Assessment of Morbidity and Mortality Collection Data 2009.

STUDY DESIGN: A retrospective analysis of the morbidity and mortality data collected by the SRS in 2009 with comparison to previous years. OBJECTIVES: Objective of this study was to assess the new format of morbidity and mortality data collection by the SRS in 2009 and evaluate the data collected with comparison to previous years. SUMMARY OF BACKGROUND DATA: 2009 morbidity and mortality reporting format was dramatically changed from previous years. This was done in an attempt to simplify the reporting process and to narrow the reporting to only three sentinel events: death, blindness, and neurologic injury. Only deformity cases including scoliosis, kyphosis, and Grade III or greater spondylolisthesis were included. METHODS: Results were obtained from the SRS M & M reporting summary for 2009. These included detailed analysis for complications including death, blindness, and neurologic injury. These were compared to similar statistics obtained from the years dating back to 2001. Blindness has not previously been reported. RESULTS: 80.1% of SRS members submitted 35,267 deformity cases. Both the percentage of members submitting data and the number of deformity cases far exceeded any previous year total. 57.6% of cases involved scoliosis, 10.5% kyphosis, and 31.9% spondylolisthesis. Neurologic complications were lower in each major category (scoliosis, kyphosis, and spondylolisthesis) compared to previous years. The death rate was similar to prior reporting 0.12%. Three cases of blindness were reported, two occurred in AIS. All three resolved. CONCLUSIONS: The altered format and requirement for all members to participate has dramatically increased the total number of deformity cases reported and percent of membership responding. Neurologic injury rates are decreased from previous years. Three cases of blindness occurred, all of which resolved. Further collection of data is needed to elucidate mechanism and prevention.

Morbidity and mortality in the surgical treatment of six hundred five pediatric patients with isthmic or dysplastic spondylolisthesis.

STUDY DESIGN: Retrospective analysis of prospectively collected database. OBJECTIVE: To analyze the rate of complications, including neurologic deficits, associated with operative treatment of pediatric isthmic and dysplastic spondylolisthesis. SUMMARY OF BACKGROUND DATA: Pediatric isthmic and dysplastic spondylolisthesis are relatively uncommon dis-orders. Several prior studies have suggested a high rate of complication associated with operative intervention. How-ever, most of these studies were performed with sufficiently small sample sizes such that the presence of one complication could significantly affect the overall rate. The Scoliosis Research Society (SRS) prospectively collects morbidity and mortality (M&M) data from its members. This multicentered, multisurgeon database permits analysis of the surgical treatment of this relatively rare condition on an aggregate scale and provides surgeons with useful information for preoperative counseling. METHODS: Patients who underwent surgical treatment for isthmic or dysplastic spondylolisthesis from 2004 to 2007 were identified from the SRS M&M database. Inclusion criteria for analysis included age ≤ 21 and a primary diagnosis of isthmic or dysplastic spondylolisthesis. RESULTS: Of 25,432 pediatric cases reported, there were a total of 605 (2.4%) cases of pediatric dysplastic (n ∇ 62, 10%) and isthmic (n ∇ 543, 90%) spondylolisthesis, with a mean age of 15 years (range, 4-21). Approximately 50% presented with neural element compression, and less than 1% of cases were revisions. Surgical procedures included fusions in 92%, osteotomies in 39%, and reductions in 38%. The overall complication rate was 10.4%. The most common complications included postoperative neurologic deficit (n ∇ 31, 5%), dural tear (n ∇ 8, 1.3%), and wound infection (n ∇ 12, 2%). Perioperative deep venous thrombosis and pulmonary embolus were reported in 2 (0.3%) and 1 (0.2%) patients, respectively. There were no deaths in this series. CONCLUSION: Pediatric isthmic and dysplastic spondylolisthesis are relatively uncommon disorders, representing only 2.4% of pediatric spine procedures in the present study. Even among experienced spine surgeons, surgical treatment of these spinal conditions is associated with a relatively high morbidity.

Incidence of unintended durotomy in spine surgery based on 108,478 cases.

