Peter R. Loughenbury

A survey of current controversies in scoliosis surgery in the United Kingdom.

Study Design. A 10-point questionnaire was constructed to identify the philosophy of surgeons on various aspects of scoliosis surgery, such as choice of implant, bone graft, autologous blood transfusion, cord monitoring, and computer-assisted surgery. Comparisons were then made with recommendations published in the spinal literature. Objective. To determine certain aspects of the current practice of scoliosis surgery in the United Kingdom. Summary of Background Data. Guidelines for good clinical practice in spinal deformity surgery are available in the United Kingdom but do not cover a number of controversial issues. Methods. Consultants and fellows attended the 2009 British Scoliosis Society meeting. Fifty questionnaires were completed by 45 consultants and 5 fellows. Results. All pedicle screw constructs favored by 25 of 50, hybrid 24 of 50 (1 undecided). Posterior construct of fewer than 10 levels, 20 of 50 would not cross-link, 11 of 50 used 1, and 19 of 20 used 2 or more. More than 10 levels 17 of 50 considered cross-links unnecessary, 4 of 50 used 1 and 29 of 50 used 2 or more. Eighty-eight percent preferred titanium alloy implants, whereas others used a mixture of stainless steel and cobalt chrome. When using bone graft, respondents used bone substitutes (24), iliac crest graft (14), allograft (12) and demineralized bone matrix (9) in addition to local bone. Ten of 50 would use recombinant bone morphogenetic protein (3 for revision cases only). Thirty-nine of 50 routinely used intraoperative cell salvage and 4 of 50 never used autologous blood. All used cord monitoring: sensory (19 of 50), motor (2 of 50), and combined (29 of 50). None used computer-aided surgery. Twenty-six operated alone, 12 operated in pairs, and 12 varied depending on type of case. Conclusion. This survey shows interesting variations in scoliosis surgery in the United Kingdom. It may reflect the conflicting evidence in the literature.

Risk Factors for Developing Scoliosis in Cerebral Palsy: A Cross-Sectional Descriptive Study

This study aims to identify the risk factors leading to the development of severe scoliosis among children with cerebral palsy. A cross-sectional descriptive study of 70 children (aged 12-18 years) with severe spastic and/or dystonic cerebral palsy treated in a single specialist unit is described. Statistical analysis included Fisher exact test and logistic regression analysis to identify risk factors. Severe scoliosis is more likely to occur in patients with intractable epilepsy (P = .008), poor gross motor functional assessment scores (P = .018), limb spasticity (P = .045), a history of previous hip surgery (P = .048), and nonambulatory patients (P = .013). Logistic regression model confirms the major risk factors are previous hip surgery (P = .001), moderate to severe epilepsy (P = .007), and female gender (P = .03). History of previous hip surgery, intractable epilepsy, and female gender are predictors of developing severe scoliosis in children with cerebral palsy. This knowledge should aid in the early diagnosis of scoliosis and timely referral to specialist services.

Single rod instrumentation in patients with scoliosis and co-morbidities: Indications and outcomes

AIM To present our results on the use of a single rod instrumentation correction technique in a small number of patients with major medical co-morbidities. METHODS This study was a prospective single surgeon series. Patients were treated with single rod hybrid constructs and had a minimum 2-year follow-up. Indications included complex underlying co-morbidities, conversion of growing rods to definitive fusion, and moderate adolescent idiopathic primarily thoracic scoliosis with severe eczema and low body mass index (BMI). RESULTS We included 99 consecutive patients. Mean age at surgery was 12.8 years (SD 3.5 years). Mean scoliosis correction was 62% (SD 15%) from 73° (SD 22°) to 28° (SD 15°). Mean surgical time was 153 min (SD 34 min), and blood loss was 530 mL (SD 327 mL); 20% BV (SD 13%). Mean clinical and radiological follow-up was 3.2 years (range: 2-12) post-operatively. Complications included rod failure, which occurred in three of our complex patients with severe syndromic or congenital kyphoscoliosis (3%). Only one of these three patients required revision surgery to address a non-union. Our revision rate was 2% (including a distal junctional kyphosis in a Marfan’s syndrome patient). CONCLUSION The single rod technique has achieved satisfactory deformity correction and a low rate of complications in patients with specific indications and severe underlying medical conditions. In these children with significant co-morbidities, where the risks of scoliosis surgery are significantly increased, this technique has achieved low operative time, blood loss, and associated surgical morbidity.

