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Development of Consensus-Based Best Practice Guidelines for the Perioperative and Postoperative Care of Pediatric
Walter H Truong1,2, Hiroko Matsumoto3,4, Jaysson T Brooks5,6
1Department of Orthopedics-Spine, Gillette Children's, Saint Paul, MN.
Insights
This study established best practices for pediatric spinal deformity surgery in patients with implanted programmable devices (IPDs). Experts reached consensus on safe use of monitoring, cautery, and magnetically controlled growing rods (MCGRs) during surgery.
Area of Science:
- Pediatric Orthopedics
- Neurosurgery
- Medical Device Technology
Background:
- Pediatric patients with neuromuscular or syndromic scoliosis often have implanted programmable devices (IPDs).
- Lack of established guidelines for managing these IPDs during spinal deformity surgery poses a clinical challenge.
- This study addresses the critical need for perioperative care standards for these complex cases.
Purpose of the Study:
- To develop consensus-based best practices for managing pediatric patients with IPDs undergoing spinal deformity surgery.
- To provide clear guidance on the perioperative and postoperative care for these unique patient populations.
- To enhance surgical safety and optimize outcomes for children with scoliosis and co-existing IPDs.
Main Methods:
- A modified Delphi consensus study involving 25 multidisciplinary experts.
- Initial postulates based on literature review and prior surveys, covering various IPDs like VNS, VPS, ITBP, pacemakers, ICDs, DBS, and cochlear implants.
- Multiple survey rounds and a virtual meeting to achieve ≥80% expert agreement on best practice postulates.
Main Results:
- Consensus achieved on 39 postulates across 6 types of IPDs, with agreement rates from 94.4% to 100%.
- Established guidelines for intraoperative monitoring and cautery use, noting variations based on specific IPD types.
- Confirmed the safe surgical application and lengthening of magnetically controlled growing rods (MCGRs) in patients with various IPDs.
Conclusions:
- Spinal deformity correction surgery can safely incorporate intraoperative monitoring, cautery, and MCGRs in patients with IPDs.
- The developed postulates offer crucial guidance for spinal deformity surgeons managing pediatric patients with scoliosis and IPDs.
- This consensus provides a foundation for improved perioperative and postoperative care protocols.
Study Design:
Modified Delphi consensus study.
Objective:
To develop consensus-based best practices for the care of pediatric patients who have implanted programmable devices (IPDs) and require spinal deformity surgery.
Summary Of Background Data:
Implanted programmable devices (IPDs) are often present in patients with neuromuscular or syndromic scoliosis who require spine surgery. Guidelines for monitoring and interrogating these devices during the perioperative period are not available.
Methods:
A panel was assembled consisting of 25 experts (i.e., spinal deformity surgeons, neurosurgeons, neuroelectrophysiologists, cardiologists, and otolaryngologists). Initial postulates were based on a literature review and results from a prior survey. Postulates addressed the following IPDs: vagal nerve stimulators (VNS), programmable ventriculoperitoneal shunts (VPS), intrathecal baclofen pumps (ITBP), cardiac pacemakers and implantable cardioverter-defibrillators (ICD), deep brain stimulators (DBS), and cochlear implants. Cardiologist and otolaryngologist participants responded only to postulates on cardiac pacemakers or cochlear implants, respectively. Consensus was defined as ≥80% agreement, items that did not reach consensus were revised and included in subsequent rounds. A total of 3 survey rounds and 1 virtual meeting were conducted.
Results:
Consensus was reached on 39 total postulates across 6 IPD types. Postulates addressed general spine surgery considerations, the use of intraoperative monitoring and cautery, the use of magnetically controlled growing rods (MCGRs), and the use of an external remote controller to lengthen MCGRs. Across IPD types, consensus for the final postulates ranged from 94.4% to 100%. Overall, experts agreed that MCGRs can be surgically inserted and lengthened in patients with a variety of IPDs and provided guidance for the use of intraoperative monitoring and cautery, which varied between IPD types.
Conclusion:
Spinal deformity correction surgery often benefits from the use of intraoperative monitoring, monopolar and bipolar cautery, and MCGRs. The final postulates from this study can inform the perioperative and postoperative practices of spinal deformity surgeons who treat patients with both scoliosis and IPDs.
Level Of Evidence:
V-Expert opinion.
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