Paediatric spinal surgery and perioperative management

The aim of this dissertation is to improve perioperative management of adolescent patients undergoing posterior spinal fusion surgery. Posterior spinal fusion surgery is one of the most common major surgical procedures in adolescents. It is the main surgical procedure performed in adolescents with adolescent idiopathic scoliosis, Scheuermann kyphosis, or spondylolisthesis. The first part of this thesis was a randomised, double-blinded, and placebo-controlled clinical trial of 64 patients. The purpose of the first study was to determine whether perioperative pregabalin reduces the persistent pain in adolescent patients after posterior spinal fusion for spinal deformities compared to placebo. The second and third part of this thesis were retrospective analyses of a prospectively collected paediatric spine register. In the second study, 159 consecutive adolescent idiopathic scoliosis patients undergoing posterior spinal fusion were screened to determine the predictors of postoperative urinary retention. The third part of this thesis included 158 adolescent idiopathic scoliosis, 19 Scheuermann kyphosis, and 36 spondylolisthesis patients undergoing posterior spinal fusion surgery, with the aim of evaluating the predictors of acute and chronic pain. In our first study, we showed that pregabalin did not affect the chronic postoperative pain two years after surgery, and there is no reason to combine pregabalin to a multimodal treatment protocol in adolescents undergoing posterior spinal fusion. In our second study, we revealed that postoperative opioid consumption after posterior spinal fusion was associated with an increased risk of postoperative urinary retention in adolescent idiopathic scoliosis patients, and multimodal pain management to reduce the opioid amount may be beneficial. The third publication of this thesis demonstrated that after posterior spinal fusion, acute postoperative pain was associated with more extensive tissue trauma (adolescent idiopathic scoliosis and Scheuermann kyphosis), and chronic pain was related to the disease pathology (spondylolisthesis). Multimodal analgesia may reduce the persistent pain, but an optimal treatment protocol is still not established, and more studies are needed.Lasten selkäleikkausten perioperatiivinen hoito Tämän väitöskirjan tavoitteena on parantaa nuorten selän luudutusleikkaus potilaiden perioperatiivista hoitoa. Selän luudutusleikkaus on yksi yleisimpiä laajaa kirurgiaa vaativista toimenpiteistä nuorilla. Se on yleisin kirurginen toimenpide, joka tehdään nuorille, joilla on idiopaattinen skolioosi, Scheuermannin kyfoosi tai spondylolisteesi. Suomessa tehdään vuosittain n. 250 selän luudutusleikkausta nuorille. Tämän väitöskirjan ensimmäinen osatutkimus oli satunnaistettu, kaksoissokkoutettu ja lumekontrolloitu kliininen tutkimus 64 potilaalla. Ensimmäisen tutkimuksen tarkoituksena oli selvittää, vähentääkö perioperatiivinen pregabaliini kroonista kipua nuorilla selän luudutusleikkauksen jälkeen verrattuna lumelääkkeeseen. Toinen ja kolmas tutkimus olivat retrospektiivisiä analyysejä prospektiivisesti kerätystä lasten selkärekisteristä. Toisessa tutkimuksessa tarkastettiin rekisteristä 159 peräkkäisen selkäluudutetun nuoren idiopaattisen skolioosipotilaan tiedot. Tarkoituksena oli löytää virtsaummen esiintyvyys ja riskitekijät. Kolmannessa tutkimuksessa oli 158 nuorta idiopaattista skolioosi-, 19 Scheuermannin kyfoosi- ja 36 spondylolisteesipotilasta, joille oli tehty selän luudutusleikkaus. Tavoitteenamme oli selvittää, miten eri sairaudet vaikuttavat leikkauksen jälkeiseen akuuttiin ja krooniseen kipuun. Ensimmäisessä tutkimuksessamme osoitimme, että pregabaliini ei vaikuttanut krooniseen leikkauksen jälkeiseen kipuun kaksi vuotta luudutusleikkauksen jälkeen, eikä ole mitään syytä yhdistää pregabaliinia multimodaaliseen hoitokäytäntöön nuorille selän luudutusleikkauksen jälkeen. Toisessa tutkimuksessamme osoitimme, että nuorilla idiopaattista skolioosia sairastavilla luudutusleikkauksen jälkeinen opioidien kulutus korreloi virtsaummen esiintyvyyden kanssa. Multimodaalisella kivunhoidolla saatetaan vähentää virtsaummen riskiä. Kolmannessa julkaisussa osoitimme, että selän luudutusleikkauksen jälkeinen akuutti kipu liittyi laajempaan kudostraumaan (nuorten idiopaattinen skolioosi ja Scheuermannin kyfoosi), ja krooninen kipu liittyi sairauden patologiaan (spondylolisteesi). Multimodaalinen kivunhoito vähentää akuuttia ja voi vähentää kroonista kipua, mutta optimaalista hoitokäytäntöä ei ole vielä löydetty, ja lisää tutkimuksia tarvitaan