BACKGROUND: Unintended durotomy is a common complication of spinal surgery. However, the incidences reported in the literature vary widely and are based primarily on relatively small case numbers from a single surgeon or institution. OBJECTIVE: To provide spine surgeons with a reliable incidence of unintended durotomy in spinal surgery and to assess various factors that may influence the risk of durotomy. METHODS: We assessed 108,478 surgical cases prospectively submitted by members of the Scoliosis Research Society to a deidentified database from 2004 to 2007. RESULTS: Unintended durotomy occurred in 1.6% (1745 of 108 478) of all cases. The incidence of unintended durotomy ranged from 1.1% to 1.9% on the basis of preoperative diagnosis, with the highest incidence among patients treated for kyphosis (1.9%) or spondylolisthesis (1.9%) and the lowest incidence among patients treated for scoliosis (1.1%). The most common indication for spine surgery was degenerative spinal disorder, and among these patients, there was a lower incidence of durotomy for cervical (1.0%) vs thoracic (2.2%; P = .01) or lumbar (2.1%, P < .001) cases. Scoliosis procedures were further characterized by etiology, with the highest incidence of durotomy in the degenerative subgroup (2.2% vs 1.1%; P < .001). Durotomy was more common in revision compared with primary surgery (2.2% vs 1.5%; P < .001) and was significantly more common among elderly (> 80 years of age) patients (2.2% vs 1.6%; P = .006). There was a significant association between unintended durotomy and development of a new neurological deficit (P < .001). CONCLUSION: Unintended durotomy occurred in at least 1.6% of spinal surgeries, even among experienced surgeons. Our data provide general benchmarks of durotomy rates and serve as a basis for ongoing efforts to improve safety of care.

Short-term morbidity and mortality associated with correction of thoracolumbar fixed sagittal plane deformity: a report from the Scoliosis Research Society Morbidity and Mortality Committee.

STUDY DESIGN: Retrospective review. OBJECTIVE: Our objective was to assess the short-term complication rate in patients undergoing treatment of thoracolumbar fixed sagittal plane deformity (FSPD). SUMMARY OF BACKGROUND DATA: The reported morbidity and mortality for the surgical treatment of thoracolumbar FSPD is varied and based on studies with small sample sizes. Further studies are needed to better assess FSPD complication rate, and the factors that influence it. METHODS: The Scoliosis Research Society (SRS) Morbidity and Mortality Database was queried to identify cases of thoracolumbar FSPD from 2004 to 2007. Complications were analyzed based on correction technique, surgical approach, surgeon experience (SRS membership status used as a surrogate), patient age, and history of prior surgery. RESULTS: Five hundred and seventy-eight cases of FSPD were identified. Osteotomies were performed in 402 cases (70%), including 215 pedicle subtraction osteotomies (PSO), 135 Smith-Petersen osteotomies (SPO), 19 anterior discectomy with corpectomy procedures (ADC), 18 vertebral column resections (VCR), and 15 unspecified osteotomies. There were 170 complications (29.4%) in 132 patients. There were three deaths (0.5%). The most common complications were durotomy (5.9%), wound infection (3.8%), new neurologic deficit (3.8%), implant failure (1.7%), wound hematoma (1.6%), epidural hematoma (1.4%), and pulmonary embolism (1.0%). Procedures including an osteotomy had a higher complication rate (34.8%) than cases not including an osteotomy (17.0%, P < 0.001), and this remained significant after adjusting for the effects of patient age, surgeon experience, and history of prior surgery (P = 0.003, odds ratio = 2.070, 95% CI = 1.291-3.321). Not significantly associated with complication rate were patient age (P = 0.68), surgeon experience (P = 0.18), and history of prior surgery (P = 0.10). Complication rates were progressively higher from no osteotomy (17.0%), to SPO (28.1%), to PSO (39.1%), to VCR (61.1%). CONCLUSION: The short-term complication rate for treatment of FSPD is 29.4%. The complication rate was significantly higher in patients undergoing osteotomies, and more aggressive osteotomies were associated with progressively higher complication rates.

