Long-term reoperation rates following spinal fusion for neuromuscular scoliosis in nonambulatory patients with cerebral palsy.

PURPOSE: To describe the incidence of reoperation and factors contributing to surgical revision within a minimum of 10 years after spinal fusion for scoliosis in patients with nonambulatory cerebral palsy (CP). METHODS: We conducted a retrospective review of consecutive nonambulatory patients with CP who underwent primary spinal fusion at a single specialty care center with a minimum of 10 years from their index surgery (surgery dates 2001-2011). Causes of reoperation were classified as implant failure/pseudoarthrosis, surgical site infection (SSI), proximal junctional kyphosis, prominent/symptomatic implants, and implant removal. Reoperation rates with 95% confidence intervals were calculated for each time interval, and an actuarial survival curve was generated. RESULTS: 144 patients met inclusion criteria (mean age = 14.3 ± 2.6 years, 62.5% male); 85.4% had 5 years follow-up data; and 66.0% had 10 years follow-up data. Estimates from the actuarial analysis suggest that 14.9% (95% CI: 10.0-22.0) underwent reoperation by 5 years postsurgery, and 21.7% (95% CI: 15.4-30.1) underwent reoperation by 10 years postsurgery. The most common causes for reoperation were implant failure/pseudoarthrosis, SSI, and prominent/symptomatic implants. CONCLUSIONS: To our knowledge, this study is the largest long-term follow-up of nonambulatory patients with CP and neuromuscular scoliosis who underwent spinal fusion. Approximately 22% of these patients required reoperation 10 years after their index surgery, primarily due to implant failure/pseudoarthrosis, SSI, and prominent/symptomatic implants. Complications and reoperations continued throughout the 10 years period after index surgery, reinforcing the need for long-term follow-up as these patients transition into adulthood. LEVEL OF EVIDENCE: III.

Ultra-long-term follow-up of pediatric spinal deformity problems: 23 patients with a mean follow-up of 51 years.

BACKGROUND: The aim of this study was to analyze the true outcomes of a unique cohort of patients with spinal deformities who were treated as children and followed for 40 or more years. METHODS: Altogether, 23 patients were reviewed who had been originally treated in our community, whose original charts and radiographs were still available, and who had undergone recent evaluation. RESULTS: The diagnoses were congenital deformity in eight, adolescent idiopathic scoliosis in four, poliomyelitis in three, infantile idiopathic scoliosis in two, spondylolisthesis in two, and one each of tuberculosis and dwarfism. Sixteen had undergone fusion surgery. CONCLUSIONS: Early spine fusion for deformity produced far better results than delayed fusion. A solid fusion at the end of growth remained unchanged. Degenerative changes outside the fusion area were rare and seldom required further surgery. In summary, 23 patients with a mean follow-up of 51 years after treatment are presented. Early fusion was far superior to delayed or nonsurgical treatment.

Multiple diagnostic X-rays for spine deformities and risk of breast cancer.

BACKGROUND: Ionizing radiation is a well-established human mammary carcinogen. Women historically monitored by radiography at young ages for abnormal spinal curvature are an exposed population suitable for investigating radiation-related risk and its variation by modifying factors. In this historic cohort, 95% of daily dose increments (when exposure to the breast occurred) were under 2.4 cGy, with mean 1.1 cGy. METHODS: A retrospective cohort of 3,010 women, diagnosed with spinal curvature between 1912 and 1965 in 14 U.S. pediatric orthopedic centers and who completed a questionnaire by telephone interview or mail survey in 1992, were studied for risk of breast cancer by radiation dose to the breast (mean, 12 cGy) after adjustment for established breast cancer risk factors. RESULTS: A borderline-significant radiation dose response (excess relative risk/Gy = 2.86; P = 0.058; one-tailed P = 0.029) was observed during 118,905 woman-years of follow-up (median, 35.5 years) based on 78 cases of invasive breast cancer. The dose response was significantly greater (P = 0.03) for women who reported a family history of breast cancer in first- or second-degree relatives (excess relative risk/Gy = 8.37; 95% confidence interval, 1.50-28.16). Radiation-related risk did not vary significantly by stage of reproductive development at exposure. CONCLUSIONS: Assuming that repair of radiation-related DNA damage requires at most a few hours, our data argue against existence of a low-dose threshold on the order of 1 to 3 cGy for radiation exposure contributing to breast carcinogenesis. The possibility that a family history of breast cancer may have enhanced a carcinogenic radiation effect requires confirmation in other studies.

Revision lumbar arthrodesis for the treatment of lumbar cage pseudoarthrosis: complications.

