Spine Deformity Preview Issue (September 2012) 39e45

www.spine-deformity.org

Preoperative Evaluation and Decreasing Errors in Pediatric Spine Surgery

Laurel C. Blakemore, MDa,*, Francisco J.S. Perez-Grueso, MDb, Matthew Cavagnaro, MDc,d,
Suken A. Shah, MDc,d
a

Childrens National Medical Center, Washington, DC, USA

b
Hospital Universitario La Paz, Madrid. Spain
c
Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
d
Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA, USA

Abstract
The treatment of pediatric spinal deformity has changed dramatically over the past several decades, and surgeons face new challenges
when managing the complications associated with these treatments. Care of the patient can be considered in 3 phases: preoperative
evaluation, perioperative period, and postoperative management period. There are opportunities to identify and prevent potential
complications during each of these phases of treatment. Comprehensive safety protocols that include the participation of all team members
should make surgery safer over time, and the use of postoperative management protocols and multidisciplinary teams to manage complex
patients can improve patient outcomes and shorten hospital stays. Surgeons, patients and payers are motivated to continue to improve safety
for the pediatric spinal deformity patient, and there will be heightened interest in defining specific measures that positively affect outcomes.
2012 Scoliosis Research Society.
Keywords: Perioperative evaluation; Safety; Scoliosis surgery

Introduction
The surgical treatment of spinal deformity is performed
with increasing frequency in the United States and internationally. Surgeons have developed modern techniques
that yield improved correction but are more technically
challenging, and are associated with a changing set of
potential complications during the perioperative period.
The surgeon and health-care industry are both motivated to
improve the safety of pediatric spine surgery, and many
measures have been undertaken in the past decade toward
this aim. The Universal Protocol introduced in the United
States in 2004 includes 3 minimum requirements: preoperative procedure verification, site marking, and a timeout.
It is designed to decrease the incidence of wrong site,
wrong patient, and wrong procedure surgical errors.

Presented at the annual pre-meeting course of the Scoliosis Research

Society, Louisville, KY, 2011.
*Corresponding author. Childrens National Medical Center, 111
Michigan Avenue, NW, Washington, DC, USA. Tel.: (202) 476-4152;
fax: (202) 476-4613.
E-mail address: LBlakemo@childrensnational.org (L.C. Blakemore).
2212-134X/$ - see front matter 2012 Scoliosis Research Society.
http://dx.doi.org/10.1016/j.jspd.2012.05.005

However, it has had no measurable effect on the rate of

wrong site surgery in spinal deformity procedures.
Minimizing perioperative complications begins with the
preoperative evaluation, which includes the assessment of
comorbidities and nutritional status. The surgeon also
controls the perioperative environment by optimizing
preoperative preparation. Equipment delays including
issues with implant sterilization, incomplete or unavailable
instrumentation, and surgeon preparation all affect surgical
outcomes. Antibiotic protocols are evolving to lower the
rate of postoperative wound infections. Vitale et al. [1]
recently presented a large multicenter series of 905 pediatric patients who underwent spinal deformity surgery, and
found a higher rate of gram-negative organisms involved in
neuromuscular patients with postoperative surgical site
infections, which suggests a role for routine gram-negative
prophylaxis in these patients. Perioperative safety measures
including the Universal Protocol and neuromonitoring have
become the standard of care in the United States for pediatric deformity surgery, and routine use of intraoperative
cell salvage, prone positioning with the abdomen free, and
relative hypotensive anesthesia have decreased allogenic
transfusion requirements.

