Higher Than Expected Rate of Reoperation Found Following Final Fusion in Early-Onset Scoliosis

George H. Thompson, MD, and Lawrence G. Lenke, MD, Comment

Peer Reviewed

Twenty percent of children with early-onset scoliosis who underwent growing-rod surgery required reoperation following final fusion. The higher than expected rate of reoperation has important implications for patient counseling, the study investigators noted in the November issue of The Journal of Bone and Joint Surgery.

young girl, back examination by physicianTwenty percent of children with early-onset scoliosis who underwent growing-rod surgery required reoperation following final fusion.The findings provide a word of caution to spine surgeons that while final fusion appears to theoretically be the end of the growing-rod treatment protocol, other complications requiring intervention may arise in both the acute postoperative phase as well as up to 2 years later, said lead author George H. Thompson, MD, who is Division Chief of Pediatric Orthopaedic Surgery at University Hospitals Rainbow Babies and Children’s Hospital in Cleveland, Ohio.

Using the multicenter, international Growing Spine Study Group, the investigators identified 100 patients with early-onset scoliosis treated with growing rods who were followed for at least 2 years after final fusion. The mean age at final fusion was 12.2 years, with a range of 8.5 to 18.7 years.

Twenty Percent of Patients Required Reoperation
Twenty patients required a total of 57 reoperations for 30 complications that occurred during a mean followup of 4.3 years. The most common complication requiring reoperation was infection (33 reoperations), followed by instrumentation failure (8 reoperations), and painful or prominent instrumentation (6 procedures). Less common causes of reoperation included coronal deformity, pseudarthrosis, sagittal deformity, and progressive crankshaft chest wall deformity.

table, number of patients requirining reoperation after final fusion in growing-rod surgery

“The average time from final fusion to reoperation was 2 years,” Dr. Thompson emphasized. Thus, in addition to acute processes, there is still the chance for other complications down the line, added Dr. Thompson, who also is Professor of Orthopaedic Surgery at Case Western Reserve University School of Medicine in Cleveland, Ohio.

“Surgeons have to give families the advice that, when you are dealing with multiply operated spines and the various syndromes, that as patients have their final fusion it might not be their last operation,” Dr. Thompson concluded.

The Future of Surgery for Early-Onset Scoliosis
In growing rod surgery, patients undergo operations every 6 months to lengthen the rod. Dr. Thompson believes that magnetically controlled growing rods that can be expanded remotely with fewer operations will be the “wave of the future” for treatment of early-onset scoliosis in the next decade.

In addition, “we are looking at what we call growth modulation techniques where we can go in and alter the range of growth on one side of the spine or the other,” Dr. Thompson said. “That, in turn, can be used to allow continued spinal growth while controlling the deformity at the same time. This technology is already available, but is not widely used yet.”

Commentary

Lawrence G. Lenke, MD
Professor of Orthopedic Surgery
Chief of Spinal Surgery
Chief of Spinal Deformity Surgery
Columbia University Medical Center
Surgeon-in-Chief
The Spine Hospital at New York-Presbyterian/Allen Hospital

This important article analyzed the fate of patients with early-onset scoliosis managed by growing rod constructs and multiple lengthenings after which they had a “final fusion” performed when appropriately skeletally mature. Final fusion is typically an important milestone for these patients who have often undergone multiple surgeries in the past to try and optimize their spine, trunk, and chest wall growth while controlling the spinal deformity through the growing rod instrumentation. This final fusion has been accepted to be a definitive procedure that would signify the end of the very long road managing these challenging spinal deformities.

However, these authors point out that in many cases, the “final fusion” is not the final operation. In 20% of the patients, additional surgeries were required. Not surprisingly, the most common reason for reoperation was for a wound infection. Given the prior number of previous spine procedures performed through the same posterior incision, patients are predisposed to a fairly high infection risk with their definitive instrumentation and fusion, which usually requires an extensive posterior dissection often along with spinal osteotomies to realign the distorted spinal column and a prolonged operative time. Other less common reasons for revision included implant prominence, curve progression, and implant failure with attendant pseudarthrosis.

So what can be gleaned from this important study? First, that surgeons taking care of these patients need to inform them and their parents of this high revision rate following these definitive fusions so that they are appropriately informed of this possibility. In addition, it also should be a reminder to the surgeons planning and performing these procedures that their best efforts will be required to minimize the risks of revision surgery. Special emphasis should be taken for proper wound handling and closure and even considering a plastic surgeon to assist in closure if appropriate.

Next, the construct being placed needs to be of appropriate profile as to not become prominent over time as tissue swelling subsides, but also needs to be securely fixed to avoid implant migration/pull-off. Also, the definitive fusion needs to be performed in a meticulous fashion with acceptable spinal alignment to avoid postoperative curve progression or implant failure associated with pseudarthrosis. These cases are not “slam-dunk” types of procedures and will require an attention to detail and technical execution that demands the best of the surgeon and his or her entire team. Hopefully, with this added level of heightened awareness for both the patient and surgeon, the term “final fusion” does end up being the “last” deformity operation for a greater percentage of early-onset patients having been managed with growing rod constructs in the future.

Updated on: 03/20/18
Continue Reading
Minimally Invasive Surgery for Adolescent Idiopathic Scoliosis Shows Same Efficacy as Open Approach with Less Transfusion Needs
Lawrence G. Lenke, MD
Professor of Orthopedic Surgery
Columbia University Medical Center
New York, NY
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