Medical complications and health-related quality of life in complex pediatric spine deformities exceeding 100 degrees or treated by 3CO.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To determine the incidence of medical complications in the pediatric population aged 10-20 years with baseline deformities exceeding 100 degrees or who had 3CO at surgery. Severe pediatric spine deformity poses a great challenge to the treating physician and carries a high complication rate. Pulmonary complications are among the most life threatening. The onus is on the treating surgeon to identify patients who are high risk and institute measures to mitigate the risk for successful outcomes. METHOD: Data of 251/311pts from FOX pediatric database from 17 international sites was queried for incidence of major medical complications. Comparative analysis was done to determine the impact of such complications on HRQoL using paired t-test. Risk factors associated with medical complications were assessed using Firth logistic regression. RESULTS: 251/311pts had min 2 year f/u. 142F/109 M, average age 14.61years (10-20). Etiologies included 96 Cong,94 Idiopathic, 14-Post TB, 12-NM,12-NF,10-syndromic,8 others. Curve types included Scoliosis-121, Kyphoscoliosis 72, Kyphosis 58. Coronal and sag cobb avg 88° ± 41.47 and 91.92° ± 39.17, respectively. Deformity apices were in the thoracic region in 88% of patients. Pre-op co-morbidities included 54 (21.5%) cardiopulmonary; 7(2.79%) Genitounrinary;13 (5.18%) GI;13 (5.18%) Anxiety/depression; neurological 24 (9.56%). HGT was utilized in 103pts (41%) at an average duration of 68 days. Mean OR time was 459 min, blood loss averaged 1465 ml. VCR was performed in 120(47.81%), PSO in 16 pts (6.37%), SPO in 145pts (57.77%), Thoracoplasty in 132 pts (52.8%). 96% had blood and other blood products transfusion (FFP and platelets). There were 35 post-op medical complications occurring in 29pts (11.6%). Event-specific cumulative incidence was 24 (9.6%) pulmonary, 5(2.0%) gastrointestinal, 3(1.2%) cardiovascular, 1(0.4%) genitourinary and 1(0.4%) other complication. There was no mortality. Osteotomy grade was found to be an independent predictor of pulmonary complication. Despite significant improvement in baseline SRS total and Domain scores at 2 year FU irrespective of medical complication, the improvement in SRS scores were blunted in the complication group. CONCLUSION: Medical complications are common among pediatric patients undergoing complex spine surgery for severe deformity. However, medical complications can be managed successfully. Although baseline HRQoL improved irrespective of medical complication status, clinical differences in the magnitude of the changes in HRQoL were observed in some domains.

The Effect of Prolonged Pre-Operative Halo Gravity Traction for Severe Spinal Deformities on the Cervical Spine Radiographs.

STUDY DESIGN: Retrospective review of consecutive series. OBJECTIVE: The study sought to assess the effect of prolonged pre-operative halo gravity traction (HGT) on the c-spine radiographs. METHODS: Data of 37 pediatric and adult patients who underwent ≥ 12wks pre-op HGT prior to definitive spine surgery from 2013-2015 at a single site in West Africa was reviewed. Radiographic assessment of the c-spine including ADI, SVA and C2-C7 Lordosis were done at pre HGT and at 4 weekly intervals. Paired T-Test was performed to evaluate changes in these parameters during HGT. RESULTS: 37pts, 18/19 (F/M). Average age 18.2yrs. Diagnoses: 22 idiopathic, 6 congenital, 3 Post TB, 2 NM and 4 NF. Average duration of HGT: 125 days. Baseline coronal Cobb:130 deg, corrected 30% in HGT; baseline sagittal Cobb:146 deg, corrected 32% post HGT. Baseline ADI (3.17 ± 0.63 mm) did not change at 4wks (P > 0.05) but reduced at 8wks (2.80 ± 0.56 mm) and 12wks (2.67 ± 0.51 mm) post HGT (P < 0.05). Baseline HGT SVA (20.7 ± 14.98 mm) significantly improved at 4wks (11.55 ± 10.26 mm), 8wks (7.54 ± 6.78 mm) and 12wks (8.88 ± 4.5 mm) (P < 0.05). Baseline C2-C7 lordosis (43 ± 20.1 deg) reduced at 4wks (26 ± 16.37 deg), 8wks (17.8 ± 14.77 deg) and 12wks (16.7 ± 11.33 deg) post HGT (P < 0.05). There was no incidence of atlanto-axial instability on flexion extension radiographs at any interval. CONCLUSION: Prolonged HGT, while providing partial correction of severe spine deformities, also appeared to have no adverse effect on atlanto-axial stability or cervical alignment. Therefore, HGT can be safely applied for several weeks in the preoperative management of severe spine deformities in pediatric/adult patients.

