Sumeet Garg, MD The Children’s Hospital, Colorado

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Presentation transcript:

Increased Rates of Anchor Failure Can Be Predicted by an Early Onset Scoliosis Severity Score Sumeet Garg, MD The Children’s Hospital, Colorado University of Colorado Denver Health Sciences Center Anna McClung, BSN, RN Charles E. Johnston, MD Texas Scottish Rite Hospital for Children Dallas, TX University of Texas Southwestern Medical Center 4th ICEOS – Toronto, Nov 19-20, 2010

Early Onset Scoliosis Deformity diagnosed < 6 yrs Wide spectrum of severity Infantile “idiopathic” Congenital Syndromic Associated medical co-morbidities Complications frequent (up to100% surgical)

Hypothesis Implant complications (anchor failure) rates higher in fragile patients with more severe deformity and more medical co-morbidities Needed: severity scoring index to assist with prognostic issues and outcome determination

Methods EOS severity score developed at TSRH Retrospectively applied to initial experience with growth-sparing surgery Diagnoses Syndromic (20) Muscular dystrophy (7) Congenital (5) Idiopathic (3) Thoracogenic (2)

Methods 37 patients with EOS treated since 2003 with growth sparing surgery 1 with less than 12 mo f/u 20 boys 17 girls Age at initial surgery 5 yrs (1.3 – 9.3 yrs) 5 have completed lengthenings All have had definitive fusion 32 still undergoing lengthenings Average f/u 3.8 years

Components (4) 1. Fragility index score (0-5 points) 0 = BMI > 20 1 = BMI <20, no other co-morbidities 2 = BMI < 20, ambulatory w/ co-morbidities 3 = BMI < 20, non-ambulatory additional 1 point each for: - osteopenia - connective tissue/bone dysplasia (NF, Marfan, E-D, OI)

EOS Severity Score 2. Age (0-2 points) 3. Respiratory (0-3 points) 0 = normal 1 = night assistance (CPAP/BiPAP) without oxygen 2 = tracheostomy, supplemental oxygen, or night-only ventilator assistance 3 = full time ventilatory support

4. Radiographic Score Max score = 12 Points awarded (up to 3) for severity of 4 separate anatomic deformities points AP Cobb Sag Cobb Congenital segments Ribs (fused or absent) <50 10-50 None 1 50-70 <10, 50-70 <3 levels <3 2 71-90 3-6 levels 3-6 3 >90 >6 levels >6 Max score = 12

4. Radiographic Score Length T1-12 (anatomic size) Flexibility Max score = 4 points T1-T12 height Flexibility >50th % >33% 1 5-50 15-33% 2 <5th % <15% Emans Spine 2005

Radiographic Conversion 1 = 1-3 xray points 2 = 4-6 “ 3 = 7-10 “ 4 = 11-16 “

7 yo = 0 Respiratory = 0 Fragility = 5 Radiograph = 2 Total 7 Example 1 : 7 yo male, non-ambulatory, connective tissue syndrome, no respiratory support, myelopathic, VSD repair, osteopenia 7 yo = 0 Respiratory = 0 Fragility = 5 Radiograph = 2 Total 7 BMI<20, non-amb,osteopenic, connective tissue, myelopathy AP> 90 =3 sagittal =0 flexible = 0 T1-12<5th%=2 noncong.=0 Index points 2 5 91o, (bends 30) sagittal plane nl

Severity Index - Results Range 2-11 (mean 6) 23 pts with spine based surgery (growing rods) Average score 5.4 14 with rib based surgery (VEPTR) Average score 7.9 (p<0.003) 1 excluded (f/u < 1 yr) from complication analysis

Results - Severity Index Overall anchor failures/procedures = 0.6 Overall rib anchor failures/procedure = 0.5 Overall spine anchor failures/procedure = 0.25 rib/spine failure rate difference not statistically significant Mean score for pts with > 0.5 anchor failures/procedure = 7.6 Mean score for pts with < 0.5 anchor failures/procedure = 5.5 (p<0.03)

Results Other complications not related to severity score 7 infections requiring surgical debridement 4 intraoperative neuromonitoring changes 2 late motor deficits 1 brachial plexus injury after VEPTR lengthening 1 paraplegia from thoracic pedicle screw migration 3 implant erosion through skin 1 domino set plug failure requiring rod replacement severity

Discussion Many EOS patients have significant comorbidities Growth-sparing rx requires repeat surgery over time, inviting complications Wide spectrum of severity characteristic of EOS patients

Discussion Severity index 8 or greater is prognostic for anchor failures Anchor failure should be anticipated and technique strategies planned in advance

Thank You