Length of stay, readmission, and mortality after primary surgery for pediatric spinal deformities: a 10-year nationwide cohort study.

BACKGROUND CONTEXT: Extended length of stay (extLOS) and unplanned readmissions after first time pediatric spinal deformity surgery are a considerable challenge to both the patient and the health-care system. To our knowledge, only a limited number of nationwide studies reporting short-term comorbidity with complete follow-up exist. PURPOSE: The purpose of this study was to identify the postoperative complications leading to extLOS, readmissions, and mortality within 90 days after surgery. Furthermore, to identify risk factors for readmission. DESIGN: Retrospective national cohort study. PATIENT SAMPLE: A nationwide registry study including all pediatric spinal deformity patients (≤21 years of age) undergoing primary surgery during 2006-2015 (n=1,310). OUTCOME MEASURES: Reasons for extLOS and 90-day readmissions as well as mortality risk. METHODS: Patients were identified by procedure and diagnosis codes in the Danish National Patient Registry (DNPR). Data on length of stay (LOS), readmissions, and mortality within 90 days were retrieved from the DNPR. Patients were categorized in six groups according to etiology. Reasons for extLOS and readmission were collected from medical records and discharge summaries. RESULTS: For the 1,310 patients, the median LOS was 8 days (interquartile range 7-9). Etiologies were idiopathic deformity (53%), neuromuscular deformity (23%), congenital/structural deformity (9%), spondylolisthesis (7%), Scheuermann kyphosis (5%), and syndromic deformity (3%). A total of 274 (21%) patients had extLOS and the most common reason was pain/mobilization issues but with considerable variation between etiologies; Scheuermann kyphosis (91%), idiopathic (59%), syndromic (44%), spondylolisthesis (38%), and congenital (30%). Pulmonary complications were the primary reason for extLOS in the neuromuscular group (22%). The 90-day readmission rate was 6%; 67% of readmissions were medical, mainly infections unrelated to the surgical site (23%); 33% of readmissions were surgical and 14% of patients required revision surgery. Neuromuscular deformity, spondylolisthesis, Scheuermann kyphosis, and LOS >9 days were independent risk factors for readmission; odds ratio (OR) 4.4 (95% confidence interval: 2.2-9.1, p<.01), OR 3.0 (1.1-8.0, p=.03), OR 4.9 (1.7-13.6, p<.01), and OR 1.8 (1.0-3.1, p=.04), respectively. The 90-day mortality risk was 0.4%. CONCLUSIONS: In this nationwide cohort, pain/mobilization issues are the most common reason for extLOS. The most common reason for readmission is infection unrelated to the surgical site. Readmission after pediatric spinal surgery is related to the etiology and increased focus on patients operated for neuromuscular deformity, spondylolisthesis and Scheuermann kyphosis is warranted.

Revision risk after pediatric spinal deformity surgery: a nationwide study with 2-year follow-up.

BACKGROUND CONTEXT: Revision risk after pediatric spine surgery is not well established and varies between deformity etiologies. PURPOSE: To report the 2-year revision risk following surgery for primary pediatric spinal deformity in a nationwide cohort and to evaluate potential risk factors and reasons for revision surgery. DESIGN: Retrospective nationwide cohort study. PATIENT SAMPLE: A national registry study of all pediatric spinal deformity patients undergoing surgery during 2006-2015 (n=1310). OUTCOME MEASURES: Two-year revision risk. METHODS: All patients ≤21 years of age undergoing spinal deformity surgery in Denmark during 2006-2015 were identified by procedure and diagnosis codes in the Danish National Patient Registry (DNPR). Data on revision surgery were retrieved from the DNPR. Patients were categorized in six groups according to etiology. Medical records were reviewed for reason for revision in all patients. Potential risk factors for revision were assessed with multiple logistic regression analyses and included age, etiology, sex, Charlson comorbidity index (CCI), and growth-preserving treatment. RESULTS: Patients were categorized according to etiology: idiopathic deformity (53%), neuromuscular deformity (23%), congenital/structural deformity (9%), spondylolisthesis (7%), Scheuermann's kyphosis (5%), and syndromic deformity (3%). Of 1,310 included patients, 9.2% underwent revision surgery within 2 years and 1.5% was revised more than once. Median time to revision was 203 (interquartile range 35-485) days. The multivariable logistic regression found significantly higher odds ratio (OR) for revision in patients with growth-preserving treatment (OR=5.1, 95% confidence interval [CI] 2.6-10.1), congenital deformity (OR=2.7, 95% CI 1.3-5.3), spondylolisthesis (OR=3.5, 95% CI 1.9-6.7), Scheuermann kyphosis (OR=3.9, 95% CI 1.9-8.3), and CCI score ≥3 (OR=2.5 95% CI 1.1-5.6). The most common reason for revision was implant failure (32.5%) followed by residual deformity and/or curve progression (15.8%). CONCLUSIONS: In this nationwide study, the 2-year revision risk after primary pediatric spinal deformity surgery is 9.2%. Risk factors for revision are etiology of congenital deformity, spondylolisthesis, Scheuermann kyphosis as well as patients with growth-preserving treatment and higher CCI. The most common reason for revision is implant failure.