One-stage multiple posterior column osteotomies and fusion and pre-op halo-gravity traction may result in a comparative and safer correction of complex spine deformity than vertebral column resection.

STUDY DESIGN: A retrospective review of prospectively collected from patients recruited at a single center. PURPOSE: To test whether safe and optimal correction can be obtained with preoperative halo-gravity traction and posterior spinal fusion with adjunctive procedures but without VCR. Posterior vertebral column resection(VCR) is gaining popularity for correction of severe spinal deformity. However, it is a highly technically demanding procedure with potential risk for complications and neurological injury. METHODS: In total, 72 patients with severe spinal deformity (Cobb angle > 100º) who underwent HGT followed by definitive PSF with PCO, with or without concave rib osteotomy and thoracoplasty. Demographic and surgical data were collected. Conventional coronal and sagittal radiographic measurements were obtained pre-traction, post-traction, post-op and at follow-up to determine the final deformity correction. Postoperative neurological and major complications were reviewed. We used Chi-square to compare proportion between groups and t test to compare groups in quantitative/ordinal variables. RESULTS: There were 72 patients (35 females, 37 males). The etiology was congenital (21),idiopathic (45), neurofibromatosis (2) and neuromuscular (4). The mean was: age 18 ± 4.6 years; duration of HGT 103 ± 35 days; coronal Cobb angle before traction 131.5 ± 21.4º vs 92. ± 15.9º after HGT (30% correction) and 72.8 ± 12.7º after fusion (47% correction); kyphosis angle before traction 134.7 ± 32.3º vs 97.1 ± 22.4º after HGT and 73.7 ± 21.3º post-fusion. Number of fusion levels 14 ± 1; EBL 1730 ± 744 cc; number of PCOs done 5 ± 2; number of concave rib osteotomies (2 ± 2). There were 16 patients with postoperative complications (22.2%), 10 medical, one wound infection, 2 implant related and 3 post-op neuro-deficits (all of whom recovered at follow-up). There was one death (cardiac arrest). CONCLUSION: HGT and one-stage posterior fusion with PCO, with or without concave rib resection and thoracoplasty, without VCR, achieved satisfactory correction of rigid complex spine deformity with minimal neurological complications. The results compare favorably with previous reports of similar deformities treated with VCR. LEVEL OF EVIDENCE: III.

Surgical management of complex post-tuberculous kyphosis among African patients: clinical and radiographic outcomes for a consecutive series treated at a single institution in West Africa.

STUDY DESIGN: Retrospective review of consecutive series. OBJECTIVE: To assess the clinical and radiographic outcomes after surgical management of post-tuberculous kyphosis. Post-tuberculous (TB) kyphosis can lead to progressive pulmonary and neurological deterioration. Surgery is indicated to decompress neural elements and correct the spine deformity. Although posterior vertebral column resection (PVCR) has been established as the treatment of choice for severe TB kyphosis, there is paucity of studies on the clinical outcomes among patients treated in West Africa. METHODS: Clinical and radiographic data of 57 patients (pts) who underwent surgical correction of post-TB kyphosis at a single site in West Africa between 2013 and 2018 (≥ 2-year follow-up in 36 pts, ≥ 1-year FU in 21 pts). Pre- and post-op SRS scores and radiographic outcomes were compared using Paired t test. RESULTS: 57 patients, 36M:21F. Mean age 19 (11-57 years). 22/57 pts (39.3%) underwent pre-op halo gravity traction (HGT) for an average duration of 86 days (8-144 days). HGT pts had a higher baseline regional kyphosis (125.1 ± 20.9) compared to non-HGT pts (64.6 ± 31.8, p < 0.001). Post-HGT regional kyphosis corrected to 101.2 ± 23 (24° correction). 53 pts (92.9%) underwent posterior-only surgery and 4 (7.0%) combined anterior-posterior surgery. 39 (68.4%) had PVCR, 11 (19.3%) PSO, and 16 (28.1%) thoracoplasty. Intraoperative neuromonitoring (IOM) signal changes occurred in 23/57 pts (≈ 40%), dural tear in 5 pts (8.8%), pleural tear in 3 pts (5.3%), ureteric injury in 1 pt (1.7%), and vascular injury in 1 pt (1.7%). Post-op complications included four (7.0%) infection, three (5.3%) implant related, two (3.5%) radiographic (one PJK and one DJK), one (1.7%) neurologic, one (1.7%) wound problem, and two (3.5%) sacral ulcers. IOM changes were similar in the VCR (48.7%) and non-VCR (23.5%) pts, p > 0.05. Complication rates were similar among HGT and non-HGT groups. Significant improvements from baseline were seen in the average SRS Total and domains scores and radiographic measurements for patients who attained 2-year follow-up. CONCLUSION: PVCR ± HGT can provide safe and optimal correction in cases of severe post-TB kyphosis with good clinical and radiographic outcomes in underserved regions.