Rates of infection after spine surgery based on 108,419 procedures: a report from the Scoliosis Research Society Morbidity and Mortality Committee.

STUDY DESIGN: Retrospective review of a prospectively collected database. OBJECTIVE: Our objective was to assess the rates of postoperative wound infection associated with spine surgery. SUMMARY OF BACKGROUND DATA: Although wound infection after spine surgery remains a common source of morbidity, estimates of its rates of occurrence remain relatively limited. The Scoliosis Research Society prospectively collects morbidity and mortality data from its members, including the occurrence of wound infection. METHODS: The Scoliosis Research Society morbidity and mortality database was queried for all reported spine surgery cases from 2004 to 2007. Cases were stratified based on factors including diagnosis, adult (≥ 21 years) versus pediatric (<21 years), primary versus revision, use of implants, and whether a minimally invasive approach was used. Superficial, deep, and total infection rates were calculated. RESULTS.: In total, 108,419 cases were identified, with an overall total infection rate of 2.1% (superficial = 0.8%, deep = 1.3%). Based on primary diagnosis, total postoperative wound infection rate for adults ranged from 1.4% for degenerative disease to 4.2% for kyphosis. Postoperative wound infection rates for pediatric patients ranged from 0.9% for degenerative disease to 5.4% for kyphosis. Rate of infection was further stratified based on subtype of degenerative disease, type of scoliosis, and type of kyphosis for both adult and pediatric patients. Factors associated with increased rate of infection included revision surgery (P < 0.001), performance of spinal fusion (P < 0.001), and use of implants (P < 0.001). Compared with a traditional open approach, use of a minimally invasive approach was associated with a lower rate of infection for lumbar discectomy (0.4% vs. 1.1%; P < 0.001) and for transforaminal lumbar interbody fusion (1.3% vs. 2.9%; P = 0.005). CONCLUSION: Our data suggest that postsurgical infection, even among skilled spine surgeons, is an inherent potential complication. These data provide general benchmarks of infection rates as a basis for ongoing efforts to improve safety of care.

Morbidity and mortality in the surgical treatment of 10,242 adults with spondylolisthesis.

OBJECT: This is a retrospective review of 10,242 adults with degenerative spondylolisthesis (DS) and isthmic spondylolisthesis (IS) from the morbidity and mortality (M&M) index of the Scoliosis Research Society (SRS). This database was reviewed to assess complication incidence, and to identify factors that were associated with increased complication rates. METHODS: The SRS M&M database was queried to identify cases of DS and IS treated between 2004 and 2007. Complications were identified and analyzed based on age, surgical approach, spondylolisthesis type/grade, and history of previous surgery. Age was stratified into 2 categories: > 65 years and ≤ 65 years. Surgical approach was stratified into the following categories: decompression without fusion, anterior, anterior/posterior, posterior without instrumentation, posterior with instrumentation, and interbody fusion. Spondylolisthesis grades were divided into low-grade (Meyerding I and II) versus high-grade (Meyerding III, IV, and V) groups. Both univariate and multivariate analyses were performed. RESULTS: In the 10,242 cases of DS and IS reported, there were 945 complications (9.2%) in 813 patients (7.9%). The most common complications were dural tears, wound infections, implant complications, and neurological complications (range 0.7%-2.1%). The mortality rate was 0.1%. Diagnosis of DS had a significantly higher complication rate (8.5%) when compared with IS (6.6%; p = 0.002). High-grade spondylolisthesis correlated strongly with a higher complication rate (22.9% vs 8.3%, p < 0.0001). Age > 65 years was associated with a significantly higher complication rate (p = 0.02). History of previous surgery and surgical approach were not significantly associated with higher complication rates. On multivariate analysis, only the grade of spondylolisthesis (low vs high) was in the final best-fit model of factors associated with the occurrence of complications (p < 0.0001). CONCLUSIONS: The rate of total complications for treatment of DS and IS in this series was 9.2%. The total percentage of patients with complications was 7.9%. On univariate analysis, the complication rate was significantly higher in patients with high-grade spondylolisthesis, a diagnosis of DS, and in older patients. Surgical approach and history of previous surgery were not significantly correlated with increased complication rates. On multivariate analysis, only the grade of spondylolisthesis was significantly associated with the occurrence of complications.

