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Risk factors for pulmonary complications after posterior spinal instrumentation and fusion in the treatment of congenital scoliosis: a case-control study

Risk factors for pulmonary complications after posterior spinal instrumentation and fusion in the... Background: Although surgery prevents the progression of deformity and maintains the overall balance of the spine in congenital scoliosis (CS) patients, it is associated with a high risk of perioperative complications. Pulmonary complication is one of the most common complications. This retrospective study aimed to investigate the risk factors for pulmonary complications in CS patients after posterior spinal instrumentation and fusion. Methods: Analysis of consecutive patients who underwent posterior spinal instrumentation and fusion for congenital scoliosis was performed. Preoperative clinical data, intraoperative variables, and perioperative radiographic parameters were collected to analyze the risk factors for pulmonary complications. Patients were separated into groups with and without postoperative pulmonary complications. Potential risk factors were identified by univariate testing. Multivariate logistic regression was used to evaluate independent predictors of pulmonary complications. Results: Three hundred and twenty-three CS patients were included. Forty-five (13.9%) patients developed postoperative pulmonary complications, which included pleural effusion in 34 (75.6%) cases, pneumonia in 24 (53.3%) cases, pneumothorax in 3 (6.7%) cases, atelectasis in 4 (8.9%) cases, pulmonary edema in 2 (4.4%) cases, respiratory failure in 2 (4.4%) cases, and prolonged mechanical ventilation in 4 (8.9%) cases. The independent risk factors for development of pulmonary complications included age (Odds ratio (OR) = 1.088, P = 0.038), reoperation (OR = 5.150, P = 0.012), preoperative pulmonary disease (OR = 10.504, P = 0.004), correction rate (OR = 1.088, P = 0.001), middle thoracic screw-setting (OR = 12.690, P = 0.043), and thoracoplasty (OR = 5.802, P = 0.001). The area under the receiver operating characteristic (ROC) curve based on predicted probability of the logistic regression was 0.903. Conclusions: Age, reoperation, preoperative pulmonary disease, correction rate, middle thoracic screw-setting, and thoracoplasty were independent risk factors for pulmonary complications after posterior spinal instrumentation and fusion in CS patients. Keywords: Congenital scoliosis, Pulmonary complications, Risk factors, Posterior spinal instrumentation and fusion * Correspondence: haiyongccmu@163.com Department of Orthopedics, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Rd, Beijing 100043, China Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Wu et al. BMC Musculoskeletal Disorders (2019) 20:331 Page 2 of 8 Background pulmonary disease, operation history, preoperative white Congenital scoliosis (CS) is an early-onset spinal deformity blood cell (WBC) count and proportion of neutrophil, caused by vertebral abnormalities, which are classified on American Society of Anesthesiologists (ASA) grade and the basis of failures of formation, segmentation, or both preoperative pulmonary function (e.g., forced expiratory [1, 2].The prevalence of CS is approximately 0.5 to 1 in volume in 1 s/forced vital capacity (FEV1/FVC), residual every 1000 live births [3, 4]. Conservative management for volume/total lung capacity (RV/TLC)). CS, such as bracing and serial derotational casting, is less Operative parameters included the instrumentation effective than for idiopathic scoliosis. Therefore, the surgi- and fusion levels, spinal osteotomy levels, thoracoplasty, cal treatment is usually performed for CS patients with intra-operative blood loss, operation time, and blood progressively worsening deformities [5]. Although scoli- transfusion. osis surgery prevents the progression of deformity and maintains the overall balance of the spine, it is associated Radiographic measurements with a high risk of perioperative complications [6]. Preoperative radiographs of the patients include chest X-ray, Pulmonary complication is one of the most common standing anterior-posterior and lateral radiographs of the complications because congenital spine deformities de- whole spine, supine right and left bending radiographs, creases not only the volume but also the function of the three-dimensional computed tomography (CT) reconstruc- lungs [7–10]. However, little has been reported about tions, and whole-spine magnetic resonance (MR) images. Pa- postoperative pulmonary complication in CS patients. Yin rameters measured in the coronal plane and sagittal plane et al. recently investigated the pulmonary complication in include the position and the Cobb angle of the curves, the CS patients, but the sample size of their study was small upper and lower end vertebras of the curve, the direction of and the observation variables were inadequate [11]. the curve, and the number of vertebras affected by curves. Therefore, we conducted this retrospective study to de- Postoperative radiographicdataincludethedegreeofspinal scribe the morbidity and further try to find the risk factors curvature correction postoperatively. All the radiographic of postoperative pulmonary complications after posterior measurements were performed independently by two spinal spinal instrumentation and fusion surgery in CS patients. surgeons (LW, YSW) in order to decrease the intra-observer. Methods Pulmonary complications assessment Participants Pulmonary complication data, which were collected The clinical data were obtained from a single-center retro- postoperatively, included: pleural effusion, pneumonia, spective comparative study of 323 CS patients treated by pneumothorax, atelectasis, pulmonary edema, respira- posterior spinal instrumentation and fusion