Surgical Complication Rates

[LindaRacine]

Spine. 2006 Feb 1;31(3):345-9. Related Articles, Links

Complications in spinal fusion for adolescent idiopathic scoliosis in the new millennium. A report of the Scoliosis Research Society Morbidity and Mortality Committee.

Coe JD, Arlet V, Donaldson W, Berven S, Hanson DS, Mudiyam R, Perra JH, Shaffrey CI.

Center for Spinal Deformity and Injury, Suite 1F, 360 Dardanelli Lane, Los Gatos, CA 95032, USA. jcoe@jcoemd.com

STUDY DESIGN: The Morbidity and Mortality database of the Scoliosis Research Society (SRS) was queried as to the incidence and type of complications as reported by its members for the treatment of adolescent idiopathic scoliosis (AIS) with spinal fusion and instrumentation procedures regarding surgical approach (anterior, posterior, or combined anterior-posterior) during a recent 3-year period. OBJECTIVE: To evaluate the incidence of surgeon-reported complications in a large series of spinal fusions with instrumentation for a single spinal deformity diagnosis and age group regarding surgical approach. SUMMARY OF BACKGROUND DATA: The SRS has been collecting morbidity and mortality data from its members since its formation in 1965 with the intent of using these data to assess the complications and adverse outcomes (death and/or spinal cord injury) of surgical treatment for spinal deformity. Surgical approaches to the management of treatment of AIS have a measurable impact on efficacy of correction, levels fused, and operative morbidity. However, there is a lack of consensus on the choice of surgical approach for the treatment of spinal deformity. METHODS: Of the 58,197 surgical cases submitted by members of the SRS in the years 2001, 2002, and 2003, 10.9% were identified as having had anterior, posterior, or combined spinal fusion with instrumentation for the diagnosis of AIS, and comprised the study cohort. All reported complications were tabulated and totaled for each of the 3 types of procedures, and statistical analysis was conducted. RESULTS: Complications were reported in 5.7% of the 6334 patients in this series. Of the 1164 patients who underwent anterior fusion and instrumentation, 5.2% had complications, of the 4369 who underwent posterior instrumentation and fusion, 5.1% had complications, and of the 801 who underwent combined instrumentation and fusion, 10.2% had complications. There were 2 patients (0.03%) who died of their complications. There was no statistical difference in overall complication rates between anterior and posterior procedures. However, the difference in complication rates between anterior or posterior procedures compared to combined procedures was highly significant (P < 0.0001). The differences in neurologic complication rates between combined and anterior procedures, as well as combined and posterior procedures were also highly statistically significant (P < 0.0001), but not between anterior and posterior procedures. CONCLUSIONS: This study shows that complication rates are similar for anterior versus posterior approaches to AIS deformity correction. Combined anterior and posterior instrumentation and fusion has double the complication rate of either anterior or posterior instrumentation and fusion alone. Combined anterior and posterior instrumentation and fusion also has a significantly higher rate of neurologic complications than anterior or posterior instrumentation and fusion alone.

[Singer]

So the implication of this study is that the risk of the anterior/posterior procedure - which most adults need -- is double that of either approach by itself, right?

The more research I do, the more reluctant I am to have this g**m'd surgery. I don't like any of my options right now and I'm pissed as hell about it.

[LindaRacine]

Yes. I think it makes perfect sense that A/P surgery would have about double the complication rate because 1) it's 2 surgeries and 2) it's usually done on a population older than just anterior surgery or just posterior surgery.

You should not let a 10% complication rate scare you away from surgery if you need it. Many of these complications are very minor.

--Linda

[Singer]

Yes, I guess you're right. I was feeling sorry for myself last night; my family is in turmoil over the possibility of me being out of commission for a while.

We'll see what Boachie says next Thursday.

[CHRIS WBS]

More food for thought when considering surgery

Mortality Following Major Spinal Deformity Corrective Surgery in Adults

David F. Antezana
Baltimore, MD, USA

Ricardo Gonzalez
Baltimore, MD, USA

Jen-Yi Chang
Baltimore, MD, USA

John P. Kostuik
Baltimore, MD, USA

Exhibit from the SRS 2002 Annual Meeting
OBJECTIVE: To determine the incidence of mortality following major spinal deformity corrective surgery in adults and factors which may contribute to postoperative mortality.

INTRODUCTION: Incidence of mortality following major spinal deformity corrective surgery has reportedly ranged from 1.4-20%. Few studies assess mortality in a large series. We report our experience in 417 patients.

