Adrian Gardner

Deep Surgical Site Infection Following 2344 Growing-Rod Procedures for Early-Onset Scoliosis: Risk Factors and Clinical Consequences.

BACKGROUND Deep surgical site infection may change the course of growing-rod treatment of early-onset scoliosis. Our goal was to assess the effect of this complication on subsequent treatment. METHODS A multicenter international database was retrospectively reviewed; 379 patients treated with growing-rod surgery and followed for a minimum of two years were identified. Deep surgical site infection was defined as any infection requiring surgical intervention. RESULTS Forty-two patients (11.1%; twenty-five males and seventeen females) developed at least one deep surgical site infection. The mean age at the initial growing-rod surgery was 6.3 years (range, 0.6 to 13.2 years) and the mean duration of follow-up was 5.3 years (range, 2.2 to 14.3 years). The mean interval between the initial surgery and the first deep surgical site infection was 2.8 years (range, 0.02 to 7.9 years). Ten (2.6%) of the 379 patients developed deep surgical site infection before the first lengthening. Twenty-nine patients (7.7%) developed the infection during the course of the lengthening procedures, and three patients (0.8%) developed it after final fusion surgery. Thirty (13.6%) of 221 patients with stainless-steel implants had at least one deep surgical site infection compared with twelve (8%) of 150 patients with titanium implants (p < 0.05). (The remaining patients were treated with chromium-cobalt implants.) Twenty-two (52.4%) of the forty-two patients with deep surgical site infection underwent implant removal, which was complete in thirteen and partial in nine. Growing-rod treatment was terminated in two patients with partial removal and six patients with complete removal. An increased risk of deep surgical site infection was associated with stainless-steel implants (odds ratio [OR] = 5.7), non-ambulatory status (OR = 2.9), and the number of revisions before the development of deep surgical site infection (OR = 3.3). Neuromuscular etiology and non-ambulatory status increased the possibility of implant removal to treat infection (p < 0.05). CONCLUSIONS The prevalence of deep surgical site infection associated with growing-rod surgery is higher than that associated with standard pediatric spinal fusion (historical data). Non-ambulatory status, more revisions, and stainless-steel implants increased the risk of deep surgical site infection. After eight surgical procedures, the risk of deep surgical site infection increased to approximately 50%. When patients have implant removal, efforts should be made to retain one longitudinal implant to continue treatment. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Translaminar screw fixation of a kyphosis of the cervical and thoracic spine in neurofibromatosis

The spinal manifestations of neurofibromatosis include cervicothoracic kyphosis, in which scalloping of the vertebral body and erosion of the pedicles may render conventional techniques of fixation impossible. We describe a case of cervicothoracic kyphosis managed operatively with a vascularised fibular graft anteriorly across the apex of the kyphus, followed by a long posterior construct using translaminar screws, which allow segmental fixation in vertebral bodies where placement of the pedicle screws was impracticable.

The management of scoliosis in children with cerebral palsy: a review

Children who suffer with cerebral palsy (CP) have a significant chance of developing scoliosis during their early years and adolescence. The behavior of this scoliosis is closely associated with the severity of the CP disability and unlike idiopathic scoliosis, it continues to progress beyond skeletal maturity. Conservative measures may slow the progression of the curve, however, surgery remains the only definitive management option. Advances in surgical technique over the last 50 years have provided methods to effectively treat the deformity while also reducing complication rates. The increased risk of surgical complications with these complex patients make decisions about treatment challenging, however with careful pre-operative optimization and post-operative care, surgery can offer a significant improvement in quality of life. This review discusses the development of scoliosis in CP patient, evaluates conservative and surgical treatment options and assesses post-operative outcome.

The measurement of the normal thorax using the Haller index methodology at multiple vertebral levels.

The Haller index is a ratio of thoracic width and height, measured from an axial CT image and used to describe the internal dimensions of the thoracic cage. Although the Haller index for a normal thorax has been established (Haller et al. 1987; Daunt et al. 2004), this is only at one undefined vertebral level in the thorax. What is not clear is how the Haller index describes the thorax at every vertebral level in the absence of sternal deformity, or how this is affected by age. This paper documents the shape of the thorax using the Haller index calculated from the thoracic width and height at all vertebral levels of the thorax between 8 and 18 years of age. The Haller Index changes with vertebral level, with the largest ratio seen in the most cranial levels of the thorax. Increasing age alters the shape of the thorax, with the most cranial vertebral levels having a greater Haller index over the mid thorax, which does not change. A slight increase is seen in the more caudal vertebral levels. These data highlight that a ‘one size fits all’ rule for chest width and depth ratio at all ages and all thoracic levels is not appropriate. The normal range for width to height ratio should be based on a patients age and vertebral level.