Characterization of complex vertebral transposition (gamma deformity) > 180 degrees: clinical and radiographic outcomes of halo gravity traction and vertebral column resection (VCR).

STUDY DESIGN: Prospective case series OBJECTIVE: Results of surgical treatment of complex vertebral transposition "Gamma Deformity" > 180 degrees with halo gravity traction (HGT) and vertebral column resection (VCR). We recently published a novel classification system for complex spine deformities of which complex vertebral transposition > 180 degrees (Gamma; type 3) was described. Halo gravity traction (HGT) has been shown to mitigate surgical risk in complex spine deformity correction and in some cases obviates the need for three-column osteotomy. However, we are not aware of report of its utilization in treating Gamma deformities with or without vertebral column resection (VCR). METHODS: A consecutive series of 13 patients with Gamma deformity (GD) were prospectively enrolled at a single site in West Africa. Standard radiographs and 3D computerized tomography (CT) were done to assess coronal and sagittal vertebral transposition (CVT and SVT). The HGT with 50% of body weight was applied over several weeks followed by VCR. Demographics, operative data, radiographic parameters, and complications data were collected. RESULTS: 13 pts with GD underwent HGT for an avg of 110 days prior to definitive surgery. Etiologies were Congenital-11 pts and Neurofibromatosis-2 pts. Average age: 17.8 years; Pts were reviewed at 3 months post-op and at minimum 2-year follow-up. Preop myelopathy was present in five patients. Pre-op CVT avg 75% and was corrected in all cases post-op. SVT avg 211 deg and improved with HGT by 36% and corrected to 53 deg (74% correction) post-op. Thoracic kyphosis avg -42 deg and averaged 48 deg post-op. Intra-op spinal cord monitoring (SCM) alerts occurred in 8 pts (61%). Post-operative LEM deficits occurred in 5 pts: 2 fully recovered by 3 months and 2 year follow-up, while the remaining 3 improved but had residual motor deficits at final follow-up. There was one post-operative mortality. CONCLUSION: The management of complex vertebral transposition (Gamma deformity) > 180 degrees with HGT prior to VCR is not only effective in some patients, but also associated with high SCM alerts and neurologic injury rates. Myelopathic patients with thoracic deformities are at higher risk of developing permanent neurologic deficits. Surgeons should be aware of this rare and unusual deformity and consider HGT and VCR bearing in mind the technical challenges and high complication rate.

Does thoracoplasty adversely affect lung function in complex pediatric spine deformity? A 2-year follow-up review.

