Complications in Adult Spinal Deformity Surgery

Transcription

1 Complications in Adult Spinal Deformity Surgery Jacob M. Buchowski, M.D., M.S. Professor of Orthopaedic and Neurological Surgery Director, Washington University Spine Fellowship Director, Center for Spinal Tumors Washington University in St. Louis St. Louis, Missouri Spine Masters Surgical Techniques May 18-20, 2017

2 Disclosures Consultant: None Royalties: Globus Medical, Inc. (<$50,000 per year) K2M, Inc. (<$20,000 per year) Lippincott Williams & Wilkins (<$250 per year) Speakers Bureau: None Fellowship Support: AO North America OMeGA

3 Introduction Complications in adult deformity spine surgery are common Reported complication rates vary tremendously 0 to >50% depending on study! Complications can be classified into minor and major complications No consensus on what is a minor or a major complication

4 Yadla S et al. Adult scoliosis surgery outcomes: a systemic review. Neurosurg Focus 2010;28(3):E3. Systemic review of 49 articles on adult spinal deformity surgery Inclusion criteria: Adult spinal deformity surgery Follow-up 2 years Age 18 years 49 articles with information on 3299 patients

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6 Yadla S et al. Adult scoliosis surgery outcomes: a systemic review. Neurosurg Focus 2010;28(3):E3. Complications: 41 articles 897 complications in 2175 patients Complication rates varied from 0 to 53% Overall rate of complications: 41.2%!

7 Yadla S et al. Adult scoliosis surgery outcomes: a systemic review. Neurosurg Focus 2010;28(3):E3. Pseudarthrosis was the most common observed complication: Pseudarthrosis rate varied from 0 to 41% Overall pseudarthrosis rate: 12.9%

8 Zimmerman RM et al. Functional Outcomes and Complications After Primary Spinal Surgery for Scoliosis in Adults Aged Forty Years or Older: A Prospective Study With Minimum Two-Year Follow-up. Spine 2010;35(20): Prospective case series of 35 patients 40 years (mean age 56.3 years) undergoing adult deformity surgery Statistically significant improvement in ODI, SF-36, and SRS-22 after surgery

9 Zimmerman RM et al. Functional Outcomes and Complications After Primary Spinal Surgery for Scoliosis in Adults Aged Forty Years or Older: A Prospective Study With Minimum Two-Year Follow-up. Spine 2010;35(20): Overall complication rate was 49% 26% had a major complication 31% had a minor complication No deaths

10 Zimmerman RM et al. Functional Outcomes and Complications After Primary Spinal Surgery for Scoliosis in Adults Aged Forty Years or Older: A Prospective Study With Minimum Two-Year Follow-up. Spine 2010;35(20): There were no significant differences in outcomes related to presence of complications

11 Zimmerman RM et al. Functional Outcomes and Complications After Primary Spinal Surgery for Scoliosis in Adults Aged Forty Years or Older: A Prospective Study With Minimum Two-Year Follow-up. Spine 2010;35(20): Adults 40 years with symptomatic scoliosis benefit from surgical treatment, despite the high complication rate

12 Cho SK. Comparative Analysis of Clinical Outcome and Complications in Primary Versus Revision Adult Scoliosis Surgery. Spine 2012;37(5): Retrospective comparison of 250 consecutive adult patients who underwent P versus R surgery for idiopathic or de novo scoliosis Minimum 2-year follow-up

13 Cho SK. Comparative Analysis of Clinical Outcome and Complications in Primary Versus Revision Adult Scoliosis Surgery. Spine 2012;37(5): Primary patients had significantly lower overall complications than revision patients (P = 45.2% vs. R = 58.2%, P = 0.042)

14 Cho SK. Comparative Analysis of Clinical Outcome and Complications in Primary Versus Revision Adult Scoliosis Surgery. Spine 2012;37(5): Overall complication rates for primary and revision patients were 45.2% and 58.9%, respectively (p=0.042) When complications were divided into major and, the differences were not significant Major (P=27.8% vs. R=31.5%, p=0.62) Minor (P=17.5% vs. R=27.4%, p=0.082) When complications were divided into perioperative and follow-up, the differences were not significant Perioperative (P=21.4% vs. R=27.4, p=0.34) Follow-up (P=23.8% vs. R=31.5%, p=0.23)