The surgical management of spinal deformity in children with a Fontan circulation: The development of an algorithm for treatment.

The management of spinal deformity in children with univentricular cardiac pathology poses significant challenges to the surgical and anaesthetic teams. To date, only posterior instrumented fusion techniques have been used in these children and these are associated with a high rate of complications. We reviewed our experience of both growing rod instrumentation and posterior instrumented fusion in children with a univentricular circulation. Six children underwent spinal corrective surgery, two with cavopulmonary shunts and four following completion of a Fontan procedure. Three underwent growing rod instrumentation, two had a posterior fusion and one had spinal growth arrest. There were no complications following surgery, and the children undergoing growing rod instrumentation were successfully lengthened. We noted a trend for greater blood loss and haemodynamic instability in those whose surgery was undertaken following completion of a Fontan procedure. At a median follow-up of 87.6 months (interquartile range (IQR) 62.9 to 96.5) the median correction of deformity was 24.2% (64.5° (IQR 46° to 80°) vs 50.5° (IQR 36° to 63°)). We believe that early surgical intervention with growing rod instrumentation systems allows staged correction of the spinal deformity and reduces the haemodynamic insult to these physiologically compromised children. Due to the haemodynamic changes that occur with the completed Fontan circulation, the initial scoliosis surgery should ideally be undertaken when in the cavopulmonary shunt stage.

Is the routine use of magnetic resonance imaging indicated in patients with scoliosis

Background To assess the reliability of the indicators for performing magnetic resonance imaging in patients with scoliosis and assess the incidence of neural axis anomalies in a population with scoliosis referred to a specialist centre. Methods A retrospective review of magnetic resonance imaging (MRI) reports of all patients under the age of 18 who underwent a pre-operative MRI for investigation of their scoliosis between 2009 and 2014 at a single institution was performed. Results There were 851 patients who underwent an MRI scan of their whole spine with a mean age of 14.08 years. There were 211 males and 640 females. One hundred and fourteen neural axis abnormalities (NAA) were identified. The presence of a left sided thoracic curve, a double thoracic curve, being male nor being diagnosed before the age of 10 were found to be statistically significant for the presence of a NAA. Furthermore, 2.34% of patients were also found to have an incidental finding (IF) of an extraspinal abnormality. Conclusions From our series, the reported indications for performing an MRI scan in the presence of scoliosis are not reliable for the presence of an underlying NAA. We have demonstrated that there is a number of intra and extra dural anomalies found on MRI without clinical symptoms and signs. This acts as normative information for this group. Keywords Scoliosis; magnetic resonance imaging (MRI); neural axis abnormalities (NAA); adolescent idiopathic scoliosis (AIS).

Post-Operative Neurological Observations, Are You Getting What You Ordered?

Introduction: An audit at our spinal unit in 2006 highlighted the need for a consistent approach to neurological observations in spinal surgery patients. A protocol was therefore introduced for use throughout the hospital. The aim of this audit was to assess compliance with protocol for post-operative neurological observations over the course of two subsequent audits. Materials and Methods: This was a retrospective audit. Patients selected were those admitted to the spinal unit in May 2006, February 2012 and August 2014. The case notes of 39 patients who had spinal surgery were reviewed against our gold standards on post-operative neurological observations. The mean age of the patients was 46 years (17 years to 80 years). The procedures performed included decompression, fusion, scoliosis correction, discectomy and tumour excision. Each patient’s case notes were examined to identify whether an operation note was produced, whether neurological observations were requested and if so, how frequently and whether this requested was complied with during the post-operative period. The location of the patients was also noted, as well as if any deterioration was reported to a doctor and if they subsequently acted accordingly. Results: Over the period of three consecutive audits an overall improvement was seen regarding compliance with the standards set out in the protocol. Conclusion: Clinical audit was used to highlight problems with post-operative monitoring of neurological function in spinal patients; further evaluation and implementation of the recommendations resulted in sustained improvement in delivery of healthcare.

