16 Safety and Complications in Pediatric Surgery

Introduction

With enhanced instruments, techniques, and skills, our ability to achieve significant corrections in severe spinal deformities has greatly improved. However, the risks to patients in terms of bleeding and neurologic injury have increased in parallel with increasingly aggressive attempts at deformity correction. Setting up a system with appropriate monitoring, careful planning of procedures, awareness of potential difficulties, and early recognition and treatment of impending problems will help create a safe environment in which manage these challenging surgeries.

A Multidisciplinary Approach to Comorbidities

Fortunately, the majority of patients undergoing spinal reconstructions are healthy children. However, the more complex deformities are often associated with congenital or syndromic conditions, and it is important to have a basic understanding of the disorders associated with the spinal deformity. A multidisciplinary approach involving pediatricians, geneticists, cardiologists, respirologists, and anesthesiologists can help ensure that the appropriate workup and plans for perioperative care are put in place. ¹ Preoperative recognition of surgical risks such as latex allergies, malignant hyperthermia, sickle cell disease, and bleeding disorders can greatly reduce intraoperative stresses and facilitate a safer and more efficient flow of these complex procedures.

Malnutrition is an important preoperative consideration in pediatric surgery, and patients with severe deformities or respiratory issues are potentially at risk. Although evidence is somewhat weak, addressing the patient′s nutritional status prior to surgery may minimize complications, improve wound healing, and facilitate recovery. ²

Common conditions and their associated issues are listed in Table 16.1 . Uncommon conditions should be studied carefully, and the available literature can help provide key insights into their clinical management. For example, pa tients with severe fixed thoracic hyperlordosis can have mediastinal compression secondary to the spinal deformity ( Fig. 16.1 ). This can lead to bronchial compression with secondary pneumonias. In these cases, extensive anterior releases followed by posterior column releases and correction can mobilize the spine sufficiently to bring the spine out of the chest to relieve this compression. Patients with neuro-fibromatosis frequently develop rib abnormalities with secondary migration into the spinal canal ( Fig. 16.2 ), which could potentially complicate deformity correction and cause neural injury. ³ Neurofibromatosis and Marfan′s syndrome are commonly associated with dural ectasia ( Fig. 16.3 ). This can lead to significant difficulties in achieving fixation as well as increased incidence of dural tears and pseudarthrosis. ⁴ If these anatomic variations are recognized early enough, surgeons can take the time to consider alternatives such as intraoperative traction to aid in correction without fixation at every segment, and structural bone grafts to accommodate bone deficiencies.

**Fig. 16.1** Thoracic lordoscoliosis. **(a,b)** Standing anteroposterior (AP) and lateral radiographs demonstrate an 80-degree right thoracic curve with 25 degrees of thoracic lordosis. **(c)** Axial computed tomography (CT) confirms the anterior position of the vertebral body in the mediastinum with compression of the trachea. **(d)** Axial CT at the level of the left and right main bronchi confirms bronchial compression and right distal segmental atelectasis.

**Fig. 16.2** Neurofibromatosis. Axial CT at the level of the apex of deformity demonstrates dural ectasia and rib head migration on the convexity of the curve into the spinal canal.

**Fig. 16.3** Dural ectasia. **(a)** Preoperative AP radiograph demonstrates a dystrophic 75-degree lumbar curve in a 10-year-old girl with neurofibromatosis. **(b)** A posterior T12 to pelvis instrumentation requiring hooks and pedicle screws was used to achieve stable fixation. **(c)** Sagittal T2-weighted magnetic resonance imaging (MRI) 10 years later demonstrates progressive dural ectasia with erosion of lumbar vertebral bodies and posterior elements. **(d)** Axial CT and **(e)** MRI obtained for preoperative planning prior to revision surgery demonstrate dissociation of the anterior and posterior columns at the level of the dural ectasia. Post-revision standing long-cassette **(f)** AP and **(g)** lateral radiographs illustrate construct strengthening utilizing a bilateral double-rod technique and increased bone anchors proximally, along with structural bone graft.

