Spinal deformity surgery is accompanied by serious complications: report from the Morbidity and Mortality Database of the Scoliosis Research Society from 2013 to 2020.

PURPOSE: The Morbidity and Mortality (M&M) report of the Scoliosis Research Society (SRS) has been collected since 1965 and since 1968 submission of complications has been required of all members. Since 2009, the SRS has collected information on death, blindness, and neurological deficit, with acute infection being added in 2012 and unintentional return to the operating room (OR) being added in 2017. In this report, we use the most recent data submitted to the SRS M&M database to determine the rate of neurological deficit, blindness, acute infection, unintentional return to the OR, and death, while also comparing this information to previous reports. METHODS: The SRS M&M database was queried for all cases from 2013 to 2020. The rates of death, vision loss, neurological deficit, acute infection, and unintentional return to the OR were then calculated and analyzed. The rates were compared to previously published data if available. Differences in complication rates between years were analyzed with Poisson regression with significance set at α = 0.05. RESULTS: The total number of cases submitted per year varied with a maximum of 49,615 in 2018 and a minimum of 40,464 in 2020. The overall reported complication rate from 2013 to 2020 was 2.86%. The overall mortality rate ranged from 0.09% in 2018 to 0.14% in 2015. The number of patients with visual impairment ranged from 4 to 13 between 2013 and 2015 (no data on visual impairment were collected after 2015). The overall infection rate varied from 0.95 in 2020 to 1.30% in 2015. When the infection rate was analyzed based on spinal deformity group, the neuromuscular scoliosis group consistently had the highest infection rate ranging from 3.24 to 3.94%. The overall neurological deficit rate ranged from 0.74 to 0.94%, with the congenital kyphosis and dysplastic spondylolisthesis groups having the highest rates. The rates of unintentional return to the OR ranged from 1.60 to 1.79%. Multiple groups showed a statistically significant decreasing trend for infection, return to the operating room, neurologic deficit, and death. CONCLUSIONS: Neuromuscular scoliosis had the highest infection rate among all spinal deformity groups. Congenital kyphosis and dysplastic spondylolisthesis had the highest rate of neurological deficit postoperatively. This is similar to previously published data. Contrary to previous reports, neuromuscular scoliosis did not have the highest annual death rate. Multiple groups showed a statistically significant decreasing trend in complication rates during the reporting period, with only mortality in degenerative spondylolisthesis significantly trending upwards. LEVEL OF EVIDENCE: Level III.

Use of a Standardized Perioperative Care Path for Adolescent Idiopathic Scoliosis Leads to Decreased Complications and Readmissions.

STUDY DESIGN: Retrospective review of patients ages 10-18 who underwent posterior fusion for adolescent idiopathic scoliosis (AIS) at a single institution from 2014 to 2019. OBJECTIVE: The aim was to evaluate a standardized Care Path to determine its effects on perioperative outcomes in patients undergoing spinal fusion for AIS. SUMMARY OF BACKGROUND DATA: AIS is the most common pediatric spinal deformity and thousands of posterior fusions are performed annually. Surgery presents several postoperative challenges, such as pain control, delayed mobilization, and opioid-related morbidity. Optimizing perioperative care of AIS is a high priority to reduce morbidity and improving health care efficiency. MATERIALS AND METHODS: A total of 336 patients ages 10-18 were included in this study; 117 in the pre-Care Path cohort (2014-2015) and 219 in the post-Care Path cohort (2016-2019). Data compared included intraoperative details, length of stay, timing of mobilization, inpatient complications, emergency room (ER) visits, readmissions after discharge, postoperative complications, and reoperations. RESULTS: The post-Care Path cohort had improved mobilization on postoperative day 0 (pre 16.7%, post 53.3%, P<0.00001), reduced length of stay (pre 4.14 days, post 3.36 days, P=0.00006), fewer total inpatient complications (pre 17.1%, post 8.1%, P=0.0469), and fewer instances of postoperative ileus (pre 8.5%, post 1.9%, P=0.0102). Within 60 days of surgery, the post-Care Path cohort had fewer ER visits (pre 12.8%, post 7.2%, P=0.0413), decreased postoperative infections (pre 5.1%, post 0.48%, P=0.00547), decreased readmissions (pre 6.0%, post 0.48%, P=0.0021), and decreased reoperations (pre 5.1%, post 0.96%, P=0.0195). There was a decrease in inpatient oral morphine equivalents in the Care Path cohort (pre 118.7, post 84.7, P=0.0003). CONCLUSIONS: Our Care Path for AIS patients demonstrated significant improvements in postoperative mobilization and decreases in length of stay, complications, infections, ER visits, readmissions, and reoperations.

