts on patients' HRQoL and clinical outcomes. Our study highlighted the important factors in surgical considerations of choosing the appropriate timing for spinal fusion, performing shorter fusions, and achieving an acceptable curve correction without allowing further curve progression that required re-operations. Level III.

Spinal fusion in pediatric patients with marfan syndrome: a nationwide assessment on short-term outcomes and readmission risk.

The purpose of this study was to utilize the National Readmission Database (NRD) to determine estimates for complication rates, 90-day readmission rates, and hospital costs associated with spinal fusion in pediatric patients with Marfan syndrome. The 2012-2015 NRD databases were queried for all pediatric (< 19years old) patients diagnosed with Marfan syndrome undergoing spinal fusion surgery. The primary outcome variables in this study were index admission complications and 90-day readmissions. A total of 249 patients with Marfan syndrome underwent spinal fusion surgery between 2012 and 2015 (mean age ± standard deviation at the time of surgery: 14 ± 2.0, 132 (53%) female). 25 (10.1%) were readmitted within 90days of the index hospital discharge date. Overall, 59.7% of patients experienced at least one complication during the index admission. Unplanned 90-day readmission could be predicted by older age (odds ratio 2.3, 95% confidence interval 1.3-4.2, p = 0.006), Medicaid insurance status (56.0, 3.8-820.0, p = 0.003), and experiencing an inpatient medical complication (42.9, 4.6-398.7, p = 0.001). Patients were readmitted for wound dehiscence (8 patients, 3.2%), nervous system related complications (3 patients, 1.2%), and postoperative infectious related complications (4 patients, 1.6%). This study is the first to demonstrate on a national level the complications and potential risk factors for 90-day hospital readmission for patients with Marfan syndrome undergoing spinal fusion. Patients with Marfan syndrome undergoing spinal fusion often present with multiple medical comorbidities that must be managed carefully perioperatively to reduce inpatient complications and early hospital readmissions.

Perioperative Complications After Spinal Fusion in Pediatric Patients With Congenital Heart Disease

BackgroundChildren with congenital heart disease (CHD) have been reported to be at increased risk of developing scoliosis following cardiac surgery. Previous sample studies have reported that these patients may safely undergo posterior spinal fusion (PSF) with low complication rates. The goal of this study is to provide an updated analysis of the perioperative complication profile for posterior spinal fusion in a large cohort of pediatric patients with CHD, using a nationwide database. MethodsA retrospective cohort study was conducted using 30-day perioperative outcomes data from the NSQIP-P database. Our inclusion criteria were all pediatric patients who underwent posterior spinal fusion by CPT code. Patients were subdivided into two groups: those with a history of cardiac surgery for CHD and those without. Postoperative complications were classified according to the Clavien-Dindo system. Risk factors were assessed in univariate and multivariate logistic regression analyses, with significance set at p < .05. ResultsOur results included 3,426 pediatric patients (68.2% female, 31.8% male) with a median age at spinal fusion of 13.7 ± 2.87 years. A CHD diagnosis was present in 312 patients, with 128 having had prior cardiac surgery. The overall complication rate was 6.68%, with a 10.9% rate in the prior cardiac surgery cohort (p = .068). The most common overall perioperative complications were unplanned readmission (3.5%), reoperation (2.6%), and superficial wound dehiscence (2.5%). Patients with a history of cardiac surgery were not at increased risk for postoperative complications; however, blood transfusion (p < .001), bronchopulmonary dysplasia (p < .001), combined bronchopulmonary dysplasia and previous cardiac surgery (p = .004), and a neuromuscular diagnosis (p < .001) were all risk factors for major postoperative complications in this cohort. ConclusionsChildren with scoliosis who have undergone cardiac surgery to address CHD are not at an increased risk of perioperative complications within 30 days of undergoing a posterior spinal fusion. However, patients who underwent cardiac surgery for CHD who also had bronchopulmonary dysplasia or an associated neuromuscular diagnosis are at increased risk for perioperative complications. It is important for pediatric orthopedic spine surgeons to be familiar with an updated profile of potential perioperative obstacles they may face when treating these patients, as seen in a large and representative cohort. Level of EvidenceLevel III.