**Table 16.1 Considerations for Common Pediatric Conditions Associated with Spinal Deformity**
Syndrome	Airway/Pulmonary	Cardiovascular	Spinal	Other Considerations
Cerebral palsy	Chronic pneumonia Perioperative chest infections Reactive airway disease Aspiration	Anemia Decreased platelet count and functioning	Pelvic obliquity Pedicle morphology Osteoporosis Iatrogenic	Paralytic ileus GERD/aspiration Wound infection Pseudarthrosis Thermal homeostasis Opiate sensitivity
Neurofibromatosis	In dystrophic/severe scoliosis consider PFTs and chest CT	–	Dural ectasia Rib penetration Intraspinal neurofibromata Pedicle dysgenesis	–
Marfan′s syndrome/Loeys-Dietz syndrome	Pectus excavatum Lordoscoliosis Tracheal/bronchial compression ( Fig. 16.1 )	Cardiomyopathy Aortic root dilatation Aortic aneurysms Hemorrhage	Dural ectasia Dysplastic pedicles	–
Spinal dysraphism	–	–	Deficient posterior elements Osteoporosis Hydrocephalus Shunt function	Latex and other allergy Urinary infection Wound infection Flap closure
Merosin negative muscular dystrophy: Duchenne, Becker, Merosin –ve muscular dystrophy	Restrictive lung disease	Decreased cardiac function Altered platelet function Hemorrhage loss of vascular reactivity	Steroid-induced osteoporosis	Minority have additional coagulopathies
Spinomuscular atrophy	Diaphragm breathers Difficult intubation, postoperative respiratory support	–	–	AVOID succinylcholine
Congenital muscular dystrophies	Decreased pulmonary function, postoperative infection, difficulties in extubating postoperatively	Decreased cardiac function
Hemihypertrophy syndromes (Beckwith-Wiedemann syndrome; Proteus syndrome)		Aortic arch abnormalities Vascular malformations Hemorrhage		Abdominal malignancy
Skeletal dysplasias	PFTs often approach appropriate values for patient′s stature		Cervical instability
Mucopolysaccharidoses	Tracheobronchomalacia Airway obstruction from GAG deposition Inability to intubate/ventilate Low airway collapse Difficulty extubating	Coronary artery disease (later) Valve disease Pulmonary hypertension	Cervical instability Small pedicles Soft bone
Congenital scoliosis	Rib synostosis Thoracic insufficiency	Cardiac abnormalities	Multiple anomalies Tethering of cord diastematomyelia	VACTERL association
Abbreviations: CT, computed tomography; GAG, glycosaminoglycan; GERD, gastroesophageal reflux disease; PFT, pulmonary function test; VACTERL, vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula, renal anomalies, and limb defects.

Preoperative Planning

Surgical Considerations

Preoperative preparation of a case greatly improves the flow and safety of the surgical procedure. After the medical issues are addressed, the technical issues should be thoroughly reviewed. This entails ensuring that the appropriate personnel are scheduled, that the required equipment is available, and that the surgical plan with the appropriate imaging has been reviewed. Arranging an appropriate postoperative setting, such as an intensive care unit, to provide the required care and monitoring after surgery will help ensure perioperative safety and recovery.

Personnel

Surgical assistants, neuromonitoring technicians, cell saver staff, nurses, and anesthesia teams familiar with the procedure will greatly improve the flow of the surgery. Good communication between the neuromonitoring and anesthesia teams helps provide accurate and timely data on the status of the spinal cord. A nursing team familiar with the equipment and the procedure greatly improves the flow of the surgery in terms of having the appropriate instruments and implants opened and ready for use, avoiding costly delays. Capable assistants who are familiar with the surgical techniques and methods are invaluable in the efficiency and success of the procedure.

Although having an experienced team is key, the surgeon remains the captain of the ship. The surgeon should establish a positive atmosphere for the team. Good preparation provides the needed confidence that is so important in coordinating the various team members. Although the majority of cases generally run smoothly, it is when things are not going as planned that the surgeon′s leadership will be most important. Remaining calm under these circumstances and coordinating with the team to ensure that the appropriate measures are taken to understand and manage the situation can help salvage difficult situations and lead to good outcomes. Warning the team ahead of time of high-risk steps in the procedure, having plans on hand for unexpected bleeding or neuromonitoring changes, and discussing the expected operative time, the desired blood pressure, and the use of antifibrinolytics with the anesthesia will help create a safe environment.

Planning a Case

“By failing to prepare, you are preparing to fail.”

