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Does Routine Subspecialty Consultation Before High-Risk Pediatric Spine Surgery Decrease the Incidence of
Timothy G Visser1, Erik B Lehman2, Douglas G Armstrong1
1Department of Orthopedics and Rehabilitation, PennState Health Milton S. Hershey Medical Center.
Insights
A standardized perioperative pathway for high-risk pediatric scoliosis surgery did not reduce postoperative complications. Selective subspecialty consultations may be more appropriate for these complex cases.
Area of Science:
- Pediatric Orthopedics
- Spine Surgery
- Patient Management
Background:
- High-risk pediatric patients with neuromuscular or syndromic scoliosis face increased postoperative complications.
- Complications include surgical site infections, pulmonary issues, and gastrointestinal disorders.
Purpose of the Study:
- To evaluate the impact of a standardized High-Risk Protocol (HRP) on managing high-risk pediatric scoliosis surgery patients.
- To determine if this multidisciplinary pathway reduces postoperative complications.
Main Methods:
- Retrospective chart and radiographic review of 71 pediatric patients (8-18 years) with scoliosis.
- Comparison between a group fully completing the HRP (n=35) and a control group (n=36).
- Minimum 2-year follow-up to assess outcomes and complications.
Main Results:
- The HRP group had significantly larger preoperative and postoperative curve magnitudes.
- Pulmonary disease was more prevalent in the HRP group (60% vs. 31%).
- Overall complication rates were similar between groups (29% vs. 28%), with no difference in complication types or severity.
Conclusions:
- A standardized, multidisciplinary perioperative pathway may not universally reduce complications in high-risk pediatric spine surgery.
- Selective consultation with subspecialists might be a more effective approach for this patient population.
Background:
Children with neuromuscular disorders and syndromic scoliosis who require operative treatment for scoliosis are at increased risk for postoperative complications. Complications may include surgical site infection and pulmonary system problems including respiratory failure, gastrointestinal system disorders, and others. The purpose of our study was to determine the effect of a standardized perioperative pathway specifically designed for management of high-risk pediatric patients undergoing surgery for scoliosis.
Methods:
The High-Risk Protocol (HRP) at our institution is a multidisciplinary process with subspecialty consultations before scoliosis surgery. This was a retrospective chart and radiographic review at a single institution. Inclusion criteria were high-risk subjects, age 8 to 18 years old, who underwent surgery between January, 2009 and April, 2009 with a minimum 2-year follow-up. Diagnoses included neuromuscular scoliosis or Syndromic scoliosis.
Results:
Seventy one subjects were analyzed. The mean age was 13 (±2 SD) years. Follow-up was 63 (±24 SD) months. The study group consisted of 35 subjects who had fully completed the HRP and the control group consisted of 36 subjects who did not. Nine of the 35 (26%) subjects in the HRP had surgery delayed while interventions were performed. Compared with controls, the study group had larger preoperative and postoperative curve magnitudes: 90 versus 73 degrees ( P =0.002) and 35 versus 22 degrees ( P =0.001). Pulmonary disease was more common in the HRP, 60 versus 31% ( P =0.013). The overall incidence of complications in the study group was 29% (10 of 35 subjects) and for controls 28% (10 of 36). There were no differences between groups for types of complications or Clavien-Dindo grades. Three subjects in the study group and 1 in the controls developed surgical site infection. Eleven subjects required unplanned reoperations during the study period.
Conclusions:
The findings of our study suggest a structured pathway requiring routine evaluations by pediatric subspecialists may not reduce complications for all high-risk pediatric spine patients. Selective use of consultants may be more appropriate.
Level Of Evidence:
Level III, Retrospective Cohort study.
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