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Planning Revision Spinal Surgery in Children with Spinal Deformities

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Modern medicine can perform many "miracles" these days. Among them is the ability to surgically straighten a spine that is severely curved from a childhood condition called scoliosis. Pediatric spinal deformities requiring surgery may also occur associated with other developmental problems, neuromuscular diseases, or genetic conditions.

But a one-time procedure is unlikely over the lifetime of those children as they move into and through adulthood. Revision surgery is required in up to one-fourth (25 per cent) of all cases. The reasons for revision spinal deformity surgery vary.

It could be there wasn't enough spinal correction the first time or there is a remaining imbalance in the spine that requires a two- or three-step series of operations. The fusion might not be complete and pseudoarthrosis (a false joint) develops. Loss of correction and an uncorrected second spinal curve getting worse may drive the decision to reoperate.

Sometimes the hardware (rods and screws) used to hold the spine in place break or get dislodged and must be repaired or removed and replaced. Revision surgery is needed then. If infection develops, the surgeon may have to go back in and perform additional procedures. And in some cases, the child or teenager develops pain at the operative site that must be investigated.

Whatever the reason, each case is unique and requires careful consideration and preplanning in order to gain a good result. In this article, Dr. Paul Sponseller, a pediatric orthopedic surgeon from Johns Hopkins University Hospital reviews the issues and complications associated with pediatric revision surgery for spinal deformities.

He reviewed all of the studies and reports on reoperations and summarized the information found on how often revisions occur, age of the patients, and surgical techniques used. Having this information is helpful when counseling patients and their families about what to expect for results with the first spinal correction (usually fusion) and the risk of reoperation.

Trends observed over time were also pointed out. For example, posterior fusions were more likely to require revision than anterior fusions. The overall revision rate for both anterior and posterior fusions has decreased over time. This change is most likely the result of improved surgical techniques and equipment and experience gained by surgeons over time. Most of the revisions required were for adolescents (teens).

It isn't always clear when revision surgery is required. Sometimes it's better to wait until the child has stopped growing (or at least isn't growing so fast). When the decision is made to perform a revision procedure, the surgeon must plan carefully. Every effort is made to prevent further complications.

Surgeons are advised to re-read the patient's medical record and look carefully for any clues from the previous surgery that might help. Was there quite a bit of bleeding during the index (first) surgery? Were there any other problems during the index procedure? Did the child have any unusual anatomical features to be aware of?

Preoperative imaging including X-rays and CT scans help the surgeon plan his or her correction strategy. CT scans are especially helpful in showing areas of infection or the presence of a pseudoarthrosis (false joint). Every angle and every level of the spine is taken into consideration during the pre-operative planning phase. And it is best to consult with other surgeons about each case in order to avoid missing any important decision points.

For the benefit of pediatric orthopedic surgeons who perform these procedures, the author goes over details of various procedures (e.g., resection, osteotomy, implant removal). Strategies are discussed when connecting one part of the spine to another in the revised fusion. X-rays, photos, and drawings are used to show the surgeon what to do and how to do it.

And a final point of discussion includes various ways to prevent complications such as infection, blood loss, dural tears, and spinal fluid leakage. Dr. Sponseller ends by encouraging all surgeons to aid the patient and family in facing the decision to reoperate. It's a stressful time. Both patient/family and surgeon should remain open to the thoughts and ideas of others -- even if it means both parties seek a second (or third) opinion.

Reference: Paul D. Sponseller, MD. Pediatric Revision Spinal Deformity Surgery. Issues and Complications. In Spine. December 1, 2010. Vol. 35. No.25. Pp. 2205-2210.

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