Strategies reducing risk of surgical-site infection following pediatric spinal deformity surgery.

BACKGROUND: Identifying beneficial preventive strategies for surgical-site infection (SSI) in individual patients with different clinical and surgical characteristics is challenging. The purpose of this study was to investigate the association between preventive strategies and patient risk of SSI taking into consideration baseline risks and estimating the reduction of SSI probability in individual patients attributed to these strategies. METHODS: Pediatric patients who underwent primary, revision, or final fusion for their spinal deformity at 7 institutions between 2004 and 2018 were included. Preventive strategies included the use of topical vancomycin, bone graft, povidone-iodine (PI) irrigations, multilayered closure, impermeable dressing, enrollment in quality improvement (QI) programs, and adherence to antibiotic prophylaxis. The CDC definition of SSI as occurring within 90 days postoperatively was used. Multiple regression modeling was performed following multiple imputation and multicollinearity testing to investigate the effect of preventive strategies on SSI in individual patients adjusted for patient and surgical characteristics. RESULTS: Univariable regressions demonstrated that enrollment in QI programs and PI irrigation were significantly associated, and topical vancomycin, multilayered closure, and correct intraoperative dosing of antibiotics trended toward association with reduction of SSI. In the final prediction model using multiple regression, enrollment in QI programs remained significant and PI irrigation had an effect in decreasing risks of SSI by average of 49% and 18%, respectively, at the individual patient level. CONCLUSION: Considering baseline patient characteristics and predetermined surgical and hospital factors, enrollment in QI programs and PI irrigation reduce the risk of SSI in individual patients. Multidisciplinary efforts should be made to implement these practices to increase patient safety. LEVEL OF EVIDENCE: Prognostic level III study.

A Clinical Risk Model for Surgical Site Infection Following Pediatric Spine Deformity Surgery.

BACKGROUND: Despite tremendous efforts, the incidence of surgical site infection (SSI) following the surgical treatment of pediatric spinal deformity remains a concern. Although previous studies have reported some risk factors for SSI, these studies have been limited by not being able to investigate multiple risk factors at the same time. The aim of the present study was to evaluate a wide range of preoperative and intraoperative factors in predicting SSI and to develop and validate a prediction model that quantifies the risk of SSI for individual pediatric spinal deformity patients. METHODS: Pediatric patients with spinal deformity who underwent primary, revision, or definitive spinal fusion at 1 of 7 institutions were included. Candidate predictors were known preoperatively and were not modifiable in most cases; these included 31 patient, 12 surgical, and 4 hospital factors. The Centers for Disease Control and Prevention definition of SSI within 90 days of surgery was utilized. Following multiple imputation and multicollinearity testing, predictor selection was conducted with use of logistic regression to develop multiple models. The data set was randomly split into training and testing sets, and fivefold cross-validation was performed to compare discrimination, calibration, and overfitting of each model and to determine the final model. A risk probability calculator and a mobile device application were developed from the model in order to calculate the probability of SSI in individual patients. RESULTS: A total of 3,092 spinal deformity surgeries were included, in which there were 132 cases of SSI (4.3%). The final model achieved adequate discrimination (area under the receiver operating characteristic curve: 0.76), as well as calibration and no overfitting. Predictors included in the model were nonambulatory status, neuromuscular etiology, pelvic instrumentation, procedure time ≥7 hours, American Society of Anesthesiologists grade >2, revision procedure, hospital spine surgical cases <100/year, abnormal hemoglobin level, and overweight or obese body mass index. CONCLUSIONS: The risk probability calculator encompassing patient, surgical, and hospital factors developed in the present study predicts the probability of 90-day SSI in pediatric spinal deformity surgery. This validated calculator can be utilized to improve informed consent and shared decision-making and may allow the deployment of additional resources and strategies selectively in high-risk patients. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Epiphysiodesis for Leg Length Discrepancy: A Cost Analysis of Drill Versus Screw Technique.