Distraction-to-stall Versus Targeted Distraction in Magnetically Controlled Growing Rods.

BACKGROUND: Consensus is lacking regarding the lengthening procedures in magnetically controlled growing rods (MCGR), and no studies have compared the outcome between different distraction principles. The purpose of the present study was to compare distraction-to-stall with targeted distraction and identify variables associated with achieved distraction. METHODS: We performed a 2-center retrospective study of all children treated with MCGR from November 2013 to January 2019, having a minimum of 1-year follow-up and undergoing a minimum of 3 distractions. Exclusion criteria were single-rod constructs and conversion cases. In group 1 (21 patients), we used a distraction-to-stall (maximum force) principle where each rod was lengthened until the internal magnetic driver stopped (clunking). In group 2 (18 patients), we used a targeted distraction principle, where the desired distraction was entered the remote control before distraction. In both groups we aimed for maximal distraction and curve correction at index surgery. Achieved distraction was measured on calibrated radiographs and compared between the 2 groups using a linear mixed effects model. Univariate and multivariate analyses were performed to identify variables associated with achieved distraction within the first year. RESULTS: Mean age at surgery was 9.5±2.0 years. Etiology of the deformity was congenital/structural (n=7), neuromuscular (n=9), syndromic (n=3), or idiopathic (n=20). Demographics and preoperative characteristics including spinal height (T1T12 and T1S1) did not differ significantly between the groups (P≥0.13). Time interval between distractions were mean 18 days (95% confidence interval: 10-25) shorter in group 1. Implant-related complications occurred in 10/39 patients, 5 in each group. We found no difference in achieved distraction between the groups in the linear mixed effects model. In the multivariate analysis, preoperative major curve angle was the only independent variable associated with achieved distraction. CONCLUSIONS: In 2 comparable and consecutive cohorts of patients treated with MCGR, we found no difference in achieved distraction between a distraction-to-stall and a targeted distraction principle. Preoperative major curve angle was the only independent predictor of achieved distraction. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Long-term Survival After Surgical Treatment of Spinal Metastasis - The Predictive Role of Sex.

BACKGROUND/AIM: An increasing number of patients undergo surgical treatment for metastatic spinal cord compression (MSCC). However, the possible role of sex as an independent predictor of long-term survival has not been studied. This study aimed to examine whether sex is associated with long-term survival after surgical treatment in patients with MSCC. PATIENTS AND METHODS: A total of 110 patients were operated on for MSCC from 2005 through 2006. The relation between sex and overall survival was investigated. The follow-up period was 10 years. RESULTS: Survival time was significantly longer for women compared to men (mean±SD: 29±5.2 vs. 14±3.6 month (p=0.01). With adjusted analysis, this difference remained statistically significant. After adjusting for specific primary tumor type and time since surgery, the hazard-ratio of 10-year survival for men compared to women was 1.47 (95% confidence intervaI=1.01-2.18, p=0.048). CONCLUSION: These findings indicate that sex is associated with long-term survival in patients treated for MSCC.

Correction to: Evaluation of a new sagittal classification system in adolescent idiopathic scoliosis.

Unfortunately, the names of the members of the Texas Children's Hospital Spine Study Group have not been mentioned in the published article.

Evaluation of a new sagittal classification system in adolescent idiopathic scoliosis.

PURPOSE: The purpose of the present study was to validate a new spinal sagittal classification. METHODS: We retrospectively included 105 consecutive AIS patients who underwent posterior spinal fusion. Preoperative long-standing EOS radiographs were available on all patients. Patients were classified according to the four suggested sagittal patterns: type 1, 2a, 2b or 3. Several predetermined sagittal parameters were compared between the groups. RESULTS: The mean preoperative Cobb angle was 64° ± 12°, and 73% of the patients were female. Of 105 patients, 51 were type 1, 14 were type 2a, one was type 2b and 39 were type 3. The distribution of the four sagittal patterns was significantly different compared with the original publication (p < 0.05). However, the two study populations were comparable in terms of Lenke and Roussouly types (p = 0.49 and 0.47, respectively). In our study population, the sagittal groups differed significantly in terms of thoracic kyphosis, length of thoracic and lumbar curves, lumbar lordosis, thoracic slope, C7 slope, pelvic incidence and sacral slope (p < 0.05). CONCLUSION: The distribution of the four sagittal patterns varies between AIS cohorts. Type 2b was rare, which limits the clinical applicability. Contrary to the original publication, we found that the spinopelvic parameters lumbar lordosis, pelvic incidence and sacral slope were significantly different between the Abelin-Genevois types. Hence, the corrective surgical strategy may need to incorporate these spinopelvic parameters to achieve a balanced spine requiring a minimum of energy expenditure. These slides can be retrieved under Electronic Supplementary Material.