at our hospital tory failure, and prolonged intubation with mechanical between 2011 and 2017. All the operations included in ventilation (see Table 2). According to complication out- this study were performed by one surgeon (YH). This comes, patients were divided into two groups: with and study was approved by the institutional review board fol- without pulmonary complications. lowing the declaration of Helsinki principles. Inclusion criteria for this study were operatively treated Statistical analysis CS patients with the following conditions: (1) coronal All the analyses were performed with the use of Stata soft- Cobb angle of thoracic, thoracolumbar, and lumbar scoli- ware, version 15.1 (Stata Corp). Continuous data are otic curves ≥40°; (2) deformities increasing in severity or expressed as means with standard deviations or as me- predicted to have a high risk for progression (unilateral dians with interquartile ranges, depending on normality. bar with a contralateral hemivertebra); (3) posterior spinal Categorical variables were shown as proportions. In the instrumentation and fusion; (4) complete preoperative and univariate testing, categorical variables were performed postoperative radiographic data; and (5) preoperative pul- using Pearson chi-square tests or Fisher exact tests where monary function tests (PFTs) before surgery. Exclusion appropriate. Continuous variables were examined using criteria were: (1) other kinds of scoliosis (e.g., degenerative Kruskal-Wallis equality-of-populations rank tests. Predic- scoliosis, ankylosing spondylitis, and spinal tuberculosis); tors with a P value of<0.1onunivariate analysis were (2) anterior approach or anterior and posterior approach; identified to be risk factors of pulmonary complications. (3) growing rod; and (4) spinal trauma or tumor. The variance inflation factor (VIF) and tolerance were used to test the multicollinearity of the risk factors. A Clinical and operative parameters VIF > 10 or tolerance < 0.1 was identified to be significant The baseline patient characteristic and demographic multicollinearity. Binary logistic regression was used to data were collected preoperatively (see Table 1). Clinical determine independent risk factors of pulmonary compli- parameters included age, gender, body mass index cations among patient characteristics. The Hosmer- (BMI), duration since diagnosis of scoliosis, preoperative Lemeshow test was used to estimate the goodness of fit Wu et al. BMC Musculoskeletal Disorders (2019) 20:331 Page 3 of 8 Table 1 Baseline clinical and perioperative characteristics of patients with or without pulmonary complication Variables Overall Pulmonary complication No pulmonary complication P value Number 323 45 278 Age, years 17 (12–26) 26 (19–26) 15 (12–24) < 0.001 Gender, female, no. (%) 197 (61.0%) 35 (77.8%) 162 (58.3%) 0.013 BMI, Kg/m 18.4 (15.9–20.4) 17.8 (16.2–20.4) 18.4 (15.9–20.4) 0.973 Duration since diagnosis of scoliosis, years 11 (8–20) 20 (13–24) 10 (7–17) < 0.001 Reoperation, no. (%) 41 (12.7%) 10 (22.2%) 31 (11.2%) 0.038 Preoperative pulmonary disease, no (%) 14 (4.3%) 9 (20.0%) 5 (1.8%) < 0.001 The main bending 0.006 Thoracic scoliosis, no (%) 239 (74.0%) 42 (93.3%) 197 (70.9%) Thoracolumbar scoliosis, no (%) 49 (15.2%) 2 (4.4%) 47 (16.9%) Lumbar scoliosis, no (%) 35 (10.8%) 1 (2.2%) 34 (12.2%) Preoperative Cobb angle, degree 80.2 (57.3–103) 105.3 (88.3–122.3) 75 (55.2–97.7) < 0.001 Correction rate, % 64 (57.7–71.3) 67.4 (60.1–71.3) 63.7 (57.4–71.2) 0.078 Preoperative WBC, ×10 /L 5.9 (5.1–7.1) 5.8 (5.0–6.9) 5.9 (5.1–7.1) 0.345 Preoperative neutrophil, % 53.3 (45.4–61.2) 55.4 (48.1–60.7) 53.1 (45.4–61.3) 0.540 ASA grade 2 (1–2) 2 (1–2) 2 (1–2) 0.886 Spinal osteotomy, no (%) 167 (51.7%) 26 (57.8%) 141 (50.7%) 0.379 No. of levels fused 12 (9–14) 13 (12–14) 12 (8–14) < 0.001 Upper thoracic screw-setting, no (%) 208 (64.4%) 40 (88.9%) 168 (60.4%) < 0.001 Middle thoracic screw-setting, no (%) 232 (71.8%) 44 (97.8%) 188 (67.6%) < 0.001 Lower thoracic screw-setting, no (%) 248 (76.8%) 41 (91.1%) 207 (74.5%) 0.014 Lumbar screw-setting, no (%) 291 (90.1%) 41 (91.1%) 250 (89.9%) 0.805 Thoracoplasty, no (%) 114 (35.3%) 33 (73.3%) 81 (29.1%) < 0.001 Operation time, min 240 (180–300) 285 (250–360) 232.5 (180–295) < 0.001 Volume of blood transfusion, ml 400 (0–400) 500 (0–800) 0 (0–400) < 0.001 Pulmonary function FEV1/FVC, % 85.4 (81.3–88.9) 83.8 (80.5–88.1) 85.5 (81.3–89.2) 0.130 RV/TLC, % 36.8 (29.9–41.8) 38.8 (33.8–43.2) 36.4 (29.6–41.6) 0.038 Value is expressed as the median (interquartile range) or number (percentage) Abbreviations: BMI Body mass index, WBC White blood count, ASA American Society of Anesthesiologists, No. Number, FEV1 Forced expiratory volume in 1 s, FVC Forced vital capacity, RV Residual volume, TLC Total lung capacity for the logistic regression mode. We generated a receiver operating characteristic (ROC) curve using predicted probability values from the logistic regression. A coefplot Table 2 Numbers and percentages of pulmonary complication was performed to plot the regression coefficients. A types among the 45 patients who developed a postoperative nomogram was used to demonstrate the risk points and pulmonary complication probability of independent risk factors for predicting the Pulmonary complication Number Frequency (%) pulmonary complications. A P value of < 0.05 in 2-sided Pleural effusion 34 75.6 tests was statistically significant. Pneumonia 24 53.3 Results Pneumothorax 3 6.7 Participants Atelectasis 4 8.9 Three hundred and twenty-three patients were enrolled Pulmonary edema 2 4.4 in this study. The median operative age was 17 years, Respiratory failure 2 4.4 and females made up the majority of the cohort (61.0%). Prolonged intubation with 4 8.9 The median duration since diagnosis of scoliosis was 11 mechanical ventilation years. The most common main bending was thoracic Wu et al. BMC Musculoskeletal Disorders (2019) 20:331 Page 4 of 8 scoliosis (74.0%). The median preoperative Cobb angle angle correction rate showed a trend toward a higher risk was 80.2 degree, and the median correction rate was of pulmonary complications (P = 0.082). No significant dif- 64% immediately post operation. The median number of ference in BMI, preoperative white blood cell or neutro- levels fused during an operation was 12. The incidence phil count, ASA grade, proportion of spinal osteotomy or of reoperation and preoperative pulmonary disease were lumbar screw-setting, FEV1/FVC was observed. 