Treatment of an Abscess of the Leg in a Febrile Child After Incidental Trauma from the Barb of a Freshwater Fish: A Case Report.

CASE: A 9-year-old boy suffered incidental trauma to the anterolateral leg from the barb of a freshwater fish. Within a few days of injury, the patient developed a fever and a deep abscess despite empiric antibiotic therapy. The underlying pathogen was Edwardsiella tarda. This study is the first report of such an abscess in a child, and similar reported cases have in adults have been associated with high rates of mortality. CONCLUSION: Penetrating soft-tissue trauma in association with an aquatic environment requires prompt evaluation. Empiric antibiotic regimens effective against terrestrial cellulitis may lack adequate gram-negative coverage for aquatically related injuries.

Liposomal Bupivacaine Is Both Safe and Effective in Controlling Postoperative Pain After Spinal Surgery in Children: A Controlled Cohort Study.

STUDY DESIGN: Retrospective comparative cohort study. OBJECTIVE: To evaluate: (1) pain relief efficacy; (2) opioid consumption; (3) length of stay (LOS); (4) discharge disposition (DD); and (5) safety and adverse effects of liposomal bupivacaine (LB) in pediatric patients who underwent spinal deformity correction. SUMMARY OF BACKGROUND DATA: LB is a long-acting, locally injectable anesthetic. Previous orthopedic studies investigating its use have been limited to adult patients. The use of LB as part of postoperative pain management in pediatric patients undergoing spine deformity correction surgery is yet to be evaluated. MATERIALS AND METHODS: A total of 195 patients that received LB as part of their postoperative pain management regimen were compared with 128 patients who received standard pain management without LB. Pain intensity, opioid consumption, LOS, and DD were recorded. Potential LB-related complications were reported as frequencies and statistically compared for superiority. Noninferiority tests were performed using the Farrington-Manning score test. Multivariate tests based on generalized estimating equations were performed to determine the common and average treatment effects. Odds ratios (OR) with 95% confidence intervals (CI) were calculated. RESULTS: The LB cohort demonstrated lower pain scores [postoperative day 1 (POD 1)-median=2, interquartile range (IQR)=(0-5) vs. 5 (2.5-7); POD 2-3 (0-5) vs. 4 (3-6); P<0.001], lower overall opioid consumption (78.2 vs. 129 morphine milligram equivalents; P=0.0001) and consistently from POD 0 to 3 (mean differences; 7.47, 9.04, 17.2, and 17.3 morphine milligram equivalents, respectively; P<0.01), shorter LOS (median=3 d, IQR=3-4 vs. 4 d, IQR=4-6; P<0.001), and similar to-home DD (98% vs. 97%). Complications were similar among the cohorts in superiority and 10% noninferiority analyses. Patients in the LB cohort had lower odds for complications (odds ratio=0.77; 95% CI, 0.64-0.93; P=0.009 and 0.67; 95% CI, 0.50-0.90; P=0.008). CONCLUSIONS: This study demonstrated the safety and efficacy of LB when added to the current multimodal postoperative pain management regimens after pediatric spinal surgery. LEVEL OF EVIDENCE: Level III.

Utilization of Telemedicine Virtual Visits in Pediatric Spinal Deformity Patients: A Comparison of Feasibility and Patient Satisfaction at a Large Academic Center.