Complication rates of three common spine procedures and rates of thromboembolism following spine surgery based on 108,419 procedures: a report from the Scoliosis Research Society Morbidity and Mortality Committee.

STUDY DESIGN: Retrospective review of a prospectively collected database. OBJECTIVE: The Scoliosis Research Society (SRS) collects morbidity and mortality (M and M) data from its members. Our objectives were to assess complication rates for 3 common spine procedures, compare these results with prior literature as a means of validating the database, and to assess rates of pulmonary embolism (PE) and deep venous thrombosis (DVT) in all cases reported to the SRS over 4 years. SUMMARY OF BACKGROUND DATA: Few modern series document complication rates of spinal surgery as routinely practiced across academic and community settings. Those available are typically based on relatively low numbers of procedures or confined to single-surgeon experiences. METHODS: The SRS M and M database was queried for lumbar microdiscectomy (LD), anterior cervical discectomy and fusion (ACDF), and lumbar stenosis decompression (LSD) cases from 2004 to 2007. Revisions were excluded. The database was also queried for occurrence of clinically evident PE and DVT in all cases from 2004 to 2007. RESULTS: A total of 9692 LDs, 6735 ACDFs, and 10,329 LSDs were identified, with overall complication rates of 3.6%, 2.4%, and 7.0%, respectively. These rates are comparable to previously published smaller series. For assessment of PE and DVT, 108,419 cases were identified and rates were calculated per 1000 cases based on diagnosis, age group, and implant use. Overall rates of PE, death due to PE, and DVT were 1.38, 0.34, and 1.18, respectively. Among 82,082 adults, the rate of PE ranged from 0.47 for LD to 12.4 for metastatic tumor. Similar variations were noted for DVT and deaths due to PE. CONCLUSION: Overall major complication rates for LD, ACDF, and LSD based on the SRS M and M database are comparable to those in previously reported smaller series, supporting the validity of this database for study of other less common spinal disorders. In addition, our data provide general benchmarks of clinically evident PE and DVT rates as a basis for ongoing efforts to improve care.

Morbidity and mortality in the surgical treatment of 10,329 adults with degenerative lumbar stenosis.

OBJECT: The purpose of this study was to evaluate the prospectively collected Scoliosis Research Society (SRS) database to assess the incidences of morbidity and mortality (M&M) in the operative treatment of degenerative lumbar stenosis, one of the most common procedures performed by spine surgeons. METHODS: All patients who underwent surgical treatment for degenerative lumbar stenosis between 2004 and 2007 were identified from the SRS M&M database. Inclusion criteria for analysis included an age >or= 21 years and no history of lumbar surgery. Patients were treated with either decompression alone or decompression with concomitant fusion. Statistical comparisons were performed using a 2-sided Fisher exact test. RESULTS: Of the 10,329 patients who met the inclusion criteria, 6609 (64%) were treated with decompression alone, and 3720 (36%) were treated with decompression and fusion. Among those who underwent fusion, instrumentation was placed in 3377 (91%). The overall mean patient age was 63 +/- 13 years (range 21-96 years). Seven hundred nineteen complications (7.0%), including 13 deaths (0.1%), were identified. New neurological deficits were reported in 0.6% of patients. Deaths were related to cardiac (4 cases), respiratory (5 cases), pulmonary embolus (2 cases), and sepsis (1 case) etiologies, and a perforated gastric ulcer (1 case). Complication rates did not differ based on patient age or whether fusion was performed. Minimally invasive procedures were associated with fewer complications and fewer new neurological deficits (p = 0.01 and 0.03, respectively). CONCLUSIONS: The results from this analysis of the SRS M&M database provide surgeons with useful information for preoperative counseling of patients contemplating surgical intervention for symptomatic degenerative lumbar stenosis.