12.7 and 4.3%, respectively. The rate of thoracoplasty, spinal osteotomy, and upper thoracic, middle thoracic, Multivariate analysis lower thoracic and lumbar screw-setting was 35.3, 51.7, Variables with a P value of < 0.1 on univariate analysis as 64.4, 71.8, 76.8, and 90.1%, respectively. The median mentioned above were identified to be risk factors of pul- BMI, preoperative WBC, neutrophil, FEV1/FVC, RV/ monary complications. We tested the multicollinearity of TLC, operation time, and blood transfusion volume were all the risk factors. The results showed that the largest VIF 2 9 18.4 Kg/m , 5.9 × 10 /L, 53.3, 85.4, 36.8%, 240 min and of all the risk factors was 3.19 and the smallest tolerance of 400 mL, respectively (see Table 1). all the risk factors was 0.31 (see Additional file 1). Therefore, we included all the risk factors in the logistic Summary of postoperative pulmonary complications regression model, and we found that age (Odds ratio The incidence of postoperative pulmonary complications (OR) =1.085, P = 0.043), reoperation (OR = 5.258, P=0.010), was shown in Table 2. Forty - five (13.9%) of the 323 pa- preoperative pulmonary disease (OR = 10.553, P=0.004), tients developed postoperative pulmonary complications, Cobb angle correction rate (OR = 1.086, P = 0.002), consisting of pleural effusion in 34 (75.6%) cases, pneu- thoracoplasty (OR = 5.601, P = 0.001), and middle monia in 24 (53.3%) cases, pneumothorax in 3 (6.7%) thoracic screw-setting (OR = 12.695, P = 0.043) were cases, atelectasis in 4 (8.9%) cases, pulmonary edema in the independent risk factors of postoperative pulmonary 2 (4.4%) cases, respiratory failure in 2 (4.4%) cases, and complications (see Table 3). The Hosmer-Lemeshow test prolonged intubation with mechanical ventilation in 4 showed the fit for the logistic regression model was good (8.9%) cases (Table 2). Twenty-four patients had one (P = 0.022, chi2 = 358.05). The ROC curve based on pre- pulmonary complication, and 21 had more than one dicted probability of the logistic regression was shown in complication (14 patients with 2 pulmonary complica- Fig. 1, and the area under the curve was 0.903 (95% CI, tions, 6 patients with 3 pulmonary complications, and 1 0.853 to 0.952). The coefplot of the regression coefficients patient with 4 pulmonary complications). was shown in Fig. 2. Univariate analysis Nomogram Compared with patients without postoperative pulmonary Through the logistic regression model, we built a prog- complications, patients with postoperative pulmonary nostic nomogram incorporating the above independent complications were significantly older (P < 0.001), in- prognostic factors for visualization and facilitating clin- cluded a greater proportion of females (P = 0.013), ical practice as shown in Fig. 3. and had a longer duration of symptoms (P < 0.001). The incidence of thoracic scoliosis (P =0.006), reoper- Discussion ation (P = 0.037) and preoperative pulmonary disease Congenital scoliosis (CS) may result in thoracic de- (P < 0.001) was significantly higher in patients with formity that limits normal respiration and lung postoperative pulmonary complications than in those growth [3]. Many patients with CS have progressive without. The preoperative Cobb angle (P < 0.001) was restrictive lung disease, which increases the risks of lager in patients with postoperative pulmonary com- pulmonary complications after surgical correction plications than in those without. RV/TLC value was [12]. Pulmonary complications are often cited as the also significantly higher in patients with postoperative pulmonary complications than in those without these Table 3 Logistic regression of pulmonary complication and clinical variables complications (P = 0.040). More vertebral levels were fused in patients with postoperative pulmonary Variables OR P value 95% CI complications than in those without (P < 0.001). The Age, years 1.088 0.038 1.005–1.179 rate of thoracoplasty (P < 0.001), and upper thoracic Reoperation, no. (%) 5.150 0.012 1.443–18.384 (P < 0.001), middle thoracic (P < 0.001), and lower Preoperative pulmonary disease, no (%) 10.504 0.004 2.114–52.198 thoracic screw-setting (P = 0.015) was significantly higher Correction rate, % 1.088 0.001 1.034–1.145 in postoperative pulmonary complications group. The Middle thoracic screw-setting, no (%) 12.690 0.043 1.089–147.945 operation time was longer (P < 0.001), and the blood Thoracoplasty, no (%) 5.802 0.001 2.065–16.303 transfusion volume was also higher (P < 0.001) in the post- operative pulmonary complications group. The Cobb Abbreviations: No. Number, RV Residual volume, TLC Total lung capacity Wu et al. BMC Musculoskeletal Disorders (2019) 20:331 Page 5 of 8 Fig. 1 The ROC curve using predicted probability values from the logistic regression most frequent problems after correction of scoliosis; pulmonary disease, reoperation, correction rate, middle the identification of risk factors for pulmonary com- thoracic screw-setting, and thoracoplasty are independent plications in CS patients improves surgical safety. In predictive factors for postoperative pulmonary complica- our study, the incidence of postoperative pulmonary tions in CS patients. complications after posterior spinal instrumentation and Our