STUDY DESIGN: Retrospective review of prospective multi-center cohort. OBJECTIVE: To investigate the impact of thoracoplasty on pulmonary function at 2-year follow-up among complex pediatric spine deformity patients. Complex pediatric spine deformities may be associated with significant rib prominence causing body image concerns. Surgical correction of spine deformity may include thoracoplasty to correct the rotational prominence. Some surgeons refrain from performing thoracoplasty due to its purported negative effect on pulmonary function. There is paucity of literature on the effect of thoracoplasty on pulmonary function at 2-year follow-up in pediatric patients with complex spine deformity. METHODS: We reviewed data of 312 patients (> 100°, with or without vertebral column resection (VCR)) or (< 100° with VCR)) from an international multicenter database. Data of 106 patients with complete radiographic and pulmonary function test (PFT) assessment with a minimum of 2-year follow-up was analyzed. Paired t test was performed to compare pre-op and 2-year PFT results. PFT comparison was stratified based on thoracoplasty status (thoracoplasty: Group 1 vs. no thoracoplasty: Group 2). RESULTS: 106 patients (61 patients Group 1 vs. 45 in Group 2). The average age and gender ratio were similar in both groups (p > 0.05). Group 1 had significantly lower body mass index (BMI) compared to Group 2 (18.4 kg m-2 ± 2.8 vs. 19.9 kg m-2 ± 4.8, p = 0.0351). The average baseline coronal and sagittal Cobbs were larger for Group 1 relative to Group 2 (p  < 0.05). The distribution of deformity etiology and curve types, and apices were similar between the two groups (p  >  0.05). The rate of pre-op utilization of halo gravity traction (HGT) was 52.5% vs. 26.7% (p  =  0.008), at an average duration of 103 days vs. 47 days, p  =  0.0001. The rate of surgical osteotomies was similar in both groups. Estimated blood volume (EBV) loss was greater in Group 1 (63.1% vs. 43.1%, p  =  0.0012). Post-op coronal and sagittal Cobb correction was similar in both groups. The incidence of post-op pulmonary complication was similar in both groups (8.2% vs. 8.9%, p  =  0.899). Baseline and 2-year follow-up PFT did not differ significantly between and within the groups. Vertebral column resection (VCR) did not negatively affect PFT in both groups. CONCLUSION: Despite higher curve magnitudes in patients undergoing surgical correction and thoracoplasty for complex pediatric spine deformity, our findings revealed that thoracoplasty does not negatively affect pulmonary function at 2-year follow-up.

Postoperative Pulmonary Complications in Complex Pediatric and Adult Spine Deformity: A Retrospective Review of Consecutive Patients Treated at a Single Site in West Africa.

STUDY DESIGN: Retrospective review of consecutive series. OBJECTIVES: This study sought to assess the incidence, risk factors, and outcomes of pulmonary complication following complex spine deformity surgery in a low-resourced setting in West Africa. METHODS: Data of 276 complex spine deformity patients aged 3 to 25 years who were treated consecutively was retrospectively reviewed. Patients were categorized into 2 groups during data analysis based on pulmonary complication status: group 1: yes versus group 2: no. Comparative descriptive and inferential analysis were performed to compare the 2 groups. RESULTS: The incidence of pulmonary complication was 17/276 (6.1%) in group 1. A total of 259 patients had no events (group 2). There were 8 males and 9 females in group 1 versus 100 males and 159 females in group 2. Body mass index was similar in both groups (17.2 vs 18.4 kg/m2, P = .15). Average values (group 1 vs group 2, respectively) were as follows: preoperative sagittal Cobb angle (90.6° vs 88.7°, P = .87.), coronal Cobb angle (95° vs 88.5°, P = .43), preoperative forced vital capacity (45.3% vs 62.0%, P = .02), preoperative FEV1 (forced expiratory volume in 1 second) (41.9% vs 63.1%, P < .001). Estimated blood loss, operating room time, and surgery levels were similar in both groups. Thoracoplasty and spinal osteotomies were performed at similar rates in both groups, except for Smith-Peterson osteotomy. Multivariate logistic regression showed that every unit increase in preoperative FEV1 (%) decreases the odds of pulmonary complication by 9% (OR = 0.91, 95% CI 0.84-0.98, P = .013). CONCLUSION: The observed 6.1% incidence of pulmonary complications is comparable to reported series. Preoperative FEV1 was an independent predictor of pulmonary complications. The observed case fatality rate following pulmonary complications (17%) highlights the complexity of cases in underserved regions and the need for thorough preoperative evaluation to identify high-risk patients.

The efficacy and safety of intraoperative acute normovolaemic haemodilution in complex spine surgery in a private surgical facility in Ghana.