MATERIAL AND METHODS: From 1992-1999, 417 patients (F 347, M 70) aged 20-87 (avg. 51) underwent spinal deformity corrective surgery (146 primary, 271 revision). Surgical approaches include 23 anterior, 155 posterior, 167 same-day combined, and 72 staged combined. Average introperative blood loss was 3100. Comorbiditiy risk was assessed by ASA score (1 – 28, 2 – 233, 3 – 143, 4 – 3; avg. – 2.3). Fusion levels varied as follows: <5 – 108; 5-10 – 192; >10 – 107. We retrospectively reviewed the patients who died on our service and identified factors that may have contributed to their
demise.

RESULTS: The incidence of mortality was 2.4% (10/417; M 2, F 8; aged 35-70, avg. 52). One death was intraoperative. Death occurred on average on post-op day 9. Average intraoperative blood loss was 3600cc (1300-9000). Average number of levels was 10.1 (5-15). Of the 10, 2 were anterior approaches, 5 were posterior alone, and 3 were combined; 5 were revisions. Pedicle subtraction osteotomies were performed in 6 of 8 posterior approaches. ASA scores averaged 3 (range 2 – 4);( 4 – 2, 3 – 5, 2 – 2, 1 – 0). Causes of death included pulmonary embolus (3), MI, shock, abdominal hemorrhage, seizures, multisystem organ failure, cerebral edema/brain death, and ARDS.

CONCLUSION: The incidence of mortality following major spinal corrective surgery in adults is significant. Sex, age, blood loss, and revision status were not factors affecting mortality. Patients who died tended to have higher ASA scores/comorbidities (3 vs. 2.3) and were more likely to have had osteotomies. The high incidence of pulmonary embolus as cause of death makes it imperative to further investigate PE in this patient population.

Chris

[SpineWhine]

What is an ASA score, and what does it mean?

[CHRIS WBS]

ASA score

I believe the American Society of Anesthesiologists (ASA) uses a scale to classify patients according to their physical status.

[Karen Ocker]

ASA scores

In general: ASA 1 means no medical problems

ASA 2: Medical problems which do not interfere with daily life: Controlled- high blood pressure, well managed diabetes, anyone who smokes, anyone overweight, mild heart disease etc.

ASA 3:Medical problems which significantly impact daily living, sleep apnea, morbid obesity, insulin dependent diabetes, paralysis, severe respiratory disease. There are many others.

ASA 4: A medical condition which is a constant threat to life: kidney failure, severe trauma, coma etc.

ASA 5: Moribund-near death.

An "E" after any classification means the operation to be performed is an emergency.

These are classifications which are not cut and dried but indicate the anesthetic risk before surgery and are listed on the anesthesia record. This is the pre-op assessment by the anesthesia provider based on ASA guidlines.

[lelc2002@yahoo]

give me a 1....

I so hope I'm a 1.....Ly..

[LindaRacine]

Mortality Following Major Spinal Deformity Corrective Surgery in Adults

It's important to note that this is the experience of only one center.

--Linda

[SandyC]

Not only one center, but less than 500 patients

[Singer]

Note to self: stay the hell out of Baltimore, MD........

[chrisfrie]

Due to my lung impairment, my surgeon, pulmonologist and neurologist decided on posterior only procedure. The correction is reduce some but the risks drop and my recovery time dropped along with severity of pain is much less.
Good Luck!
Christine

[Karen Ocker]

Mortality study

Average ASA class was of those patients "3" --meaning significant medical problems(also called comorbidities). Some patients were 60-70 years old.

I guess it's not a good idea to wait so long if scoliosis progresses in middle age.

Also: The last patients in this study had surgery in 1999 --6 years ago. There continues to be more advances in scoliosis surgery-- not to mention most patients are not this old. Incidence of complications increases over age 60 -- when many people have developed other medical problems.

[crookedspine]

Ok, everybody. As with every surgery, there are complications. This is a true statement. But let the record show: I AM 48 YEARS OLD and just had anterior/posterior surgery in November. Instead of two surgeries, I had three because my doctor knew when to quit and wait for another day. It was a TOTAL success, and I am doing better than great! The thing is to get to know your physician, do a lot of research, and then make your decision. Do what is right for YOUR body and your family. Singer, don't get discouraged. Keep searching! You, too, can find a doctor almost as good as mine in Boston! Linda