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Prevention of postoperative complications, especially

pulmonary and gastroenterologic, can be improved by
employing a multidisciplinary approach to patient
management, especially for high-risk patients such as those
with neuromuscular scoliosis. High-risk adult patients who
are identified preoperatively, and who undergo a multidisciplinary assessment are managed according to a perioperative care pathway designed to reduce morbidity and
improve outcomes, but no published outcomes are available
to date [2]. In the pediatric literature, Simon et al. [3]
described a retrospective analysis of results before and
after the addition of a hospitalist co-management team for
mostly neuromuscular scoliosis patients; length of stay was
decreased after the hospitalists joined the postoperative
management team.
Complications may be reduced by adding a preoperative
assessment for high-risk pediatric spinal deformity
patients, but not necessarily for otherwise healthy idiopathic patients undergoing routine spinal instrumentation
and fusion. At our institution, the anesthesiology and the
hospitalist team evaluate in a multidisciplinary preoperative clinic patients who are identified as high-risk neuromuscular scoliosis patients and those with associated
comorbidities. That team assesses the need for further
preoperative testing or consultation and workup is
completed before admission for surgery. The completed
assessment and recommendations for management are
available to the anesthesiologists, pediatric intensive care
team, and hospitalists who will be co-managing the
patients, along with the orthopedic surgeons. Outcome data
are not yet available to prove that this approach has
improved our complication rate. Many pediatric tertiary
centers also use care pathways for the postoperative
management of idiopathic and high-risk spinal fusion
patients, but there is a need for outcome data in the literature demonstrating the efficacy of such pathways in
decreasing perioperative complications.
Preoperative Evaluation
When evaluating pediatric patients with spinal deformities for surgery, 2 groups should be differentiated:
patients with secondary scoliosis, the group with the
highest morbidity and risk of complications related to
surgery; and patients with adolescent idiopathic scoliosis
(AIS), probably the healthiest population undergoing spine
surgery.
Secondary scoliosis
Patient selection in this group with congenital, neuromuscular, and syndromic deformities focuses not only on
spinal deformity, but also on associated medical comorbidities. Patients require an evaluation by cardiology,
pulmonary, pediatric, and anesthesia services; those with
underlying neurological and poor nutritional conditions

need to be evaluated by neurology and gastroenterology

services [4,5].
Cardiac assessment
A complete cardiac evaluation is indicated in patients
with congenital deformity, in whom the incidence of
congenital heart disease may reach up to 26% of cases [6].
This evaluation is mandatory in patients with muscular
dystrophies, in whom an indication for surgery will depend
ultimately on the cardiopulmonary function. Echocardiogram represents the best tool to assess the cardiac condition
in this population.
Respiratory evaluation
Preservation of pulmonary function may be the major
indication for surgery, and many candidates for surgery
may already have some respiratory impairment.
Two important facts need to be considered before
addressing surgery. After scoliosis surgery, children may
experience a 60% decrease in pulmonary function in the early
postoperative period; this value may take around 2 months to
return to baseline [7]. In addition, neuromuscular patients
with a forced expiratory volume !40% often require prolonged mechanical ventilation postoperatively. Patients with
thoracic insufficiency syndrome and patients with neuromuscular disease are at the highest risk of having respiratory
complications. They will need a complete pulmonary evaluation starting with the airway, considering the need for
tracheotomy or the likelihood of reintubation, with its
potential difficulties owing to anomalies around the neck.
Pulmonary function testing may be invasive or noninvasive, effort-dependent or independent. Measurement of
trans-diaphragm pressures represents an invasive effortdependent respiratory test. Spirometry is the best noninvasive prognostic test for postoperative respiratory morbidity.
However, because it is an effort-dependent test, it is not
reliable for children under 5 years of age. For patients who
are too young or too disabled for spirometry, the pulmonary
capacity can be evaluated under general anesthesia.
Motoyama et al. [8] reported on forced and passive deflation
techniques to evaluate lung volume and respiratory
compliance in children with thoracic insufficiency syndrome
undergoing multiple expansion thoracoplasties.
Nutrition assessment
Nutritional depletion before surgery is associated with
increased complication rates such as wound infection and
poor wound healing, excessive bleeding, and anchor
dislodgment. Neuromuscular patients are at the highest
risk of having a poor nutritional condition [9e12]. Total
lymphocyte count, and albumin, prealbumin, and transferrin
levels represent the main nutritional parameters for evaluation. They may take 6e12 months to return to baseline
after surgery. Before planning surgery, the gastrointestinal