Predictors of Increased Hospital Stay in Adolescent Idiopathic Scoliosis Patients Undergoing Posterior Spinal Fusion: Analysis of National Database

Study DesignAnalysis of population-based national hospital discharge data collected for the Nationwide Inpatient Sample (NIS). ObjectiveTo examine the predictors of increased hospital stay in adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal fusion. Summary of Background DataAs policy makers and hospitals are increasingly looking to cut costs, length of stay (LOS) after surgery has come into focus as an area for improvement. Despite this, there is limited research about the factors contributing to increased LOS for AIS patients undergoing posterior spinal fusion. MethodsThe Nationwide Inpatient Sample was used to identify pediatric patients with idiopathic scoliosis who underwent posterior spinal fusion from 2004 to 2009, using the International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) codes. Patient demographics, surgical variables, hospital characteristics, and in-hospital outcomes were retrieved. LOS was divided into two groups (longer- and shorter-stay groups) by its average. Longer stay was defined as ≥6 days. Multivariable logistic regression analysis was performed to identify the predictors of increased LOS in AIS patients undergoing posterior spinal fusion. ResultsSignificant predictors of increased LOS in posterior spinal fusion for AIS patients included increased Elixhauser Comorbidity Score, number of fused levels ≥9 vertebrae, teaching hospital status, in-hospital complications, and nonroutine disposition. Wound-related complications were the strongest predictor and patients with wound-related complications were 3.14-fold more likely to have an increased LOS compared to those without wound-related complications. ConclusionsThis study identified significant predictors of increased hospital stay in posterior spinal fusion for pediatric patients with idiopathic scoliosis and patients at higher risk of longer hospitalization can be recognized. Eventually these data are expected to help optimize LOS and cost containment.

Predictors of allogeneic blood transfusion in spinal fusion for pediatric patients with idiopathic scoliosis in the United States, 2004-2009.

Analysis of population-based National Hospital Discharge Survey data collected for the Nationwide Inpatient Sample. To examine the predictors of allogeneic blood transfusion (ALBT) in spinal fusion for pediatric patients with idiopathic scoliosis. Spinal fusion for pediatric patients with idiopathic scoliosis is associated with major blood loss and often necessitates ALBT. The Nationwide Inpatient Sample was used to identify pediatric patients with idiopathic scoliosis who underwent spinal fusion from 2004 to 2009, using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. Then, patients who received ALBT were identified using the appropriate International Classification of Diseases, Ninth Revision, Clinical Modification code. Patient demographics, surgical variables, and hospital characteristics were retrieved. Multivariate logistic regression analysis was performed to identify the predictors of ALBT in spinal fusion for pediatric patients with idiopathic scoliosis. The odds ratio (OR) increased with increasing Elixhauser Comorbidity Score (score 1: OR, 1.55; 95% confidence interval [95% CI], 1.23-1.97; score 2: OR, 2.23; 95% CI, 1.69-2.93; score 3: OR, 2.73; 95% CI, 1.6-4.66; score≥4: OR, 4.18; 95% CI, 1.93-9.06). Patients who underwent posterior approach or anterior and posterior approach surgical procedures were more likely to receive ALBT compared with those who underwent anterior approach surgery (posterior: OR, 2.24; 95% CI, 1.22-4.08; anterior and posterior: OR, 3.35; 95% CI, 1.69-6.63). Patients with a spinal fusion of 9 or more levels were more likely to receive ALBT compared with those with a spinal fusion of 4 to 8 levels (OR, 1.39; 95% CI, 1.05-1.85). There was no difference between patients with or without autologous-related blood transfusion (OR, 0.92; 95% CI, 0.59-1.43). This study identified significant predictors of ALBT in spinal fusion for pediatric patients with idiopathic scoliosis. These factors need to be taken into consideration for patient blood management before surgery. In this study, autologous-related blood transfusion could not avoid ALBT.

