Who gets staged surgery in severe pediatric and adolescent spine deformity?

BACKGROUND: There is significant debate regarding the indications of staged surgery for severe adolescent spinal deformity, and the factors associated with the decision to perform staged compared to same-day surgery have not been previously investigated. Thus, the purpose of this study was to determine which factors were most strongly associated with this decision. METHODS: A prospective multicenter registry of adolescent patients with severe spinal deformity was reviewed. Two cohorts were identified: those who underwent a planned staged surgical procedure for deformity correction and those who underwent a same-day procedure. Patients who underwent an unplanned staged procedure secondary to complications during the initial procedure were excluded. Comparisons were made between these cohorts with respect to preoperative patient and radiographic variables to determine which factors were associated with the decision to perform a staged procedure. Surgical data was also compared to evaluate for differences in the intraoperative management of staged versus same-day patients. RESULTS: Two hundred and twenty-nine patients with severe spinal deformities were identified. Forty patients (17%) underwent a planned staged procedure and 189 patients (80%) underwent a same-day procedure. On univariate analysis of preoperative variables, patients who underwent staged surgery had a significantly younger age at surgery, greater major curve magnitude, greater major curve AVT to CSVL, lesser thoracic spine height, greater radiographic trunk shift, and a greater proportion of patients undergoing revision surgery (as opposed to primary correction) compared to those who underwent a planned single-stage procedure. Multivariate logistic regression of pre-operative variables showed that age < 16 years, maximum cobb angle ≥ 120 degrees, major curve AVT to CSVL of ≥ 3.5 cm, and revision surgery were independently associated with the decision to perform a staged procedure. Intraoperatively, patients in the staged cohort more frequently underwent combined anterior and posterior procedures, grade 4 or higher Schwab osteotomies, and had a greater number of levels fused. CONCLUSION: There is substantial variability with respect to the decision to perform surgery for severe adolescent spine deformities in a staged versus same-day fashion. This large analysis of prospectively collected data is the first to describe the factors most strongly associated with the decision to perform a staged procedure and may help guide the surgical decision-making for these patients.

Revision extension to the pelvis versus primary spinopelvic instrumentation in adult deformity: comparison of clinical outcomes and complications.

OBJECTIVE: To evaluate the outcomes and complications of patients with adult spinal deformity treated in a primary versus revision fashion with long fusions to the sacropelvis. METHODS: A retrospective review was performed of a multicenter consecutive series of patients with adult spinal deformity requiring fusion to the sacropelvis, either primarily or as revision, with minimum 2-year follow-up. Clinical (Scoliosis Research Society [SRS] 22 questionnaire) and radiographic parameters (including sagittal vertical axis [SVA], coronal Cobb angle, lumbar lordosis, and thoracic kyphosis) were compared between the groups. RESULTS: There were 63 patients who met inclusion criteria; mean patient age was 51.9 years, and mean follow-up was 43 months. Patients requiring primary fusion were older (58.0 years vs. 49.5 years, P=0.01) and at baseline had a lower SVA (2.1 cm vs. 6.8 cm, P=0.01) and greater thoracolumbar Cobb angle (51.2 degrees vs. 36.5 degrees, P=0.003). At last follow-up, patients undergoing primary fusion and patients undergoing revision treatment had similar SVA (2.9 cm vs. 1.8 cm, P=0.32) and lumbar lordosis (-42.3 degrees vs. -43.4 degrees, P=0.82); patients undergoing revision treatment had more favorable SRS 22 scores (3.65 vs. 3.14, P=0.005). There was no statistical difference in complication rates between the groups (44.4% vs. 35%, P=0.68). CONCLUSIONS: Patients requiring revision extension of instrumentation to the pelvis can be treated with the same expectation of radiographic and clinical success as patients treated primarily with fusion to the sacropelvis. The complication rate for the revision procedure is not insignificant and may be similar to a primary procedure that includes pelvic fixation.

Acute reciprocal changes distant from the site of spinal osteotomies affect global postoperative alignment.

Introduction. Three-column vertebral resections are frequently applied to correct sagittal malalignment; their effects on distant unfused levels need to be understood. Methods. 134 consecutive adult PSO patients were included (29 thoracic, 105 lumbar). Radiographic analysis included pre- and postoperative regional curvatures and pelvic parameters, with paired independent t-tests to evaluate changes. Results. A thoracic osteotomy with limited fusion leads to a correction of the kyphosis and to a spontaneous decrease of the unfused lumbar lordosis (-8°). When the fusion was extended, the lumbar lordosis increased (+8°). A lumbar osteotomy with limited fusion leads to a correction of the lumbar lordosis and to a spontaneous increase of the unfused thoracic kyphosis (+13°). When the fusion was extended, the thoracic kyphosis increased by 6°. Conclusion. Data from this study suggest that lumbar and thoracic resection leads to reciprocal changes in unfused segments and requires consideration beyond focal corrections.

The use of traction in the treatment of severe spinal deformity.

STUDY DESIGN: Multicenter, retrospective, nonrandomized comparison group study of patients with severe scoliosis and kyphosis treated after 1995 with halo-gravity traction and without halo-gravity traction before definitive fusion. OBJECTIVE: Compare surgical correction of severe spine deformity with preoperative halo traction and without preoperative traction. SUMMARY OF BACKGROUND DATA: Prior studies have demonstrated that halo traction is a safe, well-tolerated method of applying gradual, sustained traction to maximize operative correction in patients with severe idiopathic scoliosis (IS) and kyphosis. However, these studies lack a comparison control group and study only a relatively small number of patients with IS. METHODS: Fifty-three patients with severe scoliosis or kyphosis were studied using hospital records, standing preoperative, traction, postoperative, and final radiographs. Thirty were treated with traction and 23 were treated without traction. Patients within each group were analyzed based on demographics, diagnosis, perioperative, and radiographic data. In addition, patients were evaluated based on diagnosis, specifically whether patients had adolescent idiopathic scoliosis. RESULTS: Within the entire study population, there was no statistically significant difference in main coronal curve correction (62% vs. 59%), operative time, blood loss, and total complication rate (27% vs. 52%). However, the nontraction group underwent vertebral column resection more often (30% vs. 3%, P = 0.015). The traction group had a statistically significant increase in average hospital stay (36 vs. 14 days) (P = 0.011). Analysis of the 23 patients with adolescent idiopathic scoliosis also showed no statistically significant differences in curve correction, blood loss, or complications. CONCLUSION: Our study shows that patients with halo traction less frequently had a vertebral body resection, but achieved comparable deformity correction.