L.C. Blakemore et al. / Spine Deformity Preview Issue (September 2012) 39e45

function should be evaluated with regard to the presence

of swallowing difficulties, aspiration risk, and reflux.
Protein and energy requirements should be significantly
supplemented over normal values. The administration can be
oral and with nasogastric or G tubes, depending on the
estimated length of the nutritional support. Once surgery is
scheduled, a 10-day program can be sufficient to decrease
surgical complications.
Imaging techniques
Standard radiographs are needed to confirm the etiology
of the deformity. Dynamic films will confirm the severity
and flexibility of the curve. The neck should be radiographically assessed in patients with syndromic conditions
in which instability at the upper cervical spine is not rare,
and in those who are going to be placed in skeletal traction.
Magnetic resonance imaging (MRI) is especially indicated
in congenital deformities, in which the incidence of neural
axis abnormalities can be as high as 52%. The indication in
infantile idiopathic scoliosis is more controversial, because
the incidence of anomalous findings inside the canal is
!20% [13,14]. Dynamics and functional MRI are currently
used to evaluate diaphragm and pulmonary function [15].
Computed tomography (CT) scan is an invaluable tool for
the diagnosis and treatment of spinal deformities. It
provides a complete analysis of chest deformity, congenital
deformities involving the chest, and the spine, lung volume,
pedicle anatomy, for example [16]. Nevertheless, there is
a risk of significant radiation exposure, which has led to
increasing efforts to limit the use of CT scans for serial
imaging.
AIS patients
Most adolescents with idiopathic scoliosis are healthy.
Therefore, there is no true consensus for standard preoperative evaluation to reduce and prevent complications
related to surgery.
The incidence of unrecognized cardiac anomalies in
healthy adolescents has been reported as !4%. Ipp et al.
[17] found a 3% incidence of unrecognized aortic anomalies in a group of 200 adolescents undergoing surgery for
scoliosis. In such cases, an electrocardiogram may not
provide meaningful information, and would be considered
a part of the preoperative workup [18].
Few AIS patients present with respiratory symptoms
because of the curve pattern or severity. In a series of 850
patients, Johnston et al. [19] found that thoracic curves over
70 and especially over 80 , and those with thoracic
hypokyphosis may present respiratory impairment defined
as a pulmonary function test under 65% of predicted value.
The radiographic protocol in this type of patients should
include standard coronal and sagittal X-rays, in addition to
dynamic studies to assess the flexibility of the deformity
and establish the surgical strategy.

41

Indications for MRI in this population remain [20e23].

Sturm et al.s [24] recommendations summarize the indication for MRI: juvenile onset scoliosis, left thoracic
curves !30 or with documented progression, patients
experiencing neck pain or headaches, and increased
kyphosis. The use of CT scan is currently related to
preoperative planning to assess pedicle size; however, there
is no evidence that preoperative CTs provide better
outcomes. Therefore, their routine use in preoperative
planning is not justified. Nevertheless, computed tomography imaging with 3-dimensional reconstruction may be
invaluable for preoperative planning in complex spinal
deformity surgery.
Intraoperative Considerations
Once the patient presents to the operating room for
surgery, a surgeon must call on a larger skill set than just
the technical ability to achieve an optimal outcome. The
day of surgery requires communication among staff, a
protocol-based approach to operating room procedure,
accurate neuromonitoring, and experienced anesthesia
support, in addition to excellent surgical technique.
Communication is key among all participants in the
patients care, and should be facilitated by a reproducible
protocol. This begins in the preoperative holding area and
should continue until the operation is complete. The
surgeon, operating room staff, anesthesia, and neuromonitoring personnel need to keep each other updated on
all events, raise alerts if problems arise, and communicate
the steps taken to address those problems. Gawande [25]
showed how essential checklists are in todays world of
advancing technology and increasing complexity; the
operating room is no exception. A checklist helps ensure
that all safety measures are addressed each time. Safety
measures include checking equipment, identifying patients,
marking sites, identifying vertebral levels, having blood
products and equipment available, positioning the patient,
verifying appropriate consent, confirming all infection
prevention measures are completed (ie, timing of antibiotics, prep, room traffic), and discussing the patient
disposition plan. A timeout before beginning surgery will
help coordinate all operating room participants.
The role of a dedicated anesthesia team is critical to
achieving optimal outcomes in spinal deformity surgery. To
optimize outcomes, the anesthesiologist should limit the
use of paralytic agents, maintain controlled hypotension to
limit blood loss, include temperature regulation, and
anticipate and adequately address hypovolemia. Adequate
fluid resuscitation and blood product administration can
help avoid hemodynamic problems and limit blood loss by
improving coagulation. An intraoperative protocol can be
useful. One institution has implemented a protocol that
involves drawing laboratories every 2 hours for the first
6 hours, and then hourly for the remainder of the case.
Transfusions of red blood cells, cryoprecipitate, platelets,