National trends in spinal fusion for pediatric patients with idiopathic scoliosis: demographics, blood transfusions, and in-hospital outcomes.

Analysis of population-based national hospital discharge data collected for the Nationwide Inpatient Sample database. To analyze trends in spinal fusion for pediatric patients with idiopathic scoliosis on a national level with regard to demographics, blood transfusions, and in-hospital outcomes. Spinal fusion for pediatric patients with idiopathic scoliosis is required for rapid curve progression. For such patients and their families, blood transfusions and complications are important aspects of the surgery. The Nationwide Inpatient Sample database was used to identify pediatric patients with idiopathic scoliosis who underwent spinal fusion from 2000 to 2009 using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. Demographics of the patients were retrieved. Trends in demographics, blood transfusion methods, and in-hospital outcomes were analyzed. The total number of patients included in this study was 43,983. A total of 30.4% of patients received a blood transfusion. Predonated autologous blood transfusions decreased over time, whereas perioperative autologous blood transfusions increased over time (P < 0.05, respectively). The in-hospital overall complication rate was 14.4%. The respiratory complication rate was the highest among complications; however, the rate decreased over time (P = 0.003). In-hospital blood transfusion, complication, and mortality rates were high in certain subgroups of patients, such as those with increased Elixhauser Comorbidity Score and those who underwent anterior and posterior fusion. The mean length of hospital stay decreased over time (P = 0.043). During the last decade, 30% of pediatric patients with idiopathic scoliosis who underwent spinal fusion received some type of blood transfusion; and strategies for blood transfusion methods have changed over the years. A decreasing trend in the respiratory complication rate and reduction in length of hospital stay may indicate better postoperative care. 3.

A Retrospective Quality Improvement Study of Ketorolac Use Following Spinal Fusion in Pediatric Patients

There are studies and literature that support the claim that ketorolac use after spinal fusion in the adult population can increase the risk of pseudarthrosis, instrumentation failure, and/or nonunion. There is limited research when using ketorolac in the pediatric population, especially short-term use. Chart review of 46 pediatric patients who had prior spinal fusions for scoliosis between July 2003 and August 2005. Twenty-five of the patients received ketorolac and 21 did not. The lengths of stay, incidence of curve progression, and/or incidence of nonunion or instrumentation failure were compared in the 2 groups. At the 1-year follow-up, 95% of the patients returned and at the 3-year follow-up, 52% of the patients returned and there was no clinical or radiographic evidence of curve progression, nonunion, or instrumentation failure. This is a retrospective study looking at results of 2 patient groups. This is a level III study.

Comparison of Same-Day Sequential Anterior and Posterior Spinal Fusion With Delayed Two-Stage Anterior and Posterior Spinal Fusion

This was a retrospective review. Short-term outcomes were compared based on two different surgical techniques. To determine the safety, efficacy, and cost effectiveness of two different surgical techniques of anterior and posterior spinal fusion for pediatric patients with spinal deformity. Brown et al, Floman et al, and Bradford et al have reported on combined anterior and posterior spine fusions with a 1-2-week recovery period between stages. However, advances in surgical and anesthetic techniques combined with the prohibitive cost of prolonged hospitalization and theoretical advantages in pulmonary function and nutrition have led to increasing use of combined anterior and posterior spinal fusion under one anesthetic. The authors reviewed records and radiographs of patients with pediatric spinal deformities who underwent anterior spine fusion/posterior spine fusion and instrumentation performed by the senior author (HAK) at one institution. Same-day sequential anterior spine fusion/posterior spine fusion resulted in less blood loss (575 +/- 275 ml; P < or = 0.0045), shorter hospital stay (8.00 +/- 2.68 days; P < or = 0.0001), and reduced hospital costs ($18,762 +/- $4,925; P < or = 0.0001). Operative time and complication rate were not affected. In selected patients with pediatric spinal deformity, experienced spinal surgeons can reduce blood loss, hospital stay, and costs by performing anterior and posterior spinal fusions sequentially under one anesthetic.