study showed that age was an independent risk fusion in the treatment of CS is 13.9%. Age, preoperative factor for the development of postoperative pulmonary Fig. 2 Coefplot of the Logistic regression coefficient. Abbreviation: No. number, RV residual volume, TLC total lung capacity Wu et al. BMC Musculoskeletal Disorders (2019) 20:331 Page 6 of 8 Fig. 3 Nomogram for pulmonary complication using the independent prognostic factors complications. Our result is consistent with that of pre- with postoperative pulmonary complications in the vious studies [12–14]. Yuan et al. [12] reported that surgical treatment of scoliosis. Although the results of older patients (> 13 years) required prolonged postopera- previous studies were controversial, knowledge of pul- tive mechanical ventilation after scoliosis repair surgery. monary comorbidity provided the identification of a Patil et al. [13] found that in idiopathic scoliosis patients, patient with high risk for postoperative pulmonary older ones (> 18 years) were more likely to develop post- complications. operative complications that included pulmonary prob- Our results demonstrated that the history of previ- lems. Shaw et al. [14] concluded that increasing age was ous operations was an independent risk factor for the correlated with higher rates of major short-term compli- development of postoperative pulmonary complica- cations (including pulmonary complications) in adult tionsinCSpatientsand more attentionshould be scoliosis surgery. A possible reason for the association of paid to reoperation patients. Sansur et al. [17] age with pulmonary complications is that restrictive ven- reported that patients with a previous history of tilatory impairment and pulmonary function damage spinal surgery were significantly more likely to have caused by scoliosis are progressive with age. complications than patients undergoing initial correc- In our study, CS patients with pulmonary comorbidity tions through adult scoliosis surgery. Toll et al. [15] were more likely to have postoperative pulmonary complica- showed that having previous operations had a strong tions than those without pulmonary comorbidity. Pulmonary association with infectious complications, including comorbidity in CS patients, which was probably associated pulmonary ones. with impaired lung function, increased the risk of pulmonary According to our logistic regression analysis, the cor- complications following surgical correction. Patil et al. rection rate is an independent risk factor for the devel- [13] reported that patients with preoperative pulmon- opment of postoperative pulmonary complications. ary comorbidities were more likely to develop However, little has been reported about correction rate pulmonary complications after surgical correction of as an independent risk factor for pulmonary complica- idiopathic scoliosis. Toll et al. [15] also identified tions in CS patients. In our univariate analysis study, the pulmonary comorbidity in neuromuscular scoliosis preoperative Cobb angle (P < 0.001) is also larger in patients as a risk factor for perioperative infection patients with postoperative pulmonary complications following surgical deformity correction. On the other than in those without. After the test of the collinearity side, Zhang et al. [16] found that preoperative pul- diagnostics, we included all the risk factors in the logistic monary symptoms usually predicted abnormal results regression model. We found that the Cobb angle correc- of pulmonary function tests but had no correlation tion rate (OR = 1.086, P = 0.002) was an independent risk Wu et al. BMC Musculoskeletal Disorders (2019) 20:331 Page 7 of 8 factor of postoperative pulmonary complications, but, pulmonary complications before surgery; rather than add- the preoperative Cobb angle (OR = 1.012, P = 0.246) was ing thoracoplasty whenever indicated, we can instead per- not. In other words, the Cobb angle correction rate is a form it in one-stage with posterior spinal instrumentation better predictor of postoperative pulmonary complica- and fusion surgery. tions than the preoperative Cobb angle. A possible ex- This study has several limitations. First, this is a single planation is that the degree of Cobb angle correction is center retrospective study. Second, we did not consider more difficult for the lung and pleura to accommodate the postoperative pulmonary function and the outcomes than the preoperative Cobb angle. of pulmonary complications, such as mechanical ventila- It is well known that thoracic pedicle screw fixation tion time, postoperative analgesia, hospital cost, and which has excellent deformity correction and a high mortality. Third, we derived six independent risk factors margin of safety, is a reliable method of treating spinal of postoperative pulmonary complications, and built a deformities [18]. Yet, pulmonary complications have also nomogram for visualization and facilitating clinical prac- been reported after thoracic pedicle screw fixation [18– tice. However, we did not validate the nomogram in a 20]. In our univariate analyses, the rates of upper, new database. A prospective, multicenter study is needed middle, and lower thoracic screw-settings were all sig- to address these issues and validate our findings. nificantly higher in the postoperative pulmonary compli- cations group than in the group without complications, Conclusions while the rate of lumbar screw-setting showed no signifi- We conclude that it is important for surgeons to predict cant difference between the two groups. However, in postoperative pulmonary complications in CS patients multivariate analysis, only middle thoracic screw-setting before surgery. Logistic regression analysis shows that was the independent predictive factor for postoperative the independent risk factors to develop pulmonary com- pulmonary complications. This