STUDY DESIGN: A study documenting major complications encountered in revision procedures for lumbar cage pseudoarthrosis. OBJECTIVE: To document the perioperative complications associated with revision surgery for threaded cylindrical cage pseudoarthrosis. SUMMARY OF BACKGROUND DATA: Pseudoarthrosis after cylindrical cage placement manifests as persistent or recurrent pain and disability after surgery. Revision strategies include isolated posterior stabilization and posterior bone grafting, versus circumferential revision where an attempt is made to remove the cages anteriorly, followed by posterior stabilization and fusion. Potential complications associated with these revision procedures have not been adequately documented in the past. METHODS: Forty-seven consecutive patients with the diagnosis of cylindrical cage pseudoarthrosis were surgically treated with either a circumferential revision (AP) or an isolated posterior instrumented fusion (P). All intraoperative and postoperative complications were documented. Radiographic interbody fusion rates and preoperative and postoperative visual analog scale (VAS) scores were documented. RESULTS: Three of the AP patients, all with anterior cage placement at L5-S1, had iliac vein lacerations requiring repair. A fourth patient had a ureteral injury requiring subsequent nephrectomy. Three patients who underwent circumferential revision and 2 patients who had an isolated posterior procedure had postoperative complications, including 2 infections (1 AP and 1 P), 1 radiculopathy (P), and 2 patients with prolonged ileus (both AP). There was a statistically significant decrease in overall VAS scores postoperatively for the 2 groups using the paired t test (P<0.0001). There was no difference in either the preoperative (P=0.22) or 2-year postoperative (P=0.30) VAS scores between the AP and P groups [rank-sum (Mann-Whitney) t tests]. Interbody fusion was achieved in 79% (30 of 38 levels) in the AP group. The interbody fusion rate was 37% (8 of 22) for the P group. CONCLUSIONS: Circumferential revision including cage removal, structural allograft placement, and posterior stabilization is associated with increased perioperative complications. Although an anterior approach showed increased interbody fusion rates, this technique did not lead to more superior clinical outcomes based on VAS scores. It remains to be shown by larger prospective studies if there is a true difference in outcome between these 2 groups that will justify the increased perioperative morbidity associated with attempted cage removal.

Long-term Outcome of Early Fusions for Congenital Scoliosis.

STUDY DESIGN: The current literature on outcomes of early fusions for early-onset scoliosis (EOS) has a short follow-up of 7.7 to 12.5 years, with many patients not at the end of growth. The forced vital capacity (FVC) at follow-up ranged from 40.8% to 64% of predicted. A study was undertaken to evaluate the long-term outcome of these fusions. METHODS: The study is of congenital patients who had a fusion under age 8 years, with the current age being >20 years. A follow-up consisting of radiographs, outcome questionnaires, and pulmonary function tests was performed. Of the 42 patients identified, 20 were traced and 11 agreed to participate, and completed all the data. The average follow-up was 37 years. All the fusions included the thoracic spine, with an average of 10.2 levels fused, of which an average of 8.8 levels were thoracic. RESULTS: The average scoliosis at presentation was 52°, 56° at surgery and 47° at follow-up. At follow-up, the average FVC was 53% of predicted, with an average PaO2 of 86 and PaCO2 of 44 mm Hg. The mean T1-T12 length was 20 cm. There was no correlation of the FVC percentage predicted and the proximal extent of the fusion, the T1-T12 length or the number of thoracic levels fused. The average ODI was 23. On the SF36, the average Physical Component t score was 50; with the average Mental Component t score was 52. CONCLUSION: At a long-term average follow-up of 37 years, the patients had a low FVC of 53%, with one on permanent oxygen and 5 with dyspnea. The patients were functioning well at follow-up, but it is unknown what their function would be without surgery or with longer follow-up.

Selective Thoracic Fusion for Adolescent Idiopathic Scoliosis: Long-Term Radiographic and Functional Outcomes.

INTRODUCTION: Selective thoracic fusions (STFs) were introduced by Moe to treat the structural thoracic curve when a more flexible lumbar component existed. It is unknown how the curves behave and how the patients function beyond 20 years after surgery. METHODS: Of the 152 eligible patients with STF, 67 were traced and contacted and 40 completed outcome questionnaires (Oswestry Disability index [ODI], Scoliosis Research Society-30 [SRS-30]) and had follow-up standing radiographs. The preoperative, postoperative, 1-year, and follow-up films were compared, and the lumbar spine on follow-up assessed for signs of degeneration-disc space narrowing, osteophyte formation, rotatory subluxation, and lateral spondylolisthesis. RESULTS: The average follow-up was 32.7 years. There were 27 Lenke 1C, 10 Lenke 2C, and 3 Lenke 1B curves. A posterior fusion was performed in 37, with a Harrington rod used in 28 and all-hook constructs in 12 with fusion to T10 (1), T11 (10), T12 (22), or L1 (7). The average preoperative right thoracic curves were 56.1°, 36.2° 1 year postoperation, and 38.6° at follow-up. The average preoperative lumbar curve was 44.6°, being 35.2° at 1 year postoperation, and 36.9° at follow-up. Five patients had additional surgery, 3 pseudarthrosis repairs (one with extension of the fusion to L4), 1 implant removal, and 1 microdiscectomy 35 years postoperatively. At follow-up, the average ODI was 8.7 (0-62) and the average SRS-30 3.8 (1.4-4.9). Nine patients took nonnarcotic medication, usually weekly or less, with only one taking daily narcotics. The most common lumbar radiographic finding was disc space narrowing at the apex of the lumbar curve, and osteophytes at L2-L3. There was no correlation of the lumbar changes to ODI, with a tendency to more medication use with longer follow-up (older subjects). CONCLUSION: At an average 33-year follow-up, the lumbar curve in STF is unchanged, with patients functioning well and mild radiographic changes in the lumbar spine.