Research has demonstrated similar efficacy of drill epiphysiodesis and percutaneous epiphysiodesis using transphyseal screws for the management of adolescent leg length discrepancy. A cost analysis was performed to determine which procedure is more cost-effective. Patients seen for epiphysiodesis of the distal femur and/or proximal tibia and fibula between 2004 and 2017 were reviewed. A decision analysis model was used to compare costs. Two hundred thirty-five patients who underwent either drill (155/235, 66%) or screw (80/235, 34%) epiphysiodesis were analyzed with an average age at initial procedure of 13 years (range, 8.4 to 16.7 years). There was no significant difference in average initial procedure cost or total cost of all procedures across treatment groups (n = 184). The cost difference between drill and screw epiphysiodesis is minimal. In order for screw epiphysiodesis to be cost-favored, there would need to be a significant decrease in its cost or complication rate. (Journal of Surgical Orthopaedic Advances 30(3):181-184, 2021).

Perioperative acute neurological deficits in instrumented pediatric cervical spine fusions.

OBJECTIVE: Pediatric cervical deformity is a complex disorder often associated with neurological deterioration requiring cervical spine fusion. However, limited literature exists on new perioperative neurological deficits in children. This study describes new perioperative neurological deficits in pediatric cervical spine instrumentation and fusion. METHODS: A single-center review of pediatric cervical spine instrumentation and fusion during 2002-2018 was performed. Demographics, surgical characteristics, and neurological complications were recorded. Perioperative neurological deficits were defined as the deterioration of preexisting neurological function or the appearance of new neurological symptoms. RESULTS: A total of 184 cases (160 patients, 57% male) with an average age of 12.6 ± 5.30 years (range 0.2-24.9 years) were included. Deformity (n = 39) and instability (n = 36) were the most frequent indications. Syndromes were present in 39% (n = 71), with Down syndrome (n = 20) and neurofibromatosis (n = 12) the most prevalent. Eighty-seven (48%) children presented with preoperative neurological deficits (16 sensory, 16 motor, and 55 combined deficits).A total of 178 (96.7%) cases improved or remained neurologically stable. New neurological deficits occurred in 6 (3.3%) cases: 3 hemiparesis, 1 hemiplegia, 1 quadriplegia, and 1 quadriparesis. Preoperative neurological compromise was seen in 4 (67%) of these new deficits (3 myelopathy, 1 sensory deficit) and 5 had complex syndromes. Three new deficits were anticipated with intraoperative neuromonitoring changes (p = 0.025).Three (50.0%) patients with new neurological deficits recovered within 6 months and the child with quadriparesis was regaining neurological function at the latest follow-up. Hemiplegia persisted in 1 patient, and 1 child died due a complication related to the tracheostomy. No association was found between neurological deficits and indication (p = 0.96), etiology (p = 0.46), preoperative neurological symptoms (p = 0.65), age (p = 0.56), use of halo vest (p = 0.41), estimated blood loss (p = 0.09), levels fused (p = 0.09), approach (p = 0.07), or fusion location (p = 0.07). CONCLUSIONS: An improvement of the preexisting neurological deficit or stabilization of neurological function was seen in 96.7% of children after cervical spine fusion. New or progressive neurological deficits occurred in 3.3% of the patients and occurred more frequently in children with preoperative neurological symptoms. Patients with syndromic diagnoses are at higher risk to develop a deficit, probably due to the severity of deformity and the degree of cervical instability. Long-term outcomes of new neurological deficits are favorable, and 50% of patients experienced complete neurological recovery within 6 months.

The AOSpine thoracolumbar spine injury classification system: A comparative study with the thoracolumbar injury classification system and severity score in children.