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desmopressin acetate, and recombinant factor VII are

administered based on values of laboratories, such as
fibrinogen, platelets, and international normalized ratio,
and on the amount of oozing at the surgical site [26].
Antifibrinolytics may also have an important role in
reducing blood loss. One study evaluating the use of 2
antifibrinolytics, tranexamic acid and epsilon-aminocaproic
acid in neuromuscular scoliosis patients, found that antifibrinolytics significantly reduced intraoperative EBL
associated with PSF, with no adverse effects. However, the
authors could not demonstrate significant differences in
total transfusion, except in cell salvage. Tranexamic acid
was more effective than epsilon-aminocaproic acid in
decreasing the EBL and cell salvage transfusion [27].
Finally, the anesthesiologist must be comfortable with his
part in performing a Stagnara wakeup test. This intraoperative wakeup test involves lightening of anesthesia
until the patient can voluntarily move the lower extremities.
Although it is no longer generally used as the primary
intraoperative monitoring (IOM) technique, the wakeup test
has gained new life as a supplement to other testing
methods. If another IOM test such as somatosensory
evoked potentials (SSEP) or motor evoked potentials
(MEPs) demonstrates abnormality, a normal wakeup test
can reassure the surgeon that no permanent neurologic
injury has occurred [28]. Planned wakeup requires preoperative discussion and preparation for optimal results.
Warning the anesthetist 15e30 minutes before planned
wakeup is commonly adequate, and assessment will
consume 15e20 minutes [29].
Iatrogenic neurologic injury is an infrequent but potentially catastrophic complication of spinal deformity surgery,
and techniques to monitor neurologic function intraoperatively aim to detect and reverse neural injury in a
timely manner [30e33]. Intraoperative neuromonitoring
has evolved over the past 3 decades. Currently there are
several approaches, including the wakeup test, SSEPs,
transcranial MEPs, spinal cord MEPs (neurogenic MEPs),
spontaneous electromyography, and triggered electromyography. A combination of SSEP and MEP monitoring
provides assessment of entire spinal cord functionality in
real time, and allows the detection of adverse neurologic
events [34]. The goal is to permit change of intraoperative
strategy to minimize or reverse deficit.
Each of these monitoring modalities offers its own
unique set of data, and interpretation can present a challenge. The surgeon must have a good understanding of the
monitoring modality employed to allow the best intraoperative decisions based on the data received. It is
important to have neuromonitoring personnel present in the
operating room, because optimal data collection and
interpretation often requires real-time onsite communication with the surgeon and anesthesiologist. The surgeon
must understand the possibility of neurologic deterioration
despite IOM; even in the most ideal scenarios, IOM does
not eliminate the risk of adverse neurologic events [35].

