Complications of Surgical Treatment of Pediatric Spinal Deformities

Retrospective, chart review.

The objective of this study is to investigate the impact of using two surgeons for posterior spinal fusion (PSF) in patients with AIS with large-magnitude curves (greater than 70°).

Previous studies have shown that intraoperative risk factors can be reduced by having two surgeons operate simultaneously.

A retrospective chart review identified 47 patients between January 1, 2009, and December 31, 2014, who underwent a posterior spinal fusion (PSF) with AIS with large-magnitude curves (greater than 70°). Patients with large-magnitude curves due to neuromuscular diseases or any defined pathology other than idiopathic scoliosis were excluded, as well as patients with kyphotic or kyphoscoliotic curves.

There was no statistical difference between the total operative time, anesthesia time, estimated blood loss (EBL), %EBL, and blood transfusion units. Total operative time for the two-surgeon group and single-surgeon group was 212.11 and 238.07 minutes, respectively (p = .078). The two-surgeon group averaged 0.26 blood transfusion units versus 0.39 units for the single-surgeon group (p = .50). Average hospital length of stay was decreased in the two-surgeon group (5.16 vs. 6.82 days, p = .002).

The use of two surgeons for PSF for AIS has previously been shown to decrease operative time and blood loss, factors that are correlated with prolonged hospital stay and increased risk of both neurologic and nonneurologic complications. However, in this study, the technique of having two experienced orthopedic spine surgeons work simultaneously to perform pedicle screw–only posterior spinal fusion on large-magnitude AIS curves greater than 70° did not improve blood loss or operative time. Further study needs to continue to identify ways to minimize complications for patients who undergo spinal fusion.

Level III, retrospective, comparative study.

Screening laboratory studies for bleeding disorders are of little predictive value for operative bleeding risk in adults. Predicting perioperative bleeding in pediatric patients is particularly difficult as younger patients often have not had significant hemostatic challenges. This issue is distinctly important for high bleeding risk surgeries, such as major spinal procedures. The aim of this study was to determine if the score of a detailed bleeding questionnaire (BQ) correlated with surgical bleeding in pediatric patients undergoing major spinal surgery. A total of 220 consecutive pediatric patients (mean age 14.2 years) undergoing major spinal surgery were administered the BQ preoperatively, as well as having routine screening laboratory studies (i.e., PT, aPTT, PFA) drawn. A retrospective analysis was conducted to determine if there was a correlation between either the results of the BQ and/or laboratory studies with operative outcomes. A BQ score > 2 showed a strong positive correlation with intraoperative bleeding based on both univariate and multivariate analyses. In contrast, abnormalities in screening laboratory studies showed no significant correlation with operative bleeding outcomes. Relying on screening laboratory studies alone is inadequate. The BQ used here correlated with increased intraoperative hemorrhage, suggesting this tool may be useful for assessing pediatric surgical bleeding risk, and may also be useful in identifying a subset of patients with a very low bleeding risk that may not require laboratory screening.

Case report.

To describe a patient who experienced rod fracture with subsequent caudal migration into the gluteal region after minimally invasive posterior spinal fusion for adult idiopathic scoliosis.

Rod fracture occurs in approximately 6.8% of patients who undergo multilevel instrumented arthrodesis for spinal deformity. Rod fracture can result in substantial morbidity including pain, loss of deformity correction, and pseudoarthrosis.

A retrospective chart review was used to describe the clinical course and radiographic findings after rod fracture. Previous methods of implant failure were reviewed in the literature.

The patient underwent a minimally incisional posterior spinal fusion and experienced bilateral rod fracture caused by pseudarthrosis within 2 years. One of these fractured rods disengaged from the pedicle screw sleeves and migrated caudally to the gluteal region and proximal posterior thigh. The fractured rod was surgically removed from the gluteal region without complication.

The patient presented with a highly unusual method of implant failure after posterior spinal fusion. Although uncommon, spine surgeons should be aware of the possibility of caudal migration after rod fracture.

The postoperative deterioration of the curve below spinal fusion instrumentation resulting in a distal adding-on (AO) phenomenon in idiopathic adolescent scoliosis (IAS) frequently requires surgical revision with disappointing secondary clinical results.

Analysis of AP (coronal) range of motion (cROM) and lateral (sagittal) range of motion (sROM) on dynamic (side-bending, flexion, extension) X-rays to determine the choice of the lowest instrumented vertebra (LIV) can help reduce distal adding-on. The goal of this study was to study the postoperative progression of the lumbar curve in Lenke 1 scoliosis operated on with a LIV based on dynamic X-ray results.

Right-sided Lenke 1 IAS that was treated surgically by posterior arthrodesis alone with a follow-up of at least 2 years was included in the study. The following radiographic parameters were evaluated: the Cobb angles of the curves, reducibility of the curves, the apex of the scoliosis, the central sacral vertical line, the stable vertebra (SV), the neutral vertebra (NV), the distances between the CSVL and the centroids of the LIV and of the first vertebra below instrumentation, as well as the tilt of the superior endplates. sROM and cROM were determined on dynamic X-rays.

Fifty IAS were evaluated/185 files. Only three cases fulfilled the criteria for AO including two that were secondary to peri- or postoperative complications. The lumbar curve presented with a loss of correction of 0.9° at one year and 1.14° at the final follow-up. None of the parameters studied were correlated to the deterioration of the lumbar curve.

The choice of the LIV has been shown to influence the deterioration of the lumbar curve and the development of AO. The choice of the LIV based on an analysis of AP (coronal) and lateral (sagittal) range of motion seems to prevent the development of AO.

4, retrospective study.