may be attributed to the plications after posterior spinal instrumentation and fu- anatomic characteristics of the middle thoracic spine, sion in CS patients are age, preoperative pulmonary which is located at the apex of the kyphosis of the thor- disease, reoperation, correction rate, middle thoracic acic spine. Therefore, because the middle thoracic screw-setting, and thoracoplasty. screw-setting approach is more likely to cause injury to the lungs and pleura, greater care must be given to this Additional file procedure. Thoracoplasty by means of multiple rib resections is Additional file 1: Multicollinearity test of risk factors of pulmonary complications (DOCX 15 kb) used to treat the rib cage deformity in thoracic scoli- osis and has been regarded as an important factor for Abbreviations the patient’s satisfaction [21]. Thoracoplasty in com- BMI: Body mass index; CS: Congenital scoliosis; CT: Computed tomography; bination with spine fusion is an established method FEV1/FVC: Forced expiratory volume in 1 s/forced vital capacity; to address the rib cage deformity in scoliosis surgery MR: Magnetic resonance; OR: Odds ratio; PFTs: Pulmonary function tests; ROC: Receiver operating characteristic; RV/TLC: Residual volume/total lung [22]. With respect to the impact of postoperative pul- capacity; VIF: Variance inflation factor; WBC: White blood cell monary complications on thoracoplasty after scoliotic surgery, Liang et al. [23]demonstratedthatperform- Acknowledgements We would like to acknowledge the significant contribution of the patients, ance of a thoracoplasty was the only risk factor for families, researchers, clinical staff, and sponsors included in this study. postoperative pulmonary complications in patients undergoing posterior spinal fusion. However, Suk et Authors’ contributions al. [21] reported that thoracoplasty showed satisfac- LW contributed to the conception and design of this manuscript, the acquisition of the data, the analysis and the interpretation of the data and tory clinical outcomes without pulmonary function the drafting of the manuscript. XNZ and YZL followed up and collected the compromise in the treatment of thoracic adolescent data. YSW was responsible for the data collection and radiographic idiopathic scoliosis. Hod-Feins et al. [8] suggested that measurements. YH conceived of the study and participated in its design and coordination, revised the manuscript critically for important intellectual thoracoplasty could be added whenever indicated content, and gave final approval of the version to be published. All authors because thoracoplasty did not correlate with postoper- read and approved the final manuscript. ative pulmonary complications. In our study, CS pa- Funding tients who underwent thoracoplasty were more likely This study was supported partially by research fund provided by National to have postoperative pulmonary complications than Natural Science Foundation of China (NSFC) No. 81772421. those who did not. According to our logistic This funding was not involved in the data collection, data analysis, or the preparation or editing of the manuscript. regression analysis, thoracoplasty is an independent predictive factor-but no the only one for postoperative Availability of data and materials pulmonary complications in CS patients. We could use The datasets used and analyzed during the current study are available from nomogram to evaluate the risk of postoperative the corresponding author on reasonable request. Wu et al. BMC Musculoskeletal Disorders (2019) 20:331 Page 8 of 8 Ethics approval and consent to participate 18. Suk SI, Kim WJ, Lee SM, Kim JH, Chung ER. Thoracic pedicle screw fixation in The study was approved by Ethics Committee of Chaoyang Hospital. This spinal deformities: are they really safe? Spine (Phila Pa 1976). 2011;26:2049–57. study was in accordance with the ethical standards of the institutional 19. Jin M, Liu Z, Qiu Y, Yan H, Han X, Zhu Z. Incidence and risk factors for the research committee, the 1964 Helsinki declaration, and its later amendments. misplacement of pedicle screws in scoliosis surgery assisted by O-arm For this type of study formal consent is not required. navigation-analysis of a large series of one thousand, one hundred and forty five screws. Int Orthop. 2017;41:773–80. 20. Li G, Lv G, Passias P, Kozanek M, Metkar US, Liu Z, et al. Complications Consent for publication associated with thoracic pedicle screws in spinal deformity. Eur Spine J. Not applicable. 2010;19:1576–84. 21. Suk SI, Kim JH, Kim SS, Lee JJ, Han YT. Thoracoplasty in thoracic adolescent Competing interests idiopathic scoliosis. Spine (Phila Pa 1976). 2008;33:1061–7. The authors declare that they have no competing interests. 22. Min K, Waelchli B, Hahn F. Primary thoracoplasty and pedicle screw instrumentation in thoracic idiopathic scoliosis. Eur Spine J. 2005;14:777–82. Author details 23. Liang J, Qiu G, Shen J, Zhang J, Wang Y, Li S, et al. Predictive factors of Department of Orthopedics, Beijing Chaoyang Hospital, Capital Medical postoperative pulmonary complications in scoliotic patients with moderate University, No. 8 Gongti South Rd, Beijing 100043, China. Department of or severe pulmonary dysfunction. J Spinal Disord Tech. 2010;23:388–92. Orthopedics, Beijing Haidian Hospital, Haidian section of Peking University Third Hospital, No. 29 Zhongguancun St, Beijing 100080, China. Publisher’sNote Received: 29 April 2019 Accepted: 5 July 2019 Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. References 1. Hedequist D, Emans J. Congenital scoliosis: a review and update. J Pediatr Orthop. 2007;27:106–16. 2. Yaszay B, Jazayeri R, Lonner B. The effect of surgical approaches on pulmonary function in adolescent idiopathic scoliosis. J Spinal Disord Tech. 2009;22:278–83. 