Several intraoperative considerations for optimizing

outcome in spinal deformity surgery involve surgical
technique. One of the most common preventable complications in spine surgery is wrong-level surgery. A systematic review of the English language literature from 1990 to
2008 found an estimated rate of wrong-site surgery varies
widely ranging from 0.09 to 4.5 per 10,000 surgeries performed. The authors suggested that standardized checklists
are insufficient on their own to minimize this complication.
They recommended intraoperative imaging after exposure
and marking of a fixed anatomic structure. This imaging
should be compared with routine preoperative studies to
determine the correct site for spine surgery [36].
Correction of spinal deformity can be broken down into 3
stages: anchor placement, spine mobilization, and correction strategy. All 3 present opportunities to implement
safety measures [37]. In each of these phases, IOM should
be done regularly to help avoid techniques that cause
neurologic injury. Anchor placement must be done carefully
to achieve adequate fixation and avoid neurologic structures.
Severe spinal deformities often require osteotomies to
mobilize the spine and assist with correction. Although
osteotomies carry risks of increased blood loss and spine
destabilization, they make possible larger deformity
corrections than can be achieved with soft tissue release and
instrumentation alone. They also render the correction of
large deformities more successful by reducing the force
placed on spinal instrumentation [38]. Concerning correction strategy, several different methods can be employed,
but a few basic safety considerations can be applied to all
techniques. First, the surgeon must adequately evaluate the
patients bone quality to allow appropriate selection of
implants. Along with the bone quality, the relative rigidity of
the deformity must be taken into account. The implants
chosen must be able to provide enough force to adequately
resist the forces of the corrected spine, but the bone must
also be strong enough to keep the anchors from disengaging.
Some deformities, such as those with proximal thoracic
kyphosis or apical rotation and translation, present particularly difficult challenges in balancing forces during
correction. As long as the implants are placed safely, and a
biomechanically balanced construct is created for correction, even difficult deformities can be managed well.
Blood loss can have a role in complications of spinal
deformity surgery. Attention should be given to minimizing
blood loss throughout the operation. Increased bleeding can
result from surgical technique, increased surgical duration,
patient positioning, mean arterial pressure, and the number
of levels fused [39]. As discussed above, the anesthesiologist has an important role in helping minimize blood loss.
The surgeon must also help minimize blood loss in several
ways. By exercising careful tissue handling, using electrocauterization and mechanical methods, adequate hemostasis can be achieved during spine exposure. A shorter
operating room time will also contribute to less blood loss
[40]. Consideration must also be given to blood loss

L.C. Blakemore et al. / Spine Deformity Preview Issue (September 2012) 39e45

potential with planned osteotomies; if the risk is too great,

other options should be considered.
Once spinal correction has been achieved, completion of
the operation should involve a few more considerations to
help avoid complications. Final torquing of all screws will
ensure that all implants are locked in place. Adequate
irrigation may have a role in decreasing the risk of infection. One retrospective review of 223 spine operations
showed that the mean amount of saline used for irrigation
in the infected group was less than in the uninfected group.
They concluded that insufficient intraoperative irrigation of
the surgical wound was an independent and direct risk
factor for surgical site infection after spine surgery. The
authors recommended decreasing intraoperative contamination by irrigating O2,000 mL/h saline in all patients
[41]. Attention must be given to proper technique when
decorticating facets and placing bone graft, to optimize the
chance for a complete fusion. A good closure of the wound
bed cannot be overstated, and will prevent dehiscence and
persistent wound drainage. If there is concern about
continued drainage in the early postoperative period, a
drain may be considered to divert blood from leaking
through the incision. Although evidence is limited, persistent leakage through the incision can theoretically lead to
wound-healing problems, which can predispose to infection. Once closure is complete, the surgeon should place an
occlusive dressing that will keep the incision clean and dry
in the early postoperative period when superficial wound
healing is occurring. This is important for all patients, but
in the pediatric population, children who are not toilet
trained are at risk for gross contamination of the wound if
an adequate dressing is not applied. Last, final X-rays
should be obtained to check overall deformity correction
and implant placement, and to establish a baseline for
follow-up visits.
Postoperatively several considerations will optimize
outcomes after spinal deformity surgery. If the intensive
care unit is required, face-to-face disclosure of information
with the primary care team is necessary to review the
procedure and related medical problems that require
attention postoperatively. Consultants who were involved in
the patients care preoperatively should continue to assist
postoperatively. Several institutions have implemented
systems involving hospitalist co-management of pediatric
patients. When designing a co-management system, is
important to have well-defined roles for those participating,
and to foster effective communication among specialists.
Who is responsible for decisions should be decided
according to the scope of each physicians degree of
expertise [42]. Decisions related to wound management,
drains, and implants should be the responsibility of the
surgeon, whereas management of medical problems should
be the responsibility of the hospitalist. If a particular
problem falls outside the scope of the hospitalists practice,
the hospitalist should consult an appropriate subspecialist
[43]. A co-management system may offer certain benefits