Objectives: To assess the safety and clinical benefits of intraoperative acute normovolaemic haemodilution (ANH) in complex spine surgery. Design: Prospective comparative cohort study. Setting: A private orthopaedic hospital in Ghana. Patients: Seventy-six patients who underwent complex spine deformity surgery. Interventions: Patients were randomly assigned to two groups. 45 patients to the acute normovolaemic haemodilution (ANH) or Group 1 and 31patients to the non-ANH or Group 2. Following anesthetic administration and before incision, autologous blood was collected from patients in Group1 and was reinfused during/shortly after surgery while patients in Group2 were transfused with compatible allogeneic blood intraoperatively. Main Outcome Measures: Changes in haemodynamic parameters and incidence of allogeneic transfusions and related complications. Results: The mean age (years), gender ratio, deformity size and aetiology, fusion levels, and operative times were similar in both groups. Blood loss (ml) of patients in groups 1 and 2 were 1583ml± 830.48 vs 1623ml ± 681.34, p=0.82, respectively. The rate of allogeneic blood transfusion in groups 1 and 2 were 71% vs 80.65%, p=0.88, respectively. Haemoglobin levels (g/dL) in groups 1 and 2 were comparable in both groups at Post-operative Day (POD) 0 and POD 1. Incidence of minor allogeneic transfusion reaction was 1/45 vs 1/31, p=0.80, group-1 and group-2, respectively. Conclusion: Acute normovolaemic haemodilution can be safely performed in complex spine surgery in underserved regions. However, its use does not obviate allogeneic transfusion in patients with complex spine deformities in whom large volumes of blood loss is expected. Funding: None declared.

The Use of Halo Gravity Traction in the Treatment of Severe Early Onset Spinal Deformity.

STUDY DESIGN: Retrospective Review of Prospective cohort. OBJECTIVE: To describe the feasibility of preoperative halo gravity traction (HGT) with subsequent growing rod/guided growth (GR/GG) placement in early onset spinal deformity (EOSD). SUMMARY OF BACKGROUND DATA: In children with severe EOSD, primary implantation of GR/GG constructs is not always possible. We describe a staged protocol with preoperative HGT followed by GR/GG implantation. METHODS: EOSD patients treated with HGT prior to GR/GG implantation were included. HGT used traction up to 50% body weight for 4 to 29 weeks. Pulmonary function tests (PFTs) were performed before and after HGT. Coronal Cobb (CC) and Sagittal Cobb (SC) angles were measured on the Pre-HGT, Post-HGT and 6 week postop x-rays. RESULTS: Thirty patients were included. Average age at GR/GG implantation was 9 years. Most cases (n = 24, 80%) were idiopathic. Most pts had kyphoscoliosis (n = 16, 53.3%). Pre-HGT CC averaged 112 ±â€Š22° and SC averaged 106 ±â€Š26°. CC and SC improved 29% after HGT. There was a significant improvement in body mass index following HGT. CC improved further to 70 ±â€Š14° (36% vs. pre-HGT) and SC to 63 ±â€Š21° (41%) with GR/GG placement. HGT-related complications occurred in nine patients (30%); eight pin site infections, one cranial abscess. Most HGT complications were managed with local pin care and oral antibiotics. Halo revision was required in two pts (6.7%). There was no change in PFTs with HGT (P > 0.05). Averagely, 14 levels were spanned during GR/GG implantation; two patients required vertebral column resection. Surgical complications occurred in nine (30%) patients. At average 16 month follow-up, seven patients (23.3%) required reoperation. CONCLUSION: Preoperative HGT can make severe EOSD curves amenable to GR/GG implantation. HGT results in ∼30% correction with improvement to ∼35-40% following GR/GG. HGT has a 30% complication rate but most are pin-site infections managed with pin-site care and oral antibiotics; 6.7% of patients require revision. LEVEL OF EVIDENCE: 4.

Erratum to Incidence and Risk Factors for Major Surgical Complications in Patients With Complex Spinal Deformity: A Report From an SRS GOP Site [Spine Deformity 3 (2015) 57-64].

The corresponding author regret that co-author name was incorrectly published as "Elias C. Papadopoulus" in the article. The correct name of the author should be displayed as "Elias C. Papadopoulos".

Halo Gravity Traction Can Mitigate Preoperative Risk Factors and Early Surgical Complications in Complex Spine Deformity.