BACKGROUND: Telemedicine platforms have been developed to support the convenient delivery of health care services to their patients while maintaining appropriate quality of care. However, it is unclear whether they can be utilized effectively in patients with pediatric spinal deformity (PSD). Therefore, this study aimed to evaluate the feasibility and patient satisfaction associated with virtual visit (VV) utilization in PSD patients in comparison to general pediatric orthopaedic indications. METHODS: Of the 482 VVs offered to pediatric orthopaedic patients at a large academic health care system between January 1, 2017, and December 31, 2018, a total of 189 VVs conducted by board-certified orthopaedic surgeons were included in the final analysis. Patient satisfaction scores were collected at the end of each VV by patient and parent rankings of the surgeon and the telemedicine service. Data on patients, visits, and connectivity sessions characteristics were collected and statistically compared between PSD visits (n=33) versus those conducted for general pediatric orthopaedic indications (n=156). RESULTS: Although PSD patients were older (15±3.7 vs. 12±4.7 y; P<0.01), mostly female (76% vs. 47%, P=0.003), and had longer VVs (8±4.6 vs. 5±3.6 min; P=0.003) versus their general pediatric orthopaedic counterparts, they demonstrated similarly high satisfaction scores for surgeon performance (5±0 vs. 4.8±0.1 points; P=0.08) and overall satisfaction (3±2.4 vs. 3.5±2.1; P=0.23). Approximately 80% of all VVs were conducted over mobile devices. Wait time was substantially less for PSD VVs relative to subsequent office visits (13±10 vs. 41±30 min; P<0.001). CONCLUSIONS: Our analysis found that telemedicine VVs provided a convenient alternative to traditional in-office visits for PSD patients. Specifically, we found that PSD patients received faster care with comparable satisfaction. The findings of our present analysis should encourage health care systems to continually evaluate and implement telehealth platforms to improve both the accessibility and appropriate quality of care. LEVEL OF EVIDENCE: Level IV.

Correction to: Removal of a urinary catheter before discontinuation of epidural analgesia is associated with an increased risk of postoperative urinary retention and hospital episode costs in patients undergoing surgical correction for adolescent idiopathic scoliosis.

The original version of this article unfortunately contained a mistake. The spelling of Erin Ohliger's name was incorrect.

Removal of a urinary catheter before discontinuation of epidural analgesia is associated with an increased risk of postoperative urinary retention and hospital episode costs in patients undergoing surgical correction for adolescent idiopathic scoliosis.

OBJECTIVES: In adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal instrumented fusion (PSIF), we aimed to answer these questions: (1) is there a difference in postoperative urinary retention (UR) rates among patients who had removal of their Foley catheters before vs. after discontinuation of epidural analgesia (EA)? (2) Can the timing of Foley catheter removal be an independent risk factor for postoperative UR requiring recatheterization? (3) Is there an incurred cost related to treating UR? STUDY DESIGN: Retrospective cohort. BACKGROUND: EA has been widely used for postoperative pain control after PSIF for AIS. In these patients, removing the Foley catheter, inserted for intraoperative monitoring of urine output, is indicated in the early postoperative period. However, a controversy exists as to whether it should be removed before or after the EA has been discontinued. METHODS: A single-institution, longitudinally maintained database was queried to identify 297 patients who met specific inclusion and exclusion criteria. Patient characteristics and the order and timing of removing the urinary and epidural catheters were collected. Rates of UR were statistically compared in patients who had early vs. late urinary catheter removal. A univariate and multivariate regression analysis was conducted to identify independent risk factors. Hospital episode costs were analyzed. RESULTS: Patients who had early (n = 66, 22%) vs. late (n = 231, 78%) urinary catheter removal had a significantly higher incidence of UR requiring recatheterization (15 vs. 4.7%, p = 0.007). Patient with early removal were almost 4 times more likely to develop UR requiring recatheterization [odds ratio (OR) 3.8, 95% confidence interval (CI) 1.5-9.7, p = 0.005]. UR incurred additional costs averaging $15,000/patient (p = 0.204). CONCLUSION: In patients who had PSIF for AIS, removal of a urinary catheter before discontinuation of EA is an independent risk factor for UR, requiring recatheterization and associated with increased cost. LEVEL OF EVIDENCE: III.