43

to patient care compared with a traditional consultant

model; some of these have been quantified in preliminary
studies [44].
Adequate analgesia postoperatively serves to improve
patient satisfaction and allows better participation in
therapy and earlier postoperative goal achievement. Some
institutions have implemented a multimodal pain management program that involves epidurals, judicious use of
gabapentin and ketorolac, and early rehabilitation to
decrease narcotic use. These multimodal analgesia programs
have been shown to have some advantages. One study evaluating 200 spine surgery patients found that those receiving
a multimodal oral analgesia regimen of scheduled acetaminophen, gabapentin, and extended-release oxycodone
with short-acting oxycodone as needed had significantly less
opioid consumption and better overall pain scores, and
experienced less nausea, drowsiness, and interference with
walking, coughing, and deep breathing compared with the
intravenous pain-controlled analgesia group [45].
A patients care pathway is important and should be in
place for all of those with postoperative spinal deformity.
Care pathways help to clearly define a timeline for goals,
expectations, and length of stay. They also help to decrease
variability among patients, and may improve outcomes. An
implemented care pathway should be understood by all
involved in the patients care, including the patient, the
patients family, the surgeon, the nursing staff, the hospitalist, and the physical therapist. Communication among
these caretakers is necessary to alter the care pathway for
a specific patient if the need arises.
It is important to be aware of potential complications
and to look for them in all postoperative spinal deformity
patients. The most common complications after spinal
deformity surgery are infection (early or late), implant
problems, pseudarthrosis, imbalance in both the coronal
and sagittal planes, and proximal junctional kyphosis. A
thorough history and physical examination, along with
regular postoperative imaging, will help diagnose most of
these problems.
As part of the informed consent process, deformity surgeons
review the risks and possible adverse outcomes with patients
and families before surgery. Patients have a huge volume of
information available to them at present, and the families
perceptions of complications may differ from those of the
surgeon [46]. Communication among the surgeon, patient, and
family is more important than ever to ensure that expectations
are realistic and that if complications are encountered, the
surgeon will continue to maintain open communication with
the family throughout the treatment process.
Conclusions
Minimizing complications has always been the goal of
the pediatric spine surgeon. As we move forward with
efforts to minimize complications in pediatric deformity
surgery, the outcomes of treatment are being more closely

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scrutinized by other parties in the health-care system.

Measurable safety outcomes such as rate of wrong-site
surgery, rate of unanticipated returns to operating room,
and spinal fusion infection rates are examples of data that
are being scrutinized by payers and may be factors in
resource allocation in the future.
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Further Reading
DeVine J, Chutkan N, Norvell DC, Dettori JR. Avoiding wrong site
surgery: a systematic review. Spine (Phila Pa 1976) 2010;35:S28e36.
Czerwein J, Amaral T, Wollowick AL, et al. Pre-operative CT does not
appear to improve accuracy of pedicle screw placement and exposes the
patient to increased quantities of radiation. Paper presented at: Pediatric
Orthopaedic Society of North America Annual Meeting; April 30eMay 2,
2009; Boston, MA.
Stanton T. Toward safer spine surgery: proper planning and a systematic
approach optimize outcomes. AAOS Now 2012. January.