Results of Bracing for Juvenile Idiopathic Scoliosis.

STUDY DESIGN: Retrospective comparative therapeutic clinical study evaluating the results of bracing for juvenile idiopathic scoliosis (JIS). OBJECTIVES: To evaluate if bracing has a role in treatment of JIS and, if so, to report its success rate and factors associated with successful bracing. SUMMARY OF BACKGROUND DATA: Patients with JIS have higher mortality and morbidity in comparison to those with adolescent idiopathic scoliosis (AIS) or general population. Untreated JIS may cause severe cardiorespiratory compromise. METHODS: All children treated at our institute and followed up until either skeletal maturity or surgeries between 1956 and 1999 with JIS were included. Those who had an incomplete set of radiographs or those treated by mere observation were excluded. RESULTS: One hundred twenty-five patients, comprising of 93 who were braced as juveniles and 32 who were braced in adolescence, met the inclusion criteria. Fifty-six of them were successfully treated by bracing (32 juveniles and 24 adolescents) and 69 patients needed surgery despite bracing. When final curves greater than 45° were regarded as failure of bracing, the success rate was 41%. The braces used were Milwaukee brace (MB) and thoraco-lumbo-sacral orthosis (TLSO) and no statistically significant difference was found between the two. None of the patients had surgery of any kind during the juvenile phase (ie, at age <10 years). DISCUSSION: The overall success rate with bracing was 41%. A third of them (ie, 18/56) could be safely weaned prior to skeletal maturity without risking curve progression. The odds of needing a surgery when braced as a juvenile was 2-in-3 (34% success), which fell to almost 1-in-4 for an adolescent (75% success) and was statistically significant (p = .001). Curves with Cobb angle ≤29° when braced progressed to a degree warranting surgery at a lower rate as compared to those ≥30°, this difference was not statistically significant (p = .22). CONCLUSION: Bracing obviated the need for surgery during juvenile years in all patients and was a successful delaying strategy.

Results and complications after spinal fusion for neuromuscular scoliosis in cerebral palsy and static encephalopathy using luque galveston instrumentation: experience in 93 patients.

STUDY DESIGN: Retrospective cohort analysis. OBJECTIVE: To evaluate the results of spine fusion for neuromuscular scoliosis in cerebral palsy and static encephalopathy, using Luque-Galveston technique, with emphasis on the early and late complications, especially those increasing the hospital stay or requiring additional surgery. SUMMARY OF BACKGROUND DATA: There are numerous studies in the literature on the treatment of neuromuscular scoliosis using Luque-Galveston instrumentation analyzing the results and complications. Most series are small and evaluate some of the complications, with none evaluating all the early and late complications and none assessing the impact of the complication on length of hospitalization or the need for additional surgical intervention. METHODS: This was a retrospective review of a consecutive series of patients operated on for neuromuscular scoliosis in cerebral palsy and static encephalopathy with Luque-Galveston instrumentation at 1 institution from January 1997 to December 2003. Ninety-three patients were identified. RESULTS: The average age at surgery was 14.3 years, with an average age at follow-up of 18.2 years, and an average follow-up of 3.8 years. The mean preoperative scoliosis was 72° with correction postoperatively to a mean of 33°, maintained at 36° at final follow-up. There were 83 early complications in 54 patients, for a complication rate of 58% of patients for the entire study. There were no perioperative deaths or neurological complications. There was only 1 deep wound infection, for an infection rate of 1.1%. Patients with 1 complication had a longer length of stay, 9 versus 7 days, the difference being statistically significant (Mann-Whitney U test, P < 0.001). Two patients required reoperation during the initial hospitalization (1.1%): 1, one for infection and 1 for proximal hook cutout and proximal junction kyphosis. There were a total of 81 late complications in 44 patients, for a late complication rate of 47% of patients for the entire study. The majority of the complications were minor, not requiring additional care or surgery. Seven patients had a pseudarthrosis (7.5%), presenting at an average of 30 months postoperatively. Eight patients underwent 9 procedures for late complications: 5 for repair of a pseudarthrosis, 3 for removal of a prominent iliac screw, and 1 for superior junctional kyphosis. All the pseudarthrosis repairs were solid at follow-up. CONCLUSION: Spinal fusion in neuromuscular scoliosis with Luque-Galveston technique is a safe and effective procedure. Any early complication increased the length of stay, with a low rate of reoperation during the hospitalization. The majority of late complications were minor, not requiring additional care. Pseudarthroses were detected late and were the main reason for additional surgery.