Predictors of Extended Length of Hospital Stay in Adolescent Idiopathic Scoliosis Patients Undergoing Posterior Segmental Instrumented Fusion: An Analysis of 407 Surgeries Performed at a Large Academic Center.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aims of this study were to (1) compare patient and procedure-specific characteristics among those who had short versus long hospital stays and (2) identify independent risk factors that may correlate with extended length of hospital stay (LOS) in patients with adolescent idiopathic scoliosis (AIS) who underwent posterior segmental instrumented fusion (PSIF). SUMMARY OF BACKGROUND DATA: Reducing the LOS and identifying risk factors associated with extended admission have become increasingly relevant to healthcare policy makers. There is currently limited research identifying risk factors that correlate with extended stay in patients undergoing PSIF for AIS. METHODS: A single-institution, longitudinally maintained database was queried to identify 407 patients who met specific inclusion and exclusion criteria. Based on the distribution and median LOS in the cohort (4 days), patients were divided into those who had long versus short LOS. In both groups, patient demographics, comorbidities, preoperative scoliosis curve measurements, surgery-related characteristics, and complications were analyzed. A univariate and multivariate regression analysis was then conducted to identify independent risk factors associated with extended LOS. RESULTS: Patients who had extended LOS tended to be women (84.6% vs. 75%, P = 0.01), had more levels fused (9 ±â€Š2 vs. 7 ±â€Š2 levels, P < 0.001), had more major postoperative complications (0.8% vs. 7.4%, P = 0.002), had more blood loss during surgery (723 ±â€Š548 vs. 488 ±â€Š341 cm, P < 0.001), and received less epidural analgesia for pain control (69% vs. 89%, P < 0.001). Except for higher thoracic kyphosis, long LOS patients did not have worse preoperative radiographic curve parameters. Multivariate logistic analysis identified female sex, having ≥9 ±â€Š2 levels of fusion, operative blood loss, major postoperative complications, lack of epidural analgesia, and higher thoracic kyphosis as independent risk factors correlating for extended LOS. CONCLUSION: Independent risk factors identified by this study may be used to recognize patients with AIS at risk of prolonged hospital stay. LEVEL OF EVIDENCE: 3.

Cervical sagittal alignment and the impact of posterior spinal instrumented fusion in patients with Lenke type 1 adolescent idiopathic scoliosis.

BACKGROUND: Clinical decision making, preoperative planning, and surgical correction for adolescent idiopathic scoliosis (AIS) has traditionally focused on obtaining the maximum coronal plane correction to improve cosmesis and function. More recently, restoring sagittal alignment has also received increasing attention in AIS patients, correlating with positive health-related quality of life (HRQOL) outcomes in multiple studies. In this realm, cervical sagittal alignment (CSA) has also emerged as one of the variables that may correlate with clinical and functional outcomes in AIS patients undergoing surgical correction. Several studies have focused on studying the cervical sagittal plane parameters in patients with spinal deformity, while few have investigated the impact of surgical correction on CSA. In this study, we aimed to capture the baseline cervical sagittal characteristics and evaluate the changes in CSA in a cohort of AIS patients with Lenke type I curves following posterior spinal instrumented fusion (PSIF). METHODS: We evaluated our longitudinal database of patients who had surgical correction for AIS between January 1, 2015 and September 1, 2017. The initial search yielded 270 patients. Next, the following inclusion criteria were applied to identify the study cohort: (I) patients who had Lenke type 1 curves, (II) patients with adequate pre-operative and post-operative radiographs (posterior-anterior and lateral), (III) patients who had a minimum radiographic follow-up of 6 months, and (IV) patients who were treated with the same standard rod instrumentation system. In addition, the following exclusion criteria were applied: (I) patients with neuromuscular disorders, (II) patients with prior spine surgery, and (III) those who received greater than Schwab-2 osteotomies. A total of 30 patients were included in our final analysis. The C2-C7 angle, C0-C2 angle, C2-C7 sagittal vertical axis (SVA), McGregor slope (McGS), and the T1 slope angle were measured preoperatively and at 6 months. A kyphotic measurement was assigned a negative value while positive values were used to describe lordotic measurements. Descriptive statistics and paired sample t-test were used to compare pre-and post-operative data with a cutoff P value of 0.05 to determine statistical significance. RESULTS: Overall, CSA improved in most patients post-operatively, with 19/30 (63%) resulting in improved lordosis. Pre-operatively, mean C2-C7 cervical lordosis was -4.3°, which improved to -0.5° postoperatively (P=0.075), with a mean difference of 3.7°. Simultaneously, mean C0-C2, C2-C7 SVA, McGS, and T1 slope changed from 17° (range, -18° to 41°), 26.5 mm (range, 10 to 45 mm), 4° (range, -7.5° to 25°), and 17.4° (range, 1° to 42°) to 16° (range, 0° to 34.4°, mean difference =1.01°, and P=0.548), 28.2 mm (range, 9 to 57 mm, mean difference =2 mm, and P=0.244), 4.03°, (range, -7.8° to 25°, mean difference =0.16, and P=0.916), and 18° (range, 5.4° to 42°, mean difference =0.37, and P=0.761) (mean change of C2-C7 angle of 3.76°). CONCLUSIONS: This study demonstrated baseline cervical kyphosis and a trend towards cervical lordosis restoration in patients with AIS and a Lenke type 1 curve who underwent PSIF. This study adds to emerging evidence and, together with further studies, will help estimate the impact of PSIF on the cervical sagittal profile, the effect of CSA on patient reported outcomes, and ways to address cervical sagittal malalignment when undertaking the surgical correction for specific curve types in AIS.

