Surgeon practices regarding infection prevention for growth friendly spinal procedures

Purpose The rate of infection in patients having growth sparing surgery for early onset scoliosis has been reported up to 25 % during the course of treatment. A recent study demonstrated significant variability in the approach to infection prevention in adolescent and neuromuscular scoliosis. The purpose of this study is to conduct a similar survey in order to understand approaches used by experienced pediatric spinal surgeons with regard to infection prevention in growth friendly spinal procedures. Materials and methods After preliminary internal testing of a survey by the authors, a final 21-question survey was created and approved by the authors and electronically distributed to all members of the Chest Wall Spinal Deformity Study Group and the Growing Spine Study Group (n = 57). A total of 40 responses were obtained (70 %). Results: Significant variability in practice was demonstrated across the majority of the questions answered. Several of the questions demonstrated relative equipoise between practices, including preoperative MRSA screening, preoperative chlorhexidine baths, postoperative antibiotic duration after insertion, use of topical antibiotics, use of drains, use of IV gram negative coverage or vancomycin, and skin preparation. Conclusion: Other studies have demonstrated that variability in practice may have a negative impact on clinical outcomes, so one could postulate that steps that can reduce variability in the current population may help improve outcomes in this population. Areas of clinical equipoise can be used to help design and direct multicenter studies with an ultimate goal of reducing infections in this population. Level of evidence Level V. Electronic supplementary material The online version of this article (doi:10.1007/s11832-014-0584-1) contains supplementary material, which is available to authorized users

Nutritional improvement following growing rod surgery in children with early onset scoliosis

Purpose We aimed to evaluate the nutritional status of children with early onset scoliosis (EOS) and to determine if treatment with growing rod instrumentation improves weight percentile. Methods: Data was retrospectively collected on 88 EOS patients treated with growing rods at six institutions. Mean age at surgery was 5.8 years, and mean Cobb angle was 75°. All patients were followed for at least 2 years (mean 4 years). Weights were converted to normative percentiles based on the patients’ age and gender. Results: Preoperatively, 47 % (41/88) of patients were 0.05). Children with neuromuscular and syndromic diagnoses do not appear to improve their mean nutritional status after surgery when compared to patients with idiopathic or congenital/structural scoliosis (p = 0.006). Conclusion: Following growing rod treatment, there was significant improvement in nutritional status in approximately 50 % of patients, similar to that reported with VEPTR. Neuromuscular and syndromic patients did not experience nutritional improvement post-operatively. These findings support the theory that growing rods improve the clinical status of EOS patients, as nutritional improvement is one outcome of improved clinical status. The relationship between age at initial surgery and nutritional improvement is intriguing

Is There a Patient Profile That Characterizes a Patient With Adult Spinal Deformity as a Candidate for Minimally Invasive Surgery?

Study designRetrospective review.ObjectivesThe goal of this study was to evaluate the baseline characteristics of patients chosen to undergo traditional open versus minimally invasive surgery (MIS) for adult spinal deformity (ASD).MethodsA multicenter review of 2 databases including ASD patients treated with surgery. Inclusion criteria were age >45 years, Cobb angle minimum of 20°, and minimum 2-year follow-up. Preoperative radiographic parameters and disability outcome measures were reviewed.ResultsA total of 350 patients were identified: 173 OPEN patients and 177 MIS. OPEN patients were significantly younger than MIS patients (61.5 years vs 63.74 years, P = .013). The OPEN group had significantly more females (87% vs 76%, P = .006), but both groups had similar body mass index. Preoperative lumbar Cobb was significantly higher for the OPEN group (34.2°) than for the MIS group (26.0°, P < .001). The mean preoperative Oswestry Disability Index was significantly higher in the MIS group (44.8 in OPEN patients and 49.8 in MIS patients, P < .011). The preoperative Numerical Rating Scale value for back pain was 7.2 in the OPEN group and 6.8 in the MIS group preoperatively, P = .100.ConclusionsPatients chosen for MIS for ASD are slightly older and have smaller coronal deformities than those chosen for open techniques, but they did not have a substantially lesser degree of sagittal malalignment. MIS surgery was most frequently utilized for patients with an sagittal vertical axis under 6 cm and a baseline pelvic incidence and lumbar lordosis mismatch under 30°

Early and Late Reoperation Rates With Various MIS Techniques for Adult Spinal Deformity Correction.