15 Cho SK. Comparative Analysis of Clinical Outcome and Complications in Primary Versus Revision Adult Scoliosis Surgery. Spine 2012;37(5): Primary patients reported significantly higher preoperative and final clinical outcome scores than revision patients in SRS function, pain, and subscore domains as well as ODI (all P<0.05) This difference between the 2 cohorts disappeared in older patients (>60 years) Revision patients seemed to have benefited from surgery just as much as primary patients at a minimum 2-year follow-up, based on the pre- to post-operative SRS and ODI changes

16 Charosky S. Complications and Risk Factors of Primary Adult Scoliosis Surgery: A Multicenter Study of 306 Patients. Spine 2012;37(8): Retrospective review of multi-center prospectively collected data on 306 adults >50 years of age undergoing spinal deformity surgery Mean age 63 years (range, 50 83) 83% women/17% men Mean follow-up 54 months Surgery characteristics: 10% anterior surgery only 18% A/P surgery 72% posterior surgery only 74% had long fusions of 3 or more levels 44% were fused to the sacrum 40% had a decompression 18% had an osteotomy

17 Charosky S. Complications and Risk Factors of Primary Adult Scoliosis Surgery: A Multicenter Study of 306 Patients. Spine 2012;37(8): Overall complication rate: 39% 175 complications in 119 patients No deaths or blindness General complication rate was 13.7% Infection rate was 5.2% Early infection 4% Late infection 1.2%. Neurological complications rate was 7% 2 cases (0.6%) of late cord-level deficits 12 reoperations (4%) Mechanical complications rate was 24% (73 patients) 19% (58 patients) required a reoperation

18 Charosky S. Complications and Risk Factors of Primary Adult Scoliosis Surgery: A Multicenter Study of 306 Patients. Spine 2012;37(8): Risk factors for mechanical or neurological complications: Number of instrumented vertebra (P 0.01) Fusion to the sacrum (P 0.001) PSO (P = 0.01) High preoperative pelvic tilt of 26 (P 0.05)

19 Charosky S. Complications and Risk Factors of Primary Adult Scoliosis Surgery: A Multicenter Study of 306 Patients. Spine 2012;37(8): Reoperation risk of 44% at 5 years

20 Charosky S. Complications and Risk Factors of Primary Adult Scoliosis Surgery: A Multicenter Study of 306 Patients. Spine 2012;37(8): For long fusions, reoperation risk was 40% at 50 months

21 Charosky S. Complications and Risk Factors of Primary Adult Scoliosis Surgery: A Multicenter Study of 306 Patients. Spine 2012;37(8): For fusions to the sacrum, reoperation risk was 48% at 49 months

22 Charosky S. Complications and Risk Factors of Primary Adult Scoliosis Surgery: A Multicenter Study of 306 Patients. Spine 2012;37(8): One of 4 patients is at risk for a new operation in the 2- year period after the first surgery, and half of the patients may need and new operation by 6 years postoperatively Long fusions have a greater risk of reoperation than short fusions Although fusions of more than 10 segments have a higher complication rate initially, long-term survival seems better than that found for fusions of 5 to 10 segments Fusions to the sacrum have a reoperation risk of 48% at 4 years

23 Discussion Adult deformity surgery is associated with a high risk of complications (~50%)! Major complication rate: ~25-30% Minor complication rate: ~20-25% Most common complications: Pseudarthrosis Infection

24 Discussion Complications are more common in: Older patients Be weary of operating on patients older than years (especially if they require a large operation) Patients with multiple co-morbidities Patients requiring a larger operation Osteotomy Fusion to sacrum/pelvis

25 Discussion Keys to avoiding complications Patient preoperative optimization DM management Weight loss Osteopenia/osteoporosis management Preoperative cardiac/pulmonary clearance

26 Discussion Keys to avoiding complications Surgeon optimization Pick the right operation for the right patient Need to feel comfortable with the steps required to accomplish the task at hand Make sure that you don t bite off more than you can chew Need to make sure that you feel comfortable with the instrumentation system you use Have the right team in place to optimize patient management Anesthesia Spinal cord monitoring team OR team Fluoroscopy/X-ray tech

27 Thank You!