Unplanned Surgery of Congenital Scoliosis
Congenital scoliosis (CS) is a complex spinal deformity that arises from congenital vertebral anomalies, such as hemivertebrae, unsegmented vertebrae, or wedge-shaped vertebrae. While surgical intervention is often necessary to correct these deformities, there is a significant risk of unplanned surgeries following the initial procedure. This study aimed to explore the prevalence, causes, and outcomes of unplanned surgeries in patients with congenital scoliosis, providing valuable insights for clinicians and patients alike.
The study retrospectively reviewed electronic medical records of patients with congenital scoliosis who underwent unplanned surgeries at West China Hospital from 2009 to 2018. A total of 317 CS cases were identified, of which 33 cases required unplanned surgeries. Among these, 28 patients had their primary surgeries at West China Hospital, while five had their primary surgeries at other institutions. The unplanned surgery rate at West China Hospital was calculated to be 9.0% (28/312). This rate highlights the significant likelihood of patients with congenital scoliosis requiring additional surgical interventions beyond their initial procedures.
The causes of unplanned surgeries were categorized into four main groups: progressive spinal deformity or imbalance, implant-related complications, wound-related complications, and surgical error-related complications. The most common cause of unplanned surgery was progressive spinal deformity, accounting for 49% (16/33) of the cases. This category included progressive scoliosis (7 cases), progressive kyphosis (6 cases), and progressive scoliokyphosis (3 cases). Progressive spinal deformity often results from improper implant removal, suboptimal surgical strategies, or the natural growth of the patient, particularly in children.
Implant-related complications were the second most common cause of unplanned surgeries, representing 36% (12/33) of the cases. These complications included implant-related pain, discomfort, neurological deficits, and implant failure. Five cases developed late surgical-site pain, which was attributed to the implants, and required implant removal. Seven cases experienced implant failure, such as breakage, loosening, pull-out, or migration, necessitating revision surgeries. Implant failure can result from incomplete resection of the malformed hemivertebra, lack of bone graft, improper fixation instruments, or inadequate fusion. To mitigate these risks, preoperative planning with 3D reconstruction of the pedicles, complete resection of the hemivertebra, and proper postoperative care are recommended.
Wound-related complications were the third most common cause of unplanned surgeries, accounting for 12% (4/33) of the cases. These complications included delayed wound union or nonunion, deep or superficial wound infections, and surgical-site hematomas. Wound infections are often caused by contaminated surgical materials or poor hygiene at the surgical site, particularly in patients with underlying immunodeficiency. Proper wound care, hygiene, and postoperative drainage can help prevent these complications.
Surgical error-related complications were the least common cause of unplanned surgeries, representing only 3% (1/33) of the cases. The single case in this category involved a cerebrospinal fluid (CSF) leak. While surgical errors are rare, they can have significant consequences, emphasizing the importance of meticulous surgical technique and thorough preoperative planning.
The study also highlighted several factors contributing to the need for unplanned surgeries. Improper implant removal, particularly in growing children, can lead to progressive spinal deformity. Five cases in the study underwent implant removal due to surgical-site pain, discomfort, or patient request, and subsequently developed progressive spinal deformities within two years. These cases underscore the importance of avoiding implant removal in growing patients unless absolutely necessary, as well as the need for close follow-up during growth peaks.
Suboptimal surgical strategies were another significant factor. Seven cases in the study had suboptimal original surgeries, including incomplete or no resection of the malformed hemivertebrae, no bone graft utilization, or wrong selection of end instrumented vertebra. These cases subsequently developed progressive spinal deformities, highlighting the importance of optimal surgical techniques, such as complete resection of the hemivertebra, short fixation, and short fusion.
Even with optimal surgical strategies, some patients may still develop recurrent spinal deformities. Four cases in the study developed structural S-shape scoliosis after posterior resection of hemivertebrae with short fixation and fusion. These cases suggest that changes in preoperative coronal balance may lead to the progression of compensatory curves, necessitating unplanned surgeries. Early conservative treatment with bracing may help control the progression of recurrent scoliosis, but revision surgery may still be required in severe cases.
The study also provided recommendations for preventing unplanned surgeries. Preoperative planning with 3D reconstruction of the pedicles can help select proper implants for young patients. During surgery, complete resection of the hemivertebra, including both endplates, is essential. For cases with large hemivertebra or obvious kyphosis, the use of a mesh cage to reconstruct the anterior column and correct the kyphosis is recommended. Postoperatively, wearing a spinal brace may improve fusion outcomes and reduce the risk of implant failure.
In conclusion, this study provides a comprehensive analysis of the causes and prevalence of unplanned surgeries in patients with congenital scoliosis. Progressive spinal deformity or imbalance was the most common cause, followed by implant-related complications and wound-related complications. Surgical error-related complications were rare but significant. The findings emphasize the importance of optimal surgical techniques, careful preoperative planning, and close postoperative follow-up to minimize the risk of unplanned surgeries. Clinicians should be aware of these risks and inform patients accordingly when discussing the potential outcomes of surgical intervention for congenital scoliosis.
doi.org/10.1097/CM9.0000000000001786
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