Benefits of the use of blood conservation in scoliosis surgery

AIM To investigate whether autologous blood transfusion (ABT) drains and intra-operative cell salvage reduced donor blood transfusion requirements during scoliosis surgery. METHODS Retrospective data collection on transfusion requirements of patients undergoing scoliosis surgery is between January 2006 and March 2010. There were three distinct phases of transfusion practice over this time: Group A received “traditional treatment” with allogeneic red cell transfusion (ARCT) in response to an intra- or post-operative anaemia (Hb < 8 g/dL or a symptomatic anaemia); Group B received intra-operative cell salvage in addition to “traditional treatment”. In group C, ABT wound drains were used together with both intra-operative cell salvage and “traditional treatment”. RESULTS Data from 97 procedures on 77 patients, there was no difference in mean preoperative haemoglobin levels between the groups (A: 13.1 g/dL; B: 13.49 g/dL; C: 13.66 g/dL). Allogeneic red cell transfusion was required for 22 of the 37 procedures (59%) in group A, 17 of 30 (57%) in group B and 16 of 30 (53%) in group C. There was an overall 6% reduction in the proportion of patients requiring an ARCT between groups A and C but this was not statistically significant (χ2 = 0.398). Patients in group C received fewer units (mean 2.19) than group B (mean 2.94) (P = 0.984) and significantly fewer than those in group A (mean 3.82) (P = 0.0322). Mean length of inpatient stay was lower in group C (8.65 d) than in groups B (12.83) or A (12.62). CONCLUSION When used alongside measures to minimise blood loss during surgery, ABT drains and intra-operative cell salvage leads to a reduced need for donor blood transfusion in patients undergoing scoliosis surgery.

A Comparison of Stryker Xia3 and Depuy Expedium FAS Instrumentation for the Correction of Adolescent Idiopathic Scoliosis

Introduction In 2012, our institution held a tender for the supply of its instrumentation which resulted in a majority supply being awarded to Stryker for Xia3 spinal instrumentation. Prior to this we had been using Depuy Expedium FAS for the preceding 5 years. As the surgeons would have to go through a learning curve for the use of the instrumentation system, we felt it important to demonstrate that the correction of curve obtained and the intraoperative risks were the same for each from the outset of the change. Material and Methods We examined the post-operative X-rays of our patients who had adolescent idiopathic scoliosis corrected in our institution using Expedium FAS and Xia3 instrumentation between 2011 and 2014. We excluded curves that had previously had growing rods, previous pseudarthrosis or other spinal complication, anterior spinal surgery, implant removal, and incomplete records. Patients were identified using our hospitals theater management software. We measured the pre- and postoperative and 1 year follow up Cobb angle on our PACS system. Blood loss and transfusion requirements were obtained from our cell-saver and blood bank database, and other information was obtained from the clinical notes. Results 173 patients were identified. 53 had incomplete datasets. 22 were excluded due to having previous growing rod, combined anterior/posterior procedure, or a Skaggs Procedure. 63 cases using Expedium FAS and 35 of Xia3 were found. Expedium had 59 (21–99)% curve correction, 5.40 (2–12.5) hours operative time, 0.87 (0.2–1.5)l intraoperative blood loss and 8.5 (5–42) days hospital stay. The Xia3 group had 63 (34–90) % curve correction, 4.87 (3–7.5) hours operative time, 1.6L (0.4–2.5)l blood loss, and 10 (5–42) days LOS. Only the difference in blood loss reached statistical significance, however transfusion rates were the same. Conclusion Despite being at different parts of the learning curves with each instrumentation systems, a group of 4 experienced scoliosis surgeons were able to achieve equal correction of scoliosis using either instrumentation systems in all variables except for blood loss. Moving instrumentation systems can be daunting, however can be done safely if managed in a proactive manner.