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.

Surgical outcomes of severe spinal deformities exceeding 100° or treated by vertebral column resection (VCR). Does implant density matter?: an observational study of deformity groupings.

STUDY DESIGN: Prospective multicenter international observational study. OBJECTIVE: To investigate the effect of implant density on clinical outcomes in complex pediatric spine reconstruction. Implant density in spine deformity surgery has been a subject of much debate with some authors advocating higher density for better correction. Few studies have looked at the effect of implant density on severe curves > 100 deg or treated with vertebral column resection (VCR). METHODS: 250/311 pts with 2-year f/u enrolled in the FOX pediatric database from 17 international sites were queried for the impact of implant density and surgical outcomes. Patients were grouped into three implant density categories for comparative analysis Group 1 (density ≤ 1), Group 2 (1 < density < 1.5) and Group 3 (density; 1.5-2). RESULTS: 250 pts: 47 (Grp1)/99 (Grp2) /104 (Grp3); Pre-op age and etiology and curve types were similar in all groups, but body mass index (BMI) was higher in Grp3. Grps 1 and 2 had significantly higher sagittal deformity angular ratio (S-DAR) compared to Grp 3 (p < 0.001). Pre-op Halo Gravity Traction (HGT) was used in 55.3%/44.4%/31.7%, p = 0.017; Grp1/Grp2/Grp3, respectively. Average duration of surgery (min) was higher in Grp3 relative to Grp1 only: 352.5/456.5/515.0, p = 0.0029. Blood loss was similar in all Grps. Rate of VCR, PSO and SPO was similar in all Grps. Pre-op Coronal Cobb avg 96.1/83.6/88.6, p = 0.2342, attained similar correction after HGT (24.6%/27.2%/23.2%, p = 0.4864. Coronal Cobb corrections at 2-year follow-up (FU) were (37.1%/40.3%/53.5%, p = 0.0004). Pre-op sagittal Cobb was (105.4/101.9/75.9, p < 0.01.), achieved similar %correction in HGT (19.1%/22.3%/22.5%, p = 0.6851) and at 2-year FU (39.6%/41.4%/29.8%, p = 0.1916). After adjusting for C-DAR, S-DAR, pre-op coronal and sagittal Cobb, etiology, curve types, age, BMI and number of rods in multivariate analysis, the odds of developing post-operative implant complication was 11 times greater in group 1 compared to group 3 (OR = 11.17,95% CI 2.34-53.32). There was significant improvement in SRS scores in all Grps at 2-year FU. CONCLUSION: Although higher implant density was observed to be associated with greater curve correction and lower rates of post-operative implant-related complication and revision in heterogeneous case groups, the results may not imply causality of implant density on the outcomes in severe pediatric spine reconstruction.

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.