—Benjamin Franklin

Although some surgeons believe that there is no substitute for good intraoperative thinking, we are of the school that stresses planning as the key to success. As a case example, a 12-year-old girl presents with a large right thoracic deformity with coronal imbalance ( Figs. 16.4 and 16.5 ). This case illustrates the importance of obtaining an accurate diagnosis to best plan the surgical procedure.

**Fig. 16.4** Case example. Preoperative standing **(a)** AP, **(b)** lateral, and **(c)** left- and **(d)** right-side bending radiographs demonstrate a stiff thoracic curve. **(e)** Preoperative photograph demonstrates the clinical deformity with trunk shift. **(f)** Preoperative CT scan performed for surgical planning. Coronal slice through the apex demonstrates the partially fused right T8 hemivertebra. **(g,h)** Three-dimensional reconstructions show the anterior aspect of the apical deformity **(g)** and the posterior aspect **(h)** of the surgeon′s view prior to posterior spinal surgery.

**Fig. 16.5** Case example (cont′d). **(a)** Preoperative standing radiograph demonstrates rib asymmetry and trunk shift, with the center sacral vertebral line (CSVL) superimposed. **(b)** Preoperative planning “map” simplifies the key features of the deformed anatomy, the planned levels of instrumentation, the screw diameters and type, as well as the anticipated levels of osteotomies. This map is displayed in the operating room during the surgery. Postoperative standing **(c)** AP and **(d)** lateral radiographs and **(e)** clinical photograph following a T3 to L3 instrumentation with a T8 right hemivertebra resection and posterior column osteotomies at T6–T7 and T9–T10 demonstrate a well-balanced correction.

Clinical Presentation

The patient is a healthy 12-year-old girl. She does not take any medication and has no allergies. There is no family history of spinal deformity. She denies any cardiac, renal, or ocular issues. She has no previous surgeries. She is premenarchal. She has no café-au-lait spots and a normal neurologic examination.

Imaging

Radiographic assessment should include the following:

Determination of the number of thoracic and lumbar segments
Determination of the Risser grade and the status of the triradiate cartilage
Assessment of any coronal or sagittal deformities
Determination of the presence of any congenital deformities
Assessment of any spondylolisthesis
Assessment of the pedicle size and morphology
Assessment of any abnormal soft tissue or bony shadows
Measurement of all curves in the coronal and sagittal planes
Measurement of pelvic parameters (in cases involving the lumbosacral junction)

Standing radiographs in this case example demonstrate a large right thoracic curve with a secondary left lumbar curve. The patient is Risser grade 0 with closed triradiate cartilages. There are 13 ribs on the right and 12 ribs on the left. There is a small rib on the last thoracic level. There are five lumbar segments. Although the curve appears to be a large idiopathic one, closer inspection is suggestive of a congenital component. A computed tomography (CT) scan is performed showing a right-sided T8 hemivertebra, fused proximally to T7, with associated remodeling of the proximal portion of T9. A congenital fusion of T5–T6 is noted. There are 12 complete thoracic vertebrae and one hemi vertebra for a total of 13 thoracic levels. Magnetic resonance imaging (MRI) (not shown) does not demonstrate any evidence of a Chiari malformation, diastematomyelia, tethered cord, or syrinx.

Preoperatve Plan

A thorough discussion is undertaken with the patient and family to determine their goals and expectations of surgical correction for the deformity. Options for correction are provided along with the expected outcomes and associated risks. In this case, the decision is made to perform a maximal correction through a posterior hemivertebra resection, supplemental periapical posterior column osteotomies, and a posterior construct. The plan is as follows:

Instrumentation
- Å A posterior instrumentation system for a 5.5-mm rod
- Å An osteotomy set
- Å A rod reduction system
Anesthesia preoperative consultation
Coordination with nurse manager for available staff and equipment
Available intensive care unit bed
Available neuromonitoring team
Available cell saver technician
Consideration of a three-dimensional (3D) printing of the CT scan to provide a model of the spine to plan the procedure and osteotomies

A surgical map ( Fig. 16.5b) is created preoperatively with a plan for the size and location of the screws and whether the screws will be multiaxial or otherwise, the level and type of osteotomies, and the landmarks for the thoracolumbar junction. Careful analysis of the radiographs and the CT scan form the basis of this map. The nurses are able to prepare the appropriate screws allowing for greater efficiency during screw placement.

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16 Safety and Complications in Pediatric Surgery