3. Giampietro PF, Blank RD, Raggio CL, Merchant S, Jacobsen FS, Faciszewski T, et al. Congenital and idiopathic scoliosis: clinical and genetic aspects. Clin Med Res. 2003;1:125–36. 4. Wynne-Davies R. Congenital vertebral anomalies: aetiology and relationship to spina bifida cystica. J Med Genet. 1975;12:280–8. 5. Hedequist D, Emans J. Congenital scoliosis. J Am Acad Orthop Surg. 2004; 12:266–75. 6. Pahys JM, Guille JT. What's new in congenital scoliosis? J Pediatr Orthop. 2018;38:e172–9. 7. Campbell RM, Smith MD, Mayes TC, Mangos JA, Willey-Courand DB, Kose N, et al. The characteristics of thoracic insufficiency syndrome associated with fused ribs and congenital scoliosis. J Bone Joint Surg Am. 2003;85-a:399–408. 8. Hod-Feins R, Abu-Kishk I, Eshel G, Barr Y, Anekstein Y, Mirovsky Y. Risk factors affecting the immediate postoperative course in pediatric scoliosis surgery. Spine (Phila Pa 1976). 2007;32:2355–60. 9. Reames DL, Smith JS, Fu KM, Polly DW, Ames CP, Berven SH, et al. Complications in the surgical treatment of 19,360 cases of pediatric scoliosis: a review of the Scoliosis Research Society Morbidity and Mortality database. Spine (Phila Pa 1976). 2011;36:1484–91. 10. Sharma S, Wu C, Andersen T, Wang Y, Hansen ES, Bunger CE. Prevalence of complications in neuromuscular scoliosis surgery: a literature meta-analysis from the past 15 years. Eur Spine J. 2013;22:1230–49. 11. Yin S, Tao H, Du H, Feng C, Yang Y, Yang W, et al. Postoperative pulmonary complications following posterior spinal instrumentation and fusion for congenital scoliosis. PLoS One. 2018;13:e0207657. 12. Yuan N, Skaggs DL, Dorey F, Keens TG. Preoperative predictors of prolonged postoperative mechanical ventilation in children following scoliosis repair. Pediatr Pulmonol. 2005;40:414–9. 13. Patil CG, Santarelli J, Lad SP, Ho C, Tian W, Boakye M. Inpatient complications, mortality, and discharge disposition after surgical correction of idiopathic scoliosis: a national perspective. Spine J. 2008;8:904–10. 14. Shaw R, Skovrlj B, Cho SK. Association between age and complications in adult scoliosis surgery: an analysis of the Scoliosis Research Society Morbidity and Mortality database. Spine (Phila Pa 1976). 2016;41:508–14. 15. Toll BJ, Samdani AF, Janjua MB, Gandhi S, Pahys JM, Hwang SW. Perioperative complications and risk factors in neuromuscular scoliosis surgery. J Neurosurg Pediatr. 2018;22:207–13. 16. Zhang JG, Wang W, Qiu GX, Wang YP, Weng XS, Xu HG. The role of preoperative pulmonary function tests in the surgical treatment of scoliosis. Spine (Phila Pa 1976). 2005;30:218–21. 17. Sansur CA, Smith JS, Coe JD, Glassman SD, Berven SH, Polly DW, et al. Scoliosis research society morbidity and mortality of adult scoliosis surgery. Spine (Phila Pa 1976). 2011;36:E593–7. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Musculoskeletal Disorders Springer Journals

Risk factors for pulmonary complications after posterior spinal instrumentation and fusion in the treatment of congenital scoliosis: a case-control study

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Springer Journals
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Copyright © 2019 by The Author(s).
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Medicine & Public Health; Orthopedics; Rehabilitation; Rheumatology; Sports Medicine; Internal Medicine; Epidemiology
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1471-2474
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10.1186/s12891-019-2708-8
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Abstract

Background: Although surgery prevents the progression of deformity and maintains the overall balance of the spine in congenital scoliosis (CS) patients, it is associated with a high risk of perioperative complications. Pulmonary complication is one of the most common complications. This retrospective study aimed to investigate the risk factors for pulmonary complications in CS patients after posterior spinal instrumentation and fusion. Methods: Analysis of consecutive patients who underwent posterior spinal instrumentation and fusion for congenital scoliosis was performed. Preoperative clinical data, intraoperative variables, and perioperative radiographic parameters were collected to analyze the risk factors for pulmonary complications. Patients were separated into groups with and without postoperative pulmonary complications. Potential risk factors were identified by univariate testing. Multivariate logistic regression was used to evaluate independent predictors of pulmonary complications. Results: Three hundred and twenty-three CS patients were included. Forty-five (13.9%) patients developed postoperative pulmonary complications, which included pleural effusion in 34 (75.6%) cases, pneumonia in 24 (53.3%) cases, pneumothorax in 3 (6.7%) cases, atelectasis in 4 (8.9%) cases, pulmonary edema in 2 (4.4%) cases, respiratory failure in 2 (4.4%) cases, and prolonged mechanical ventilation in 4 (8.9%) cases. The independent risk factors for development of pulmonary complications included age (Odds ratio (OR) = 1.088, P = 0.038), reoperation (OR = 5.150, P = 0.012), preoperative pulmonary disease (OR = 10.504, P = 0.004), correction rate (OR = 1.088, P = 0.001), middle thoracic screw-setting (OR = 12.690, P = 0.043), and thoracoplasty (OR = 5.802, P = 0.001). The area under the receiver operating characteristic (ROC) curve based on predicted probability of the logistic regression was 0.903. Conclusions: Age, reoperation, preoperative pulmonary disease, correction rate, middle thoracic screw-setting, and thoracoplasty were independent risk factors for pulmonary complications after posterior spinal instrumentation and fusion in CS patients. Keywords: Congenital scoliosis, Pulmonary complications, Risk factors, Posterior spinal instrumentation and fusion * Correspondence: haiyongccmu@163.com Department of Orthopedics, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Rd, Beijing 