Study designA multicenter retrospective review of an adult spinal deformity database.ObjectiveWe aimed to characterize reoperation rates and etiologies of adult spinal deformity surgery with circumferential minimally invasive surgery (cMIS) and hybrid (HYB) techniques.MethodsInclusion criteria were age ≥18 years, and one of the following: coronal Cobb >20°, sagittal vertical axis >5 cm, pelvic tilt >20°, and pelvic incidence-lumbar lordosis >10°. Patients with either cMIS or HYB surgery, ≥3 spinal levels treated with 2-year minimum follow-up were included.ResultsA total of 133 patients met inclusion for this study (65 HYB and 68 cMIS). Junctional failure (13.8%) was the most common reason for reoperation in the HYB group, while fixation failure was the most common reason in the cMIS group (14.7%). There was a higher incidence of proximal junctional failure (PJF) than distal junctional failure (DJF) within HYB (12.3% vs 3.1%), but no significant differences in PJF or DJF rates when compared to cMIS. Early (<30 days) reoperations were less common (cMIS = 1.5%; HYB = 6.1%) than late (>30 days) reoperations (cMIS = 26.5%; HYB = 27.7%), but early reoperations were more common in the HYB group after propensity matching, largely due to infection rates (10.8% vs 0%, P = .04).ConclusionsAdult spinal deformity correction with cMIS and HYB techniques result in overall reoperation rates of 27.9% and 33.8%, respectively, at minimum 2-year follow-up. Junctional failures are more common after HYB approaches, while pseudarthrosis/fixation failures happen more often with cMIS techniques. Early reoperations were less common than later returns to the operating room in both groups, but cMIS demonstrated less risk of infection and early reoperation when compared with the HYB group

The Health Impact of Symptomatic Adult Spinal Deformity: Comparison of Deformity Types to United States Population Norms and Chronic Diseases.

Study designA retrospective analysis of a prospective, multicenter database.ObjectiveThe aim of this study was to evaluate the health impact of symptomatic adult spinal deformity (SASD) by comparing Standard Form Version 2 (SF-36) scores for SASD with United States normative and chronic disease values.Summary of background dataRecent data have identified radiographic parameters correlating with poor health-related quality of life for SASD. Disability comparisons between SASD patients and patients with chronic diseases may provide further insight to the disease burden caused by SASD.MethodsConsecutive SASD patients, with no history of spine surgery, were enrolled into a multicenter database and evaluated for type and severity of spinal deformity. Baseline SF-36 physical component summary (PCS) and mental component summary (MCS) values for SASD patients were compared with reported U.S. normative and chronic disease SF-36 scores. SF-36 scores were reported as normative-based scores (NBS) and evaluated for minimally clinical important difference (MCID).ResultsBetween 2008 and 2011, 497 SASD patients were prospectively enrolled and evaluated. Mean PCS for all SASD was lower than U.S. total population (ASD = 40.9; US = 50; P < 0.05). Generational decline in PCS for SASD patients with no other reported comorbidities was more rapid than U.S. norms (P < 0.05). PCS worsened with lumbar scoliosis and increasing sagittal vertical axis (SVA). PCS scores for patients with isolated thoracic scoliosis were similar to values reported by individuals with chronic back pain (45.5 vs 45.7, respectively; P > 0.05), whereas patients with lumbar scoliosis combined with severe sagittal malalignment (SVA >10 cm) demonstrated worse PCS scores than values reported by patients with limited use of arms and legs (24.7 vs 29.1, respectively; P < 0.05).ConclusionsSASD is a heterogeneous condition that, depending upon the type and severity of the deformity, can have a debilitating impact on health often exceeding the disability of more recognized chronic diseases. Health care providers must be aware of the types of SASD that correlate with disability to facilitate appropriate diagnosis, treatment, and research efforts.Level of evidence3

Acute Reciprocal Changes Distant from the Site of Spinal Osteotomies Affect Global Postoperative Alignment

Introduction. Three-column vertebral resections are frequently applied to correct sagittal malalignment; their effects on distant unfused levels need to be understood. Methods. 134 consecutive adult PSO patients were included (29 thoracic, 105 lumbar). Radiographic analysis included pre- and postoperative regional curvatures and pelvic parameters, with paired independent t-tests to evaluate changes. Results. A thoracic osteotomy with limited fusion leads to a correction of the kyphosis and to a spontaneous decrease of the unfused lumbar lordosis (−8°). When the fusion was extended, the lumbar lordosis increased (+8°). A lumbar osteotomy with limited fusion leads to a correction of the lumbar lordosis and to a spontaneous increase of the unfused thoracic kyphosis (+13°). When the fusion was extended, the thoracic kyphosis increased by 6°. Conclusion. Data from this study suggest that lumbar and thoracic resection leads to reciprocal changes in unfused segments and requires consideration beyond focal corrections