STUDY DESIGN: Retrospective review of prospective cohort. OBJECTIVE: We sought to examine the role of halo gravity traction (HGT) in reducing preoperative surgical risk. SUMMARY OF BACKGROUND DATA: The impact of HGT on procedure choice, preoperative risk factors, and surgical complications has not been previously described. METHODS: Patients treated with HGT before primary surgery were included. The FOCOS Score (FS) was used to quantify operative risk. FS was calculated using patient-factors (ASIA, body mass index, etiology), procedure-factors (PcF; osteotomy planned, number of levels fused, etc.), and curve magnitude (CM). Scores ranged from 0 to 100 with higher scores indicating increased risk. FS was calculated before and after HGT to see how changes in FS affected complication rates. RESULTS: A total of 96 patients were included. Halo-related complications occurred in 34% of patients but revision was required in only 8.3%. Average FS improved by 18 points after HGT. CM, PcF, and patient-factors all improved (P < 0.05). The greatest changes were in CM and PcF. The planned rate of three-column osteotomies dropped from 91% to 38% after HGT. FS (area under the curve [AUC]: 0.68, P = 0.023) and change in FS (AUC: 0.781, P < 0.001) was successfully able to predict the rate of surgical complications. A preoperative FS of 74 was identified as a cut-off for a higher rate of surgical complications (sensitivity 58.8%, specificity 74.7%). Patients with a reduction in FS <  = 10pts were five times more likely to have a complication (relative risk 5.2, 95% confidence interval: 1.9-14.6, P < 0.001). A multivariate regression showed that change in FS was an independent predictor of complication rates (P < 0.05). CONCLUSION: FS can successfully predict surgical risk in pediatric patients with complex spinal deformity. Preoperative HGT can reduce FS and surgical risk by improving CM, lowering three-column osteotomies use, and improving body mass index. A reduction in FS after HGT predicts a lower rate of surgical complications. LEVEL OF EVIDENCE: 3.

Apex of deformity for three-column osteotomy. Does it matter in the occurrence of complications?

BACKGROUND: Posterior vertebral column resection (PVCR) is a challenging but effective technique for the correction of complex spinal deformity. However, it has a high complication rate and carries a substantial risk for neurologic injury. PURPOSE: The aim was to test whether the apex of the deformity influences the clinical outcomes and complications in patients undergoing PVCR. STUDY DESIGN: A historical cohort was recruited from a single center and evaluated preoperatively, postoperatively, and at final follow-up. PATIENT SAMPLE: Ninety-eight hyperkyphotic patients undergoing PVCR were included. Inclusion criteria consisted of kyphoscoliosis and hyperkyphosis surgically treated with PVCR as a primary or revision procedure. OUTCOME MEASURES: The outcome measures included a number of neurologic complications. METHODS: Receiver operator characteristic (ROC) curve analysis and Youden index (J) were used to estimate the optimum cut-off to predict neurologic complications for each potential risk factor. In three ROC analyses, we included separately body mass index (BMI), kyphosis degree, and age as independent variables and neurologic complications as the dependent variable. Logistic regression was used to estimate the odds ratios (ORs) and construct 95% confidence intervals (CIs). RESULTS: Among the 98 patients, the etiologies were: post infectious (50), congenital (31), and others (17). The averages were: age 14±6.5 years, BMI 20±10 kg/m(2), American Society of Anesthesiologists 3±0.7, forced vital capacity 76±23%, fusion levels 10±3, estimated blood loss 1,319±720 mL, surgical time 375±101 minutes, and preoperative localized kyphosis 104±30°. Thirty-three patients had abnormal preoperative neurologic status. Major complications occurred in 46 patients (neurologic in 25). The apex of kyphosis was proximal thoracic T1-T5 (five patients), thoracic (TH) T6-T9 (17 patients), thoracolumbar T10-L2 (55 patients), and lumbar L3-S1 (nine patients). The level of apex and BMI were independent risk factors for neurologic complications: TH apex (OR: 101.30, 95% CI: 1.420-infinite; p=.037); BMI (OR: 1.92, 95% CI: 1.110-infinite; p=.026). CONCLUSIONS: Posterior vertebral column resection for severe spine deformity is technically demanding and carries a substantial risk. The apex is a variable that influences the occurrence of neurologic complications, and the presence of a TH apex in particular could be a preoperative risk factor for neurologic complications.