100043, China Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Wu et al. BMC Musculoskeletal Disorders (2019) 20:331 Page 2 of 8 Background pulmonary disease, operation history, preoperative white Congenital scoliosis (CS) is an early-onset spinal deformity blood cell (WBC) count and proportion of neutrophil, caused by vertebral abnormalities, which are classified on American Society of Anesthesiologists (ASA) grade and the basis of failures of formation, segmentation, or both preoperative pulmonary function (e.g., forced expiratory [1, 2].The prevalence of CS is approximately 0.5 to 1 in volume in 1 s/forced vital capacity (FEV1/FVC), residual every 1000 live births [3, 4]. Conservative management for volume/total lung capacity (RV/TLC)). CS, such as bracing and serial derotational casting, is less Operative parameters included the instrumentation effective than for idiopathic scoliosis. Therefore, the surgi- and fusion levels, spinal osteotomy levels, thoracoplasty, cal treatment is usually performed for CS patients with intra-operative blood loss, operation time, and blood progressively worsening deformities [5]. Although scoli- transfusion. osis surgery prevents the progression of deformity and maintains the overall balance of the spine, it is associated Radiographic measurements with a high risk of perioperative complications [6]. Preoperative radiographs of the patients include chest X-ray, Pulmonary complication is one of the most common standing anterior-posterior and lateral radiographs of the complications because congenital spine deformities de- whole spine, supine right and left bending radiographs, creases not only the volume but also the function of the three-dimensional computed tomography (CT) reconstruc- lungs [7–10]. However, little has been reported about tions, and whole-spine magnetic resonance (MR) images. Pa- postoperative pulmonary complication in CS patients. Yin rameters measured in the coronal plane and sagittal plane et al. recently investigated the pulmonary complication in include the position and the Cobb angle of the curves, the CS patients, but the sample size of their study was small upper and lower end vertebras of the curve, the direction of and the observation variables were inadequate [11]. the curve, and the number of vertebras affected by curves. Therefore, we conducted this retrospective study to de- Postoperative radiographicdataincludethedegreeofspinal scribe the morbidity and further try to find the risk factors curvature correction postoperatively. All the radiographic of postoperative pulmonary complications after posterior measurements were performed independently by two spinal spinal instrumentation and fusion surgery in CS patients. surgeons (LW, YSW) in order to decrease the intra-observer. Methods Pulmonary complications assessment Participants Pulmonary complication data, which were collected The clinical data were obtained from a single-center retro- postoperatively, included: pleural effusion, pneumonia, spective comparative study of 323 CS patients treated by pneumothorax, atelectasis, pulmonary edema, respira- posterior spinal instrumentation and fusion at our hospital tory failure, and prolonged intubation with mechanical between 2011 and 2017. All the operations included in ventilation (see Table 2). According to complication out- this study were performed by one surgeon (YH). This comes, patients were divided into two groups: with and study was approved by the institutional review board fol- without pulmonary complications. lowing the declaration of Helsinki principles. Inclusion criteria for this study were operatively treated Statistical analysis CS patients with the following conditions: (1) coronal All the analyses were performed with the use of Stata soft- Cobb angle of thoracic, thoracolumbar, and lumbar scoli- ware, version 15.1 (Stata Corp). Continuous data are otic curves ≥40°; (2) deformities increasing in severity or expressed as means with standard deviations or as me- predicted to have a high risk for progression (unilateral dians with interquartile ranges, depending on normality. bar with a contralateral hemivertebra); (3) posterior spinal Categorical variables were shown as proportions. In the instrumentation and fusion; (4) complete preoperative and univariate testing, categorical variables were performed postoperative radiographic data; and (5) preoperative pul- using Pearson chi-square tests or Fisher exact tests where monary function tests (PFTs) before surgery. Exclusion appropriate. Continuous variables were examined using criteria were: (1) other kinds of scoliosis (e.g., degenerative Kruskal-Wallis equality-of-populations rank tests. Predic- scoliosis, ankylosing spondylitis, and spinal tuberculosis); tors with a P value of<0.1onunivariate analysis were (2) anterior approach or anterior and posterior approach; identified to be risk factors of pulmonary complications. (3) growing rod; and (4) spinal trauma or tumor. The variance inflation factor (VIF) and tolerance were used to test the multicollinearity of the risk factors. A Clinical and operative parameters VIF > 10 or tolerance < 0.1 was identified to be significant The baseline patient characteristic and demographic multicollinearity. Binary logistic regression was used to data were collected preoperatively (see Table 1). Clinical determine independent risk factors of pulmonary compli- parameters included age, gender, body mass index cations among patient characteristics. The Hosmer- (BMI), duration since diagnosis of scoliosis, preoperative Lemeshow test was used to estimate the goodness of fit Wu et al. BMC Musculoskeletal Disorders (2019) 20:331 Page 3 of 8 Table 1 Baseline clinical and perioperative characteristics of patients with or without pulmonary complication Variables Overall Pulmonary complication No