SRS database shows 8.5% complication rate following pediatric spine surgery

Kai-Ming Fu

ORLANDO, Fla. — A retrospective database analysis of pediatric spine surgeries conducted by the Scoliosis Research Society Morbidity and Mortality Committee found that young patients’ risk of having complications after these procedures was closely linked to their original diagnosis and any surgeries performed.

Kai-Ming Fu, MD, PhD, presented results of the study here at the 2010 Annual Meeting of the North American Spine Society.

Investigators used prospectively collected data in the Scoliosis Research Society Morbidity and Mortality database, finding a low revision rate and an 8% total complication rate. Most spine surgeons who submit case information to this database are fellowship trained, according to Fu.

“There is considerable variation in the complication rates based on diagnosis and procedure type in pediatric patients undergoing spine surgery,” said Fu, a spine fellow at the University of Virginia Medical School in Charlottesville, Va. “The mortality rates for all indications were relatively low, but highest for kyphosis and trauma. Patients undergoing more aggressive corrective procedures for deformity are more likely to suffer a complication, including new neurological deficits.”

Complications, mortality

From the SRS Morbidity and Mortality database, investigators studied 23,918 pediatric spine surgery cases that were reported from 2004 to 2007 and involved patients whose average age was 13 years. Among the approximately 2,000 complications that Fu and colleagues identified in these patients, the majority of them stemmed from infections and respiratory problems.

“The most reported medical complications were respiratory complications,” Fu said, noting their frequency varied by diagnosis and occurred most often with kyphosis, followed by spondylolisthesis, scoliosis and trauma.

Revision and osteotomy

Fu and colleagues identified revision surgeries of any kind and osteotomies as the procedures most associated with a complication and a new neurological deficit. “Patients undergoing osteotomies were found to have both a higher overall complication rate and a higher overall new neurological deficit rate,” Fu said.

Respiratory concerns – the complication most often associated with mortality – accounted for 13 of the 31 deaths in the overall study population; 84% of deaths were in some way associated with corrective scoliosis procedures.

“In terms of specific surgery types, we found that revision surgeries had higher overall rates of complications; those also had higher rates of new neurological deficits,” according to Fu.

However, the results showed patients having osteotomies also had higher overall complication rates and higher new neurological deficit rates.

Study weaknesses

Fu cited the retrospective design and inherent problems with the database as the study’s main weaknesses.

The database, which he said may contain incomplete submissions, did not capture all the minor complications, did not include pseudarthrosis as a complication and did not include outcomes.

“Therefore, no determinations about the impact of the complication on the outcome can be made,” Fu said.

Discussing why this study was important, he said, “All surgical procedures have an inherent risk of complication and these rates are important tools for counseling patients and families, for quality improvement and for medicolegal reasons.” – by Susan M. Rapp

Reference:

• Fu K-M, et al. Morbidity and mortality associated with the operative treatment of disorders of the pediatric spine: A report from the SRS M&M Committee. Paper #208. Presented at the 2010 Annual Meeting of the North American Spine Society. Oct. 5-9, 2010. Orlando, Fla.

• Kai-Ming G. Fu, MD, PhD, can be reached at the Department of Neurosurgery, University of Virginia Medical School, PO Box 800212, Charlottesville, VA 22908; 434-924-2203; e-mail: kmf5e@virginia.edu.
  Disclosure: Fu has no relevant financial disclosures.

The morbidity and mortality (M & M) database report of the Scoliosis Research Society (SRS) presented at the North American Spine Society (NASS) meeting continues to be one of the centerpieces of the SRS and is eagerly awaited by spine surgeons around the world.

Of 23,918 children who had spine surgery cases reported from 2004 to 2007, the overall complication rate was 8.5%. While not having access to the breakdown of each diagnostic group, the summation revealed the major complications to be due to infections or respiratory problems. Revision surgery and osteotomy patients were at risk for new neurological deficits.

The shortcoming of the retrospective study design as in any pooled data lies in the weaknesses of incomplete submissions, lack of complete categorization of complications, ie, not listing pseudarthrosis as a complication and absence of outcome assessments. Nevertheless, the study does highlight issues of most concern such as the morbidity and mortality of infections, respiratory problems and new neurological deficits.

Vigorous preoperative assessment and early referrals of patients at risk for respiratory problems, as well as spine team strategies to include pulmonary medicine may decrease exposure to respiratory complications.

The development of aggressive surgical site infection (SSI) protocols with the perioperative team is active in most centers and if not, this report surely reinforces the need.

The development of instrumentation and surgical techniques capable of initiating tremendous forces to the spine achieving major correction of severe deformities and our ability to perform revision surgery also comes with a responsibility. Training tutorials may decrease anatomical misadventure, but developing a higher level of team strategies to achieve enhanced, direct presurgical communication with neuromonitoring personnel is paramount.

Spine surgeons will continue to look upon the results of the SRS M&M reports to improve the perioperative safety of their patients. We eagerly await the publication of the study which is always a must read for all spine teams.

– Alvin H. Crawford, MD
Orthopedics Today Editorial Board member
Division of Pediatric Orthopaedic Surgery
Cincinnati Children’s Hospital Medical Center, Cincinnati
Disclosure: He is a consultant to and his division receives educational grant support from DePuy Spine.