Hilali Noordeen

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.

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.

Early results of a remotely-operated magnetic growth rod in early-onset scoliosis

Conventional growing rods are the most commonly used distraction-based devices in the treatment of progressive early-onset scoliosis. This technique requires repeated lengthenings with the patient anaesthetised in the operating theatre. We describe the outcomes and complications of using a non-invasive magnetically controlled growing rod (MCGR) in children with early-onset scoliosis. Lengthening is performed on an outpatient basis using an external remote control with the patient awake.Between November 2009 and March 2011, 34 children with a mean age of eight years (5 to 12) underwent treatment. The mean length of follow-up was 15 months (12 to 18). In total, 22 children were treated with dual rod constructs and 12 with a single rod. The mean number of distractions per patient was 4.8 (3 to 6). The mean pre-operative Cobb angle was 69° (46° to 108°); this was corrected to a mean 47° (28° to 91°) post-operatively. The mean Cobb angle at final review was 41° (27° to 86°). The mean pre-operative distance from T1 to S1 was 304 mm (243 to 380) and increased to 335 mm (253 to 400) in the immediate post-operative period. At final review the mean distance from T1 to S1 had increased to 348 mm (260 to 420).Two patients developed a superficial wound infection and a further two patients in the single rod group developed a loss of distraction. In the dual rod group, one patient had pull-out of a hook and one developed prominent metalwork. Two patients had a rod breakage; one patient in the single rod group and one patient in the dual rod group. Our early results show that the MCGR is safe and effective in the treatment of progressive early-onset scoliosis with the avoidance of repeated surgical lengthenings.

Next generation of growth-sparing techniques: preliminary clinical results of a magnetically controlled growing rod in 14 patients with early-onset scoliosis.

Study Design. Prospective nonrandomized study. Objective. To report the preliminary results of magnetically controlled growing rod (MCGR) technique in children with progressive early-onset scoliosis. Summary of Background Data. The growing rod (GR) technique is a viable alternative for treatment of early-onset scoliosis. High complication rate is attributed to frequent surgical lengthening. The safety and efficacy of MCGR were recently reported in a porcine model. Methods. Multicenter study of clinical and radiographical data of patients who underwent MCGR surgery and at least 3 distractions. Distractions were performed in clinic without anesthesia/analgesics. T1–T12 and T1–S1 heights and the distraction distance inside the actuator were measured after lengthening. Results. Fourteen patients (7 girls, 7 boys) with a mean age of 8 years, 10 months (3 yr, 6 mo to 12 yr, 7 mo) had 14 index surgical procedures. Of the 14, 5 had single-rod (SR) surgery and 9 had dual-rod (DR) surgery, with overall 68 distractions. Diagnoses were idiopathic (N = 5), neuromuscular (N = 4), congenital (N = 2), syndromic (N = 2), and neurofibromatosis (N = 1). Mean follow-up was 10 months (5.8–18.2). The Cobb angle changed from 60° to 34° after initial surgery and 31° at latest follow-up. During distraction period, T1–T12 height increased by 7.6 mm for SR (1.09 mm/mo) and 12.12 mm for DR (1.97 mm/mo). T1–S1 height gain was 9.1 mm for SR (1.27 mm/mo) and 20.3 mm for DR (3.09 mm/mo). Complications included superficial infection in 1 SR, prominent implant in 1 DR, and minimal loss of initial distraction in 3 SR after index. Partial distraction loss observed after 14 of the 68 distractions (1 DR and 13 SR) but regained in subsequent distractions. There was no neurological deficit or implant failure. Conclusion. Preliminary results indicated MCGR was safe and provided adequate distraction similar to standard GR. DR achieved better initial curve correction and greater spinal height during distraction compared with SR. No major complications were observed during the follow-up.

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.

Adolescent idiopathic scoliosis.

#### Summary points Scoliosis is a three dimensional deformity of the spine defined as a lateral curvature of the spine in the coronal plane of more than 10°.1 It can be categorised into three major types—congenital, syndromic, and idiopathic. Congenital scoliosis refers to spinal deformity caused by abnormally formed vertebrae. Syndromic scoliosis is associated with a disorder of the neuromuscular, skeletal, or connective tissue systems; neurofibromatosis; or other important medical condition. Idiopathic scoliosis has no known cause and can be subdivided based on the age of onset—infantile idiopathic scoliosis includes patients aged 0-3 years, juvenile idiopathic scoliosis includes patients aged 4-10 years, and adolescent idiopathic scoliosis affects people aged >10 years. Adolescent idiopathic scoliosis (AIS) is the most common spinal deformity seen by primary care physicians, paediatricians, and spinal surgeons.2 This review is focused on AIS and reviews the diagnosis, management, and controversies surrounding this condition based on the available literature. #### Sources and selection criteria We searched Medline and the Cochrane Library using MeSH terms “adolescent idiopathic scoliosis”, and “scoliosis bracing”. We included systematic reviews, randomised controlled trials, and good quality prospective observational studies mainly from the past 15 years but did not …

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.

The role of imaging in the diagnosis and management of thoracolumbar burst fractures: current concepts and a review of the literature.

Abstract The burst fracture of the spine was first described by Holdsworth in 1963 and redefined by Denis in 1983 as being a fracture of the anterior and middle columns of the spine with or without an associated posterior column fracture. This injury has received much attention in the literature as regards its radiological diagnosis and also its clinical managment. The purpose of this article is to review the way that imaging has been used both to diagnose the injury and to guide management. Current concepts of the stability of this fracture are presented and our experience in the use of magnetic resonance imaging in deciding treatment options is discussed.

Minimizing Complications With Single Submuscular Growing Rods: A Review of Technique and Results on 88 Patients With Minimum Two-Year Follow-up

Study Design. Retrospective clinical and radiologic review of consecutive series of patients treated with single submuscular growing rods from a single center with a minimum of 2-year follow-up. Objectives. To describe the surgical technique and methods used to minimize complications and to report on the outcomes of a large consecutive series of patients treated with single submuscular growing rods for scoliosis in the immature spine from a single center. Summary of Background Data. Previous studies have reported on the safety and efficacy of single and dual growing-rod constructs; however, these studies have been of small patient numbers with varying results. Methods. Between 1999 and 2007, 88 patients underwent the insertion of a single, submuscular growing-rod construct for scoliosis. A clinical and radiologic review of these 88 consecutive patients with a minimum of 2-year follow-up was conducted. Diagnoses include idiopathic, neuromuscular, syndromic, and congenital. Data include Cobb angle measurements, T1-S1 heights, number, and frequency of lengthening as well as complications. Results. The patients underwent single submuscular growing-rod insertion at an average age of 7.0 years. The mean follow-up period was 42 months. Twenty-eight patients had a simultaneous apical fusion. Growing-rod lengthening was performed on an average at 9-month intervals. The average initial Cobb angle was 73° (range: 40-117) and improved to 44° (range: 9-90) at final follow-up. T1-S1 height gain was 3.37 cm; this translates to 1.04 cm growth/yr. No significant difference was noted between those who had undergone apical fusion and those without. Complications noted in this series include 8 incidences of superficial infection and 3 of deep infection, proximal junctional kyphosis in 2 patients requiring early fusion, 31 rod fractures, 10 cases of proximal anchor failure, and 6 distal anchor failures. Thirty patients within study group have reached definitive fusion. Conclusion. Favorable outcomes have been demonstrated in this large single-center series of growing-rod constructs used to treat scoliosis in the growing spine. Their safety and efficacy in controlling spinal deformity and allowing spinal growth along with an acceptable rate of complications would support the continued use of single growing-rod constructs as a scoliosis management option.