Extension of previous fusions to the Sacro-Pelvis vs. Primary spino-pelvic fusions in the setting of adult deformity: A Comparison of health related quality of life measures and complications [abstract]

Comparative Medicine - OneHealth and Comparative Medicine Poster SessionSummary: Clinical and radiographic evaluation of revision extension of previous long thoracolumbar fusion to the sacro-pelvis compared to primary lumbosacral fusion indicates that although the two patient populations are heterogeneous, clinical outcomes and complication rates of salvage procedures where a prior spinal fusion procedure is extended to the sacropelvis compare favorably to primary sacro-pelvic fusion for adult spinal deformity. Introduction: Patients previously treated with thoracolumbar fusion for spinal deformity may develop degenerative changes below the fusion requiring revision fusion to the sacro-pelvis. Little data exists on the characteristics of patients treated with revision extension to sacro-pelvis compared to primary lumbosacral fusion. We evaluated the differences between patients undergoing revision extension of fusion vs. primary fusion to the sacro-pelvis, minimum 2-year follow-up. Methods: The revision group (REVISION) included multicenter retrospective evaluation of 44 of 54 consecutive patients (1995-2006) that had a previous long fusion ending from L3-5, revised by extension fusion to the sacro-pelvis for symptomatic degeneration. The primary group (PRIMARY) included 20 of 20 consecutive patients prospectively enrolled (2000-2006) at a single center database that received primary long arthrodesis to the sacro-pelvis for adult deformity. Clinical and radiographic evaluation included demographics, coronal and sagittal measures, postoperative SRS-22 scores, and perioperative complications. Results: Mean patient age was 52 years (range 21-81 years). Mean follow up was 43 months (range 23-135 months). PRIMARY had greater median age (59 vs. 49 years; p<0.01) and longer follow up (44 vs. 31 months, p<0.05) than REVISION. PRIMARY had larger preoperative thoracolumbar curve (median TL; 48° vs. 36°; p<0.01) and less sagittal imbalance (median SVA; 0.0. vs. 5.0 cm; p<0.05) than REVISION. Postoperative SVA was similar for PRIMARY and REVISION (median 0.9 vs. 2.6 cm, respectively; p=0.25). REVISION had better postoperative SRS-22 scores (median 3.80 vs. 3.12, p<0.01) and fewer patients with minimum one complication [11 (25%) vs. 11 (55%), p<0.05] than PRIMARY (Table 1) Conclusion: Significant differences were demonstrated between patients undergoing primary vs. revision extension to the sacro-pelvis. PRIMARY were older, and had larger TL curves, whereas REVISION had greater sagittal imbalance. While PRIMARY had more complications, multiple factors could account for this other than surgery type, including differences in age or number of levels fused. The retrospective nature of the study may have also underrepresented minor complications. Although the groups were heterogeneous, radiographic, SRS-22 and complications analysis indicate clinical outcomes of salvage procedures where a prior spinal fusion procedure is extended to the sacropelvis compare favorably to primary sacro-pelvic fusion for adult spinal deformity

Concurrent Tethered Cord Release And Growing-Rod Implantation—Is It Safe?

Study Design Retrospective case series from one institution with a comparison control group., Objective To evaluate the safety of concomitant tethered cord release and growing-rod insertion in individuals with early onset scoliosis., Methods We retrospectively reviewed patients who underwent concurrent tethered cord release and growing-rod insertion. We compared our data to a comparison control group of eight patients who underwent staged tethered cord release and growing-rod insertion., Results We identified three patients meeting criteria. There were no neurological complications in the three patients who underwent concomitant surgery. Average immediate postoperative curve correction was 43.3 degrees (47.6%). We identified seven patients who underwent staged surgery from a multicenter prospective database. No neurological complications were reported, and average immediate postoperative correction was 35.1 degrees (46.2%)., Conclusion We believe that concurrent tethered cord release and growing-rod insertion can be performed safely with the use of multimodality neurophysiological monitoring techniques.PubMe