The Extension of Surgery Predicts Acute Postoperative Pain, While Persistent Postoperative Pain Is Related to the Spinal Pathology in Adolescents Undergoing Posterior Spinal Fusion

Persistent pain after posterior spinal fusion affects 12 to 42% of patients with adolescent idiopathic scoliosis. The incidence of persistent pain among surgically treated children with Scheuermann kyphosis and spondylolisthesis is not known. The aim of our study was to determine the predictors and incidence of acute and chronic postoperative pain in adolescents undergoing posterior spinal fusion surgery. The study was a retrospective analysis of a prospectively collected pediatric spine register data. The study included 213 consecutive patients (158 AIS, 19 Scheuermann kyphosis, and 36 spondylolisthesis), aged 10–21 years undergoing posterior spinal fusion at a university hospital between March 2010 and March 2020. The mean (SD) daily postoperative opioid consumption per kilogram was significantly lower in the spondylolisthesis patients 0.36 mg/kg/day (0.17) compared to adolescent idiopathic scoliosis 0.51 mg/kg/day (0.25), and Scheuermann kyphosis 0.52 mg/kg/day (0.25) patients after surgery (p = 0.0004). Number of levels fused correlated with the daily opioid consumption (rs = 0.20, p = 0.0082). The SRS-24 pain domain scores showed a statistically significant improvement from preoperative levels to two-year follow-up in all three groups (p ≤ 0.03 for all comparisons). The spondylolisthesis patients had the lowest SRS pain domain scores (mean 4.04, SD 0.94), reporting more pain two years after surgery, in comparison to AIS (mean 4.31, SD 0.60) (p = 0.043) and SK (mean 4.43, SD 0.48) patients (p = 0.049). Persistent postoperative pain in adolescents undergoing posterior spinal fusion is related to disease pathology while higher acute postoperative pain is associated with a more extensive surgery. Spondylolisthesis patients report more chronic pain after surgery compared to AIS and SK patients

Surface Electric Fields Increase Human Osteoclast Resorption through Improved Wettability on Carbonate-Incorporated Apatite

Osteoclast-mediated bioresorption can be an efficient means of incorporating the dissolution of biomaterials in the bone remodeling process. Because of the compositionally and structurally close resemblance of biomaterials with the natural mineral phases of the bone matrix, synthetic carbonate-substituted apatite (CA) is considered as an ideal biomaterial for clinical use. The present study therefore investigated the effects of electrical polarization on the surface characteristics and interactions with human osteoclasts of hydroxyapatite (HA) and CA. Electrical polarization was found to improve the surface wettability of these materials by increasing the surface free energy, and this effect was maintained for 1 month. Analyses of human osteoclast cultures established that CA subjected to a polarization treatment enhanced osteoclast resorption but did not affect the early differentiation phase or the adherent morphology of the osteoclasts as evaluated by staining. These data suggest that the surface characteristics of the CA promoted osteoclast resorption. The results of this work are expected to contribute to the future design of cell-mediated bioresorbable biomaterials capable of resorption by osteoclasts and of serving as a scaffold for bone regeneration.</p

Predictors of postoperative urinary retention after posterior spinal fusion for adolescent idiopathic scoliosis

Purpose To determine predictors for postoperative urinary retention in adolescents undergoing posterior spinal fusion for idiopathic scoliosis. Postoperative urinary retention affects almost every third adolescent after spinal fusion for idiopathic scoliosis. There are limited data regarding the risk factors of postoperative urinary retention in this patient group.Methods A retrospective study with prospectively collected urinary retention data from paediatric spine register with 159 consecutive patients (114 females, mean age 15.6 years, range 10-21 years) undergoing pedicle screw instrumentation for adolescent idiopathic scoliosis at a university hospital between May 2010 and April 2020. Postoperative urinary retention was defined as an inability to void after catheter removal and documented residual over 300 mL as confirmed using an ultrasound or by catheterization.Results Postoperative urinary retention was diagnosed in 33% (53 of 159) of the patients during hospital stay. Opioid amount on the day of catheter removal (OR 6.74 [95% CI: 2.47, 18.36], p Conclusions Higher total opioid consumption, opioid amount on the day of catheter removal, higher weight, and male gender increases the risk of postoperative urinary retention in adolescents with idiopathic scoliosis undergoing posterior spinal fusion.</p