Cost analysis of adolescent idiopathic scoliosis surgery: early discharge decreases hospital costs much less than intraoperative variables under the control of the surgeon.

BACKGROUND: Spinal fusion surgery for the treatment of adolescent idiopathic scoliosis (AIS) is increasing. Health systems and surgeons are decreasing hospital length of stay (LOS) to decrease costs. The purpose of this study was to review the contribution of an accelerated discharge protocol on the total cost of a single episode of care related to the surgical treatment of AIS at a single institution. METHODS: A retrospective cost analysis was performed over an 18-month period, from January 2014 through June 2015, before and after the institution of an accelerated discharge program. Patients treated surgically with ICD-9 code 737.30 (Idiopathic Scoliosis) were reviewed. Itemized costs and LOS were analyzed collectively and by surgeon before and after the accelerated discharge protocol. RESULTS: Eighty AIS patients were treated surgically. The accelerated discharge program significantly reduced average LOS from 4.2 days in 2014 to 3.3 days during the first 6 months of 2015 (P≤0.05). There were no increases in complications. There was a 9% decrease in the total average costs per episode of care. A weighted average, a relative average change in costs, and an average cost savings per case were calculated for 12 different categories. Average Surgical Services and Nursing costs decreased during the study period while all other costs increased. The accelerated discharge program did not directly contribute significantly to this decrease in costs. Greatest cost reduction was associated with average bone graft and pedicle screw cost, with an overall 8.5% reduction in pedicle screw use and a 58% reduction in bone graft costs. CONCLUSIONS: Intraoperative variables under the direct control of the surgeon contribute much more to cost reduction than an accelerated discharge program for surgically treated AIS patients.

Balloon Kyphoplasty for Managing Intractable Pain in Pediatric Pathologic Vertebral Fractures.