BACKGROUND: There is no uniform classification in the pediatric population for thoracolumbar (TL) fractures, nor any operative guidelines. This study evaluates the AOSpine TL spine injury classification in the pediatric population and compares it to the thoracolumbar injury classification system (TLICS), which has previously been validated in pediatric spine trauma. METHODS: Twenty-eight patients with operative TL injuries were identified from 2006 to 2016. Inclusion criteria included available imaging, operative records, age <18, and posterior approach. Each case was classified by AOSpine TL spine injury classification and TLICS. Each classification was compared to documented intraoperative posterior ligamentous complex (PLC) integrity as well as each other. RESULTS: Utilizing the AOSpine TL spine injury classification, 7 patients had type A injuries, 15 patients had type B injuries, and 6 patients had type C injuries; 21 patients had injuries classified as involving the PLC. Using TLICS, 16 patients had burst fractures, 6 patients had distraction injuries, and 6 patients had translation injuries; 21 patients had injuries classified as involving the PLC. Spearman correlation analysis substantiated convergence of AOSpine TL spine injury classification scores to TLICS scores (r = 0.75; 95% confidence interval, CI = 0.51 to 0.98; P < .001). Concordance between PLC integrity by each classification and intraoperative evaluation was 96% (27/28) of cases (k = 0.91; 95% CI = 0.73 to 1.08). Neurologic status was 100% concordant between the AOSpine TL spine injury classification and TLICS. CONCLUSION: There is high statistical correlation between the AOSpine TL spine injury classification and TLICS, and to intraoperative evaluation of the PLC, suggesting that the AOSpine TL spine injury classification is applicable to the pediatric population. LEVEL OF EVIDENCE: III.

Management of Spinal Implants in Acute Pediatric Surgical Site Infections: A Multicenter Study.

STUDY DESIGN: A retrospective review of patients who underwent posterior spinal fusion (PSF) and returned within 90 days with an acute infection. OBJECTIVES: The study motive is to identify and understand the risk factors associated with failure of retaining spinal implants and failure to treat acute infection. BACKGROUND: The natural history of early surgical site infection (SSI) (less than 3 months) after PSF is not known and removing the implants early after PSF risks pseudarthrosis and deformity progression. METHODS: Patients ranging from 1999 to 2011 with surgical site infections (SSIs) who required irrigation and debridement within 3 months of PSF were identified from 4 institutions. Univariable and multivariable regression analysis were used to identify risk factors associated with failure of acute infection treatment. RESULTS: Eighty-two patients (59 female, 23 male) with a mean age of 13.6 years were identified. Median follow-up after initial surgery was 33 months (range: 12-112 months). Sixty-two (76%) were treated successfully with acute treatment and did not return with recurrent infection (cleared infection, group C); 20 (24%) returned later with chronic infection (recurrent infection, group R). Multivariable analysis indicated that patients with stainless steel implants (OR = 6.4, 95% CI = 1.7-32.1; p = .009) and older subjects (OR = 1.3, 95% CI = 1.0-1.6; p = .03) were more likely to present with recurrent infection. There was no difference between the groups with regard to the initial time of presentation post fusion, proportion of non-idiopathic diagnosis, rate of positive cultures, culture species, presence of fusion to pelvis, and time on antibiotic treatment. CONCLUSIONS: Seventy-six percent of patients presenting with an SSI less than 3 months after PSF did not require implant removal to clear their infection. Early postoperative SSIs can be treated with retention or implant exchange. Older patients and patients with stainless steel instrumentation are more likely to present with a late recurrent infection compared to other metals. LEVEL OF EVIDENCE: Level III.

Neonatal C1 TO C2 osteomyelitis leading to instability and neurological decline: novel treatment with occiput-C1-C2 fusion and occiput to thorax growing rods. A case report.

BACKGROUND: Vertebral osteomyelitis of the upper cervical spine requiring surgical treatment in children is rare. Surgical treatment of the immature spine is commonly associated with certain risks and complications. We describe a unique treatment approach for a young child that required emergent stabilization of the upper cervical spine due to progressive instability caused by osteomyelitis. METHODS: A 3-month-old infant with neurological decline from progressive instability of the occiput C1 and C2 was admitted for surgical treatment after failed bracing. The patient had reduction and occiput to C2 posterior fusion and segmental instrumentation, with nonsegmental instrumentation extending in the soft tissues from C2 to T4 with the intent of providing stabilization without fusion and permitting further growth. RESULTS: The implants were removed 1 year after the original procedure. At 2 years following implant removal, he continued to have mild global developmental delay but was progressing well and was able to navigate independently with a posterior walker, using AFOs for support. Subaxial cervical motion and x-ray appearance were normal. CONCLUSIONS: The technique used here to overcome the difficulty of providing secure immobilization of the craniocervical junction while not creating inadvertent fusion of the subaxial cervical spine may have application in other clinical situations. LEVEL OF EVIDENCE: Level V.