Neural Axis Abnormalities in Patients With Adolescent Idiopathic Scoliosis: Is Routine Magnetic Resonance Imaging Indicated Irrespective of Curve Severity?

OBJECTIVE: Magnetic resonance imaging (MRI)-verified neural axis abnormalities (NAAs) have been described in adolescent idiopathic scoliosis (AIS), and several risk factors have been associated with the presence of NAAs in AIS patients. However, the clinical significance of these findings is unclear. The purpose of the present study was to determine the prevalence of NAAs in a large consecutive cohort of AIS patients and to evaluate the clinical significance of previously proposed risk factors. METHODS: We prospectively included AIS patients referred to a tertiary facility for evaluation. Full-spine MRI scans were performed on all included patients irrespective of curve magnitude or proposed treatment modality. MRI scans were prospectively analyzed by a neuroradiologist and the pathologic findings were confirmed by a second independent radiologist. RESULTS: NAA was observed in 34 of the 381 patients (8.9%): 32 patients had a syrinx, 1 patient had an arachnoid cyst, and 1 patient had a Chiari malformation. Four patients were referred for a neurosurgical evaluation but none received any neurosurgical treatment. No statistically significant difference was observed between the NAA and non-NAA groups in terms of sex, major curve size, thoracic kyphosis, left thoracic curve, curve convexity, curve progression, or level of pain (p>0.05). CONCLUSION: In this prospective study examining the risk factors for NAA in AIS patients, we found that previously proposed risk factors could not predict the MRI outcomes. The finding of an NAA had no clinical implications and we do not support MRI scans as a routine diagnostic modality in all AIS patients.

A revision of the Tokuhashi revised score improves the prognostic ability in patients with metastatic spinal cord compression.

PURPOSE: The Tokuhashi revised score from 2005 (TR2005) is the most recommended prognostic scoring system in patients with metastatic spinal cord compression (MSCC). However, recent studies have questioned its prognostic ability and the need for a new revision has been proposed. We aimed to assess whether a revision of the TR2005 can improve the prognostic ability of the scoring system. METHODS: In 2011 and 2012, a total of 1143 consecutive patients admitted with MSCC were prospectively included in a 2011 and a 2012 cohort. For the patients admitted in 2011 (n = 544), the components of the TR2005 including primary cancer diagnosis were analyzed regarding the prognostic ability. Based on these findings, a revision of the TR2005 score was defined as the Tokuhashi revised score 2017 (TR2017). The prognostic abilities of the TR2005 and the TR2017 were compared by Kaplan Meyer (KM) curves, and receiver-operating characteristics' (ROC) analysis was compared in a cohort of patients admitted in 2012 (n = 599). RESULTS: KM curves and ROC analysis showed that the TR2017 had better prognostic ability compared to the TR2005. The ROC areas were as follows: <6-months survival, TR2017 = 0.71 and TR2005 = 0.65, and p = 0.003; for ≥6-month survival, TR2017 = 0.71 and TR2005 = 0.65, and p = 0.003; for ≥12-month survival TR2017 = 0.72 and TR2005 = 0.67, and p = 0.0015. CONCLUSIONS: The TR2017 can improve the prognostic ability of the TR2005 in patients with MSCC. This could affect the preoperative evaluation of patients suffering from MSCC.

Survival and health related quality of life after severe trauma - a 15 years follow up study.

INTRODUCTION: As the primary treatment of patients with severe trauma continues to improve, increasing interest has been directed towards long-term survival and Health Related Quality of Life (HRQoL). In trauma patients, there are few studies describing long-term outcome using tools specifically directed at HRQoL. HYPOTHESIS: HRQoL measured with EQ-5D is significantly reduced compared to the Danish norm score 15 years after severe injury. MATERIALS AND METHODS: All patients more than 18 years of age, admitted to a level 1 trauma center from March 1996 to September 1997 were prospectively included and scored with Injury Severity Score (ISS). Survival status was recorded in May 2012 and EQ-5D questionnaires were sent out. RESULTS: 95 of the original 154 trauma patients were eligible for participation. The response rate was 66%. The average EQ-5D index score in the trauma population was significantly reduced compared to the index score in the Danish norm population (P=0.00, one-sample t-test). In addition, ISS is associated with HRQoL and ISS≥16 predicts poorer HRQoL. CONCLUSION: EQ-5D is significantly reduced 15years after severe trauma High ISS was associated with low HRQoL. Knowledge of the distribution and predictors of long-term disability can be used to develop more efficient prevention policies and to improve trauma care in general.