Preoperative halo-gravity traction for severe spinal deformities at an SRS-GOP site in West Africa: protocols, complications, and results.

STUDY DESIGN: Retrospective analysis of a prospectively collected single-center database. OBJECTIVE: We describe a modified halo-gravity traction (HGT) protocol for patients with severe spinal deformities in West Africa, and assess the clinical and radiographic outcomes. SUMMARY OF BACKGROUND DATA: Three-column osteotomies are frequently used in the correction of severe spinal deformities; however, these can be associated with high complication rates and significant risk for neurological injury. Preoperative traction is one modality used to obtain a partial correction prior to definitive fusion. Low numbers and variability of traction protocols, however, have limited previous reports of sustained HGT. METHODS: All patients who underwent HGT in Ghana from April 2012 to August 2013 were reviewed. HGT was started at 20% body weight and increased by 10% per week until 50% body weight was reached by 4 weeks or thereafter as tolerated. Demographic variables, operative data, radiographic parameters, and health-related quality of life scores were collected. A deformity reduction index was calculated at each time point by summing the scoliosis and abnormal kyphosis for each patient and reported as a percentage of the preoperative deformity. RESULTS: Twenty-nine patients underwent HGT for an average 107 days prior to definitive posterior spinal fusion (24 patients) or placement of growing rods (5 patients). The major curve improved from an average 131° to 90° (31%) after HGT, and to an average 57° (56%) postoperatively. Pure kyphotic curves were rigid (flexibility 22% after traction), with a correction index of 3.88, which is similar to historical controls. Deformity correction with HGT plateaued at 63 days. Overall Scoliosis Research Society-22 questionnaire scores improved significantly pretraction versus postoperatively, but there was no change after traction versus before traction. There were 11 pin tract infections, with no neurological complications. CONCLUSION: HGT is a safe method to partially correct severe spinal deformities prior to a definitive procedure, and may reduce the need for higher risk 3-column osteotomies. Importantly, kyphosis secondary to infection with spontaneous apical ankylosis is relatively resistant to HGT. LEVEL OF EVIDENCE: 4.

Incidence and Risk Factors for Major Surgical Complications in Patients With Complex Spinal Deformity: A Report From an SRS GOP Site.

STUDY DESIGN: Retrospective analysis of a prospectively collected single-center database. OBJECTIVES: To report the incidence of and identify risk factors for perioperative complications in surgically treated pediatric and adult patients with complex spine deformities in an underserved region and Scoliosis Research Society Global Outreach Program site. SUMMARY OF BACKGROUND DATA: Surgical treatment for complex spinal deformity is challenging and requires a multidisciplinary approach for optimal management. The incidence and risk factors for major perioperative complications in outreach sites with limited resources are unknown. METHODS: A total of 427 consecutive patients who underwent instrumented spinal fusion for complex spinal deformities were reviewed. Clinical, radiographic, and demographic data were reviewed at preoperative and postoperative time points, and potential risk factors for perioperative complications were assessed. The authors performed multivariate logistic regression analysis (LRA) to determine independent risk factors for postoperative complications and neurological deficits. RESULTS: Major complications were seen in 85 cases, which consisted of neurologic deficits (n = 27; 17 transient and 10 permanent), wound infections (n = 17), implant-related problems (n = 35), progressive deformity (n = 13), and death (n = 6). Among the possible risk factors, univariate LRA indicated 3-column osteotomies as a risk factor for postoperative major complications and multivariate LRA indicated 3-column osteotomies as an independent risk factor for neurological deficit. Curves 100° and above were at higher risk for complications. CONCLUSIONS: Postoperative complications were seen in 20% of surgically treated patients with complex spine deformities at a Scoliosis Research Society SRS Global Outreach Program site. Three-column osteotomies were identified as an independent risk factor of both postoperative complications and neurological deficits. The significant observed correlation of 3-column osteotomies and postoperative neurological deficits should serve as a guide for surgeons in the preoperative planning and management of severe spinal deformities, especially in locations with limited resources. Patients undergoing correction of large curves may also have a higher complication rate.