The Extension of Surgery Predicts Acute Postoperative Pain, While Persistent Postoperative Pain Is Related to the Spinal Pathology in Adolescents Undergoing Posterior Spinal Fusion

Persistent pain after posterior spinal fusion affects 12 to 42% of patients with adolescent idiopathic scoliosis. The incidence of persistent pain among surgically treated children with Scheuermann kyphosis and spondylolisthesis is not known. The aim of our study was to determine the predictors and incidence of acute and chronic postoperative pain in adolescents undergoing posterior spinal fusion surgery. The study was a retrospective analysis of a prospectively collected pediatric spine register data. The study included 213 consecutive patients (158 AIS, 19 Scheuermann kyphosis, and 36 spondylolisthesis), aged 10&ndash;21 years undergoing posterior spinal fusion at a university hospital between March 2010 and March 2020. The mean (SD) daily postoperative opioid consumption per kilogram was significantly lower in the spondylolisthesis patients 0.36 mg/kg/day (0.17) compared to adolescent idiopathic scoliosis 0.51 mg/kg/day (0.25), and Scheuermann kyphosis 0.52 mg/kg/day (0.25) patients after surgery (p = 0.0004). Number of levels fused correlated with the daily opioid consumption (rs = 0.20, p = 0.0082). The SRS-24 pain domain scores showed a statistically significant improvement from preoperative levels to two-year follow-up in all three groups (p &le; 0.03 for all comparisons). The spondylolisthesis patients had the lowest SRS pain domain scores (mean 4.04, SD 0.94), reporting more pain two years after surgery, in comparison to AIS (mean 4.31, SD 0.60) (p = 0.043) and SK (mean 4.43, SD 0.48) patients (p = 0.049). Persistent postoperative pain in adolescents undergoing posterior spinal fusion is related to disease pathology while higher acute postoperative pain is associated with a more extensive surgery. Spondylolisthesis patients report more chronic pain after surgery compared to AIS and SK patients

Pregabalin and persistent postoperative pain following posterior spinal fusion in children and adolescents. A randomized clinical trial

Peer reviewe

Predictors of postoperative urinary retention after posterior spinal fusion for adolescent idiopathic scoliosis

Purpose To determine predictors for postoperative urinary retention in adolescents undergoing posterior spinal fusion for idiopathic scoliosis. Postoperative urinary retention affects almost every third adolescent after spinal fusion for idiopathic scoliosis. There are limited data regarding the risk factors of postoperative urinary retention in this patient group. Methods A retrospective study with prospectively collected urinary retention data from paediatric spine register with 159 consecutive patients (114 females, mean age 15.6 years, range 10-21 years) undergoing pedicle screw instrumentation for adolescent idiopathic scoliosis at a university hospital between May 2010 and April 2020. Postoperative urinary retention was defined as an inability to void after catheter removal and documented residual over 300 mL as confirmed using an ultrasound or by catheterization. Results Postoperative urinary retention was diagnosed in 33% (53 of 159) of the patients during hospital stay. Opioid amount on the day of catheter removal (OR 6.74 [95% CI: 2.47, 18.36], p < 0.001), male gender (OR 2.26 [95% CI: 1.01, 5.05], p = 0.048), and increasing weight (OR 1.04 [95% CI: 1.01, 1.07], p = 0.014) were associated with postoperative urinary retention. Mean opioid consumption on the day of catheter removal was 0.81 mg/kg (95% CI: 0.66, 0.96) in the retention group vs 0.57 mg/kg (95% CI: 0.51, 0.64) in the non-retention group, p < 0.001. Conclusions Higher total opioid consumption, opioid amount on the day of catheter removal, higher weight, and male gender increases the risk of postoperative urinary retention in adolescents with idiopathic scoliosis undergoing posterior spinal fusion.Peer reviewe