Spinal cord monitoring using intraoperative somatosensory evoked potentials for spinal trauma.

BACKGROUND: Intraoperative spinal cord monitoring is commonplace in scoliosis surgery as an adjunct to evaluate functional integrity of the cord; however, limited information is available on its applicability in spinal trauma. METHODS: We investigated the efficacy of somatosensory evoked potential (SEP) recording during reconstructive procedures in 82 patients who sustained 20 cervical, 8 thoracic, 6 thoracolumbar, and 48 lumbar vertebral fractures or fractures-dislo-cations. Seventy-one patients underwent single anterior or posterior operations and 11 combined anterior-posterior procedures. Forty patients had incomplete injuries, and 42 had no preoperative neurologic deficit. SEP trace amplitude at insertion of electrode was considered as the baseline value and was compared with the lowest intraoperative signal amplitude and the amplitude at completion of operation. RESULTS: Fifty-nine patients had a depression in wave amplitude of >25% during surgery; in 25 patients, the trace fell by >50%, and in 7 cases, a >75% diminution was recorded. A loss of 50% in SEP signal amplitude showed 67% sensitivity and 71% specificity in predicting neurologic outcome. Increasing trace deterioration threshold from 50% to 60% improved specificity to 81% without compromising sensitivity. A loss of >50% in SEP amplitude occurred with significantly increased incidence during the anterior compared with the posterior spinal procedures. More than 20% recovery in signal amplitude at the conclusion of the procedure in patients with incomplete injuries was correlated with favorable neurologic function. CONCLUSION: Persistent intraoperative decrement in SEP amplitude and poor restitution at completion of surgery increase the risk for postoperative neurologic compromise.

Spinal manifestations in a patient with congenital insensitivity to pain.

Spinal manifestations in congenital insensitivity to pain are relatively uncommon and easily misdiagnosed. We report on a patient with absent protective pain sensation, who developed spinal neuropathic arthropathy. At age 11 years, he presented with a destructive lesion at the L1-L2 level, causing him tingling sensation in both lower limbs. He was treated with combined anteroposterior spinal fusion from T12 to L3 and had full recovery. Five years later, he presented with a long history of clicking in his low back, muscle weakness and paresthesia in both lower extremities during walking, and evidence of Charcot arthropathy at the L4-L5 level, resulting in junctional kyphosis and canal narrowing. Posterior spinal arthrodesis from L3 to the sacrum was performed, due to lack of patient and parental consent for combined anterior decompression/posterior fusion. The patient resumed normal muscle function and his previous level of activities. Spinal complications should be anticipated in this condition and create diagnostic and therapeutic dilemmas. However, surgical management can produce favorable clinical results.

Variability of clinical expression and evolution of spinal deformity in a family with late detection of dopa-responsive dystonia.

This case report documents an unusual presentation of dopa-responsive dystonia (DRD) in three siblings (two females, one male) which simulated cerebral palsy (CP) and describes the evolution of their spinal deformity in relation to growth and responsiveness to levodopa therapy. The siblings were normal at birth with a negative history of neurological disease or spinal imbalance. They showed marked phenotypic variation but all developed progressive scoliosis and neurological impairment with mixed spastic dystonic features, leading to the misdiagnosis of spastic dystonic CP. Age at establishment of the diagnosis of DRD and levodopa trial for the three patients was 12 years, 9 years 6 months, and 3 years 6 months respectively. In patients 1 and 3, spinal deformity responded dramatically to levodopa treatment and neurological symptoms were ameliorated. Patient 2 developed a rigid scoliotic curve and, despite neurological improvement with levodopa, the spinal curvature remained unresponsive necessitating surgical correction. Spinal decompensation is a common manifestation of DRD, which with early diagnosis and initiation of levodopa treatment has an excellent prognosis. This report highlights the variability of clinical expression in DRD and the importance of an adequate trial of levodopa when unexplained dystonic features are documented.