BACKGROUND: Vertebral compression fractures are a common result of osteoporosis and osteopenia secondary to steroid use and chemotherapy treatment. Balloon kyphoplasty is a treatment option with good to excellent results well described in adults. Although a few recent studies have been published regarding the use of kyphoplasty in children, no formal indication exists for the pediatric population. The purpose of this study is to describe the outcomes of 3 chronically ill children with intractable pain from vertebral compression fractures, managed with kyphoplasty. METHODS: We retrospectively reviewed 3 pediatric patients who underwent balloon kyphoplasty for vertebral compression fractures secondary to chronic illness. Patient variables included age, sex, primary diagnosis and treatments, levels of vertebral fracture, and time elapsed from initial therapy to fracture. A numeric rating scale of 0 to 10 was used for patient-reported pain, before and after kyphoplasty. Preoperative and postoperative analgesic use and physical function were also described. Surgical variables included levels of kyphoplasty, operative time, and procedure-related complications. RESULTS: The primary diagnoses were relapsed rhabdomyosarcoma, abdominal desmoplastic small round cell tumor, and IPEX-like (immune dysregulation, polyendrocrinopathy, enteropathy, X-linked) syndrome. All 3 patients were males, aged 12, 12, and 13, respectively, at the time of kyphoplasty. Pain scores were 8 to 9 preoperatively in 2 patients, severely affecting their physical function including independent walking. Excruciating back pain was a contributing factor to the respiratory distress of the third patient, who required elective intubation. All of the patients reported significant pain relief (range, 0 to 2) and improved physical function with kyphoplasty. The third patient was successfully extubated 1 week postoperatively and eventually returned to baseline activity. There were no complications related to kyphoplasty. CONCLUSIONS: Balloon kyphoplasty seems to be safe in terminally ill children and may be a useful tool for managing intractable pain due to vertebral compression fractures. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Prospective randomized controlled trial of The Stabilis Stand Alone Cage (SAC) versus Bagby and Kuslich (BAK) implants for anterior lumbar interbody fusion.

BACKGROUND: Degenerative disc disease is common and debilitating for many patients. If conservative extensive care fails, anterior lumbar interbody fusion has proven to be an alternative form of surgical management. The Stabilis Stand Alone Cage(SAC) was introduced as a method to obtain stability and fusion. The purpose of this study was to determine whether the Stabilis Stand Alone Cage (SAC) is comparable in safety and efficacy to the Bagby and Kuslich (BAK) device. METHODS: As part of a prospective, randomized, controlled FDA trial, 73 patients underwent anterior interbody fusion using either the SAC(56%) or the BAK device (44%). RESULTS: Background characteristics were similar between the two groups. There was no significant difference between the SAC and BAK groups in mean operative time or mean blood loss during surgery. Adverse event rates did not differ between the groups. Assessment of plain radiographs could not confirm solid fusion in 63% of control and 71% of study patients. Functional scores from Owestry and SF-36 improved in both groups by the two-year follow-up. There were no significant differences between the SAC and BAK patients with respect to outcome. CONCLUSIONS: Both the Stabilis Stand Alone Cage and the BAK Cage provided satisfactory improvement in function and pain relief, despite less than expected radiographic fusion rates. The apparent incongruency between fusion rates and functional outcomes suggests that either radiographs underestimate the true incidence of fusion, or that patients are obtaining good pain relief and improved function despite a lower rate of fusion than previously reported. This was a Level III study.

Pediatric physeal ankle fracture.

Ankle fracture is the second most common fracture type in children, and physeal injury is a particular concern. Growing children have open physes that are relatively weak compared with surrounding bone and ligaments, and traumatic injuries can cause physeal damage and fracture. Tenderness to palpation over the physis can aid in the clinical diagnosis of ankle fracture. Swelling, bruising, and deformity may be identified, as well. Plain radiographs are excellent for initial evaluation, but CT may be required to determine displacement and to aid in surgical planning, particularly in the setting of intra-articular fractures. The Salter-Harris classification is the most widely used system to determine appropriate management and assess long-term prognosis. Complications of physeal injury include shortening and/or angular deformity. Tillaux and triplane fractures occur in the 18-month transitional period preceding physeal closure, which typically occurs at age 14 years in girls and age 16 years in boys. Management is determined by the amount of growth remaining, with the intent of maintaining optimum function while limiting the risk of physeal damage and joint incongruity.

Back pain in the young athlete.

Back pain in the young athlete is a common finding. There are many different problems that can cause back pain in active children. It is important for the treating physician to obtain a thorough history and physical examination to help in establishing the underlying cause for the discomfort. Appropriate imaging can be determined by these findings and further help to define the pathology. Depending upon the specific pathology, appropriate treatment may help the patient to safely return to the activities that they enjoy.