A retrospective analysis of a functional restoration service for patients with persistent low back pain.

Back pain is of considerable interest in society today and is a source of ongoing disability and days lost from work in the adult population (Driscoll et al., 2014). Historically, the recommended management has encompassed conservative methods, from physiotherapy and a range of other manipulative techniques to surgical interventions in various forms. There is now agreement that adults with persistent low back pain who have failed physiotherapy and have high levels of disability and psychological distress are best managed through a combined physical and psychological approach, which should be up to 100 hours in length (NICE, 2009). This combined approach has been modified by authors in several forms, of varying duration, with good results, supporting the idea that benefit can be gained from interventions of a lesser duration (Hill et al., 2011; Hunter et al., 2006; Lamb et al., 2010). The present paper reports on the results, as measured using the Oswestry Disability Index (ODI) and Pain Self-Efficacy Questionnaire (PSEQ), of a four-week functional restoration programme (FRP) treatment intervention, run in a tertiary spinal centre, which used a combined physical and psychological approach.

Magnetically Controlled Growing Rods: TheExperience of Mechanical Failure from a SingleCenter Consecutive Series of 28 Children with aMinimum Follow-up of 2 Years

Study Design Retrospective observational study of a continuous series of 28 children. Purpose To determine the mechanical failure rate in our cohort of children treated with magnetically controlled growth rods (MCGRs). Overview of Literature Previous studies report a MCGR mechanical failure rate of 0%–75%. Methods All patients with MCGR implantation between 2012 and 2015 were examined and followed up for a minimum of 2 years. A retrospective evaluation of contemporaneously documented clinical findings was conducted, and radiographs were retrospectively examined for mechanical failure. The external remote controller (ERC)-specified length achieved in the clinic was compared to the length measured on subsequent radiographs. Results Fourteen mechanical failures were identified in 28 children (50%) across a total of 52 rods (24 pairs and four single constructs). Mechanical failures were due to: failure to lengthen under general anesthesia (seven children), actuator pin fracture (four), rod fracture (one), foundation screw failure (one), and ran out of rod length (one). Of the 14 mechanical failures, six were treated with final fusion operations (reflecting limited further growth potential), and eight patients were treated with the intention for further lengthening. We therefore consider these eight patients to represent the true incidence of mechanical failure in our cohort (29%). The difference between the ERC length and radiographic length was found to be identical in 11% cases; 35% were overestimates, and 54% were underestimates. The median underestimate was 2.45 mm whereas the median overestimate was 3.1 mm per distraction episode. In total, 95% of all ERC distractions were within ±10 mm of the radiographic length achieved over a median of nine distraction episodes. Conclusions Our series is the most comprehensive MCGR series published to date, and we present a mechanical failure rate of 29%. Clinicians should be mindful of the discrepancies between ERC length and radiographic measurements of rod length; other modalities may be more helpful in this regard.

The use of growth standards and corrective formulae to calculate the height loss caused by idiopathic scoliosis

BackgroundLoss of trunk height caused by scoliosis has been previously assessed using different mathematical formulae. However, these are of differing algebraic construction and will give a range of values for the same size of scoliosis curve. As such, the following study attempted to determine the most valid published formulae for calculating height loss caused by idiopathic scoliosis based on reported growth charts.MethodsThe height and sitting height for a group with idiopathic scoliosis were measured. These were plotted on published growth standards. The size of the coronal curves and the thoracic kyphosis was measured. Height was corrected for the size of the scoliosis using the formulae and replotted on the growth standards. The data spread on the standard was analysed for significant differences between the median and the 5th or 95th centile, and between data outside the 5th and 95th centile.ResultsThe sitting to standing height ratio growth standard was used in the analysis as it minimised errors across the different growth standards, given that these standards come from different original populations. In the female group significant differences in the data spread were seen using the formulae of Bjure, Ylikoski and Hwang. Non-significant results were seen for the Kono and Stokes formulae. All formulae caused no significant differences in data spread across the growth standard in the males group.ConclusionsWhen assessing against growth standards, the formulae of Kono and Stokes are the most valid at determining height loss caused by idiopathic scoliosis.