pulmonary complication P value Number 323 45 278 Age, years 17 (12–26) 26 (19–26) 15 (12–24) < 0.001 Gender, female, no. (%) 197 (61.0%) 35 (77.8%) 162 (58.3%) 0.013 BMI, Kg/m 18.4 (15.9–20.4) 17.8 (16.2–20.4) 18.4 (15.9–20.4) 0.973 Duration since diagnosis of scoliosis, years 11 (8–20) 20 (13–24) 10 (7–17) < 0.001 Reoperation, no. (%) 41 (12.7%) 10 (22.2%) 31 (11.2%) 0.038 Preoperative pulmonary disease, no (%) 14 (4.3%) 9 (20.0%) 5 (1.8%) < 0.001 The main bending 0.006 Thoracic scoliosis, no (%) 239 (74.0%) 42 (93.3%) 197 (70.9%) Thoracolumbar scoliosis, no (%) 49 (15.2%) 2 (4.4%) 47 (16.9%) Lumbar scoliosis, no (%) 35 (10.8%) 1 (2.2%) 34 (12.2%) Preoperative Cobb angle, degree 80.2 (57.3–103) 105.3 (88.3–122.3) 75 (55.2–97.7) < 0.001 Correction rate, % 64 (57.7–71.3) 67.4 (60.1–71.3) 63.7 (57.4–71.2) 0.078 Preoperative WBC, ×10 /L 5.9 (5.1–7.1) 5.8 (5.0–6.9) 5.9 (5.1–7.1) 0.345 Preoperative neutrophil, % 53.3 (45.4–61.2) 55.4 (48.1–60.7) 53.1 (45.4–61.3) 0.540 ASA grade 2 (1–2) 2 (1–2) 2 (1–2) 0.886 Spinal osteotomy, no (%) 167 (51.7%) 26 (57.8%) 141 (50.7%) 0.379 No. of levels fused 12 (9–14) 13 (12–14) 12 (8–14) < 0.001 Upper thoracic screw-setting, no (%) 208 (64.4%) 40 (88.9%) 168 (60.4%) < 0.001 Middle thoracic screw-setting, no (%) 232 (71.8%) 44 (97.8%) 188 (67.6%) < 0.001 Lower thoracic screw-setting, no (%) 248 (76.8%) 41 (91.1%) 207 (74.5%) 0.014 Lumbar screw-setting, no (%) 291 (90.1%) 41 (91.1%) 250 (89.9%) 0.805 Thoracoplasty, no (%) 114 (35.3%) 33 (73.3%) 81 (29.1%) < 0.001 Operation time, min 240 (180–300) 285 (250–360) 232.5 (180–295) < 0.001 Volume of blood transfusion, ml 400 (0–400) 500 (0–800) 0 (0–400) < 0.001 Pulmonary function FEV1/FVC, % 85.4 (81.3–88.9) 83.8 (80.5–88.1) 85.5 (81.3–89.2) 0.130 RV/TLC, % 36.8 (29.9–41.8) 38.8 (33.8–43.2) 36.4 (29.6–41.6) 0.038 Value is expressed as the median (interquartile range) or number (percentage) Abbreviations: BMI Body mass index, WBC White blood count, ASA American Society of Anesthesiologists, No. Number, FEV1 Forced expiratory volume in 1 s, FVC Forced vital capacity, RV Residual volume, TLC Total lung capacity for the logistic regression mode. We generated a receiver operating characteristic (ROC) curve using predicted probability values from the logistic regression. A coefplot Table 2 Numbers and percentages of pulmonary complication was performed to plot the regression coefficients. A types among the 45 patients who developed a postoperative nomogram was used to demonstrate the risk points and pulmonary complication probability of independent risk factors for predicting the Pulmonary complication Number Frequency (%) pulmonary complications. A P value of < 0.05 in 2-sided Pleural effusion 34 75.6 tests was statistically significant. Pneumonia 24 53.3 Results Pneumothorax 3 6.7 Participants Atelectasis 4 8.9 Three hundred and twenty-three patients were enrolled Pulmonary edema 2 4.4 in this study. The median operative age was 17 years, Respiratory failure 2 4.4 and females made up the majority of the cohort (61.0%). Prolonged intubation with 4 8.9 The median duration since diagnosis of scoliosis was 11 mechanical ventilation years. The most common main bending was thoracic Wu et al. BMC Musculoskeletal Disorders (2019) 20:331 Page 4 of 8 scoliosis (74.0%). The median preoperative Cobb angle angle correction rate showed a trend toward a higher risk was 80.2 degree, and the median correction rate was of pulmonary complications (P = 0.082). No significant dif- 64% immediately post operation. The median number of ference in BMI, preoperative white blood cell or neutro- levels fused during an operation was 12. The incidence phil count, ASA grade, proportion of spinal osteotomy or of reoperation and preoperative pulmonary disease were lumbar screw-setting, FEV1/FVC was observed. 12.7 and 4.3%, respectively. The rate of thoracoplasty, spinal osteotomy, and upper thoracic, middle thoracic, Multivariate analysis lower thoracic and lumbar screw-setting was 35.3, 51.7, Variables with a P value of < 0.1 on univariate analysis as 64.4, 71.8, 76.8, and 90.1%, respectively. The median mentioned above were identified to be risk factors of pul- BMI, preoperative WBC, neutrophil, FEV1/FVC, RV/ monary complications. We tested the multicollinearity of TLC, operation time, and blood transfusion volume were all the risk factors. The results showed that the largest VIF 2 9 18.4 Kg/m , 5.9 × 10 /L, 53.3, 85.4, 36.8%, 240 min and of all the risk factors was 3.19 and the smallest tolerance of 400 mL, respectively (see Table 1). all the risk factors was 0.31 (see Additional file 1). Therefore, we included all the risk factors in the logistic Summary of postoperative pulmonary complications regression model, and we found that age (Odds ratio The incidence of postoperative pulmonary complications (OR) =1.085, P = 0.043), reoperation (OR = 5.258, P=0.010), was shown in Table 2. Forty - five (13.9%) of the 323 pa- preoperative pulmonary disease (OR = 10.553, P=0.004), tients developed postoperative pulmonary complications, Cobb angle correction rate (OR = 1.086, P = 0.002), consisting of pleural effusion in 34 (75.6%) cases, pneu- thoracoplasty (OR = 5.601, P = 0.001), and middle monia in 24 (53.3%) cases, pneumothorax in 3 (6.7%) thoracic screw-setting (OR = 12.695, P = 0.043) were cases, atelectasis in 4 (8.9%) cases, pulmonary edema in the independent risk factors of postoperative pulmonary 2 (4.4%) cases, respiratory failure in 2 (4.4%) cases, and complications (see Table 3). The Hosmer-Lemeshow test prolonged intubation with mechanical ventilation in 4 showed the fit for the logistic regression model was good (8.9%) cases (Table 2). Twenty-four patients had one (P = 0.022, chi2 = 358.05). The ROC curve based on pre- pulmonary complication, and 21 had more than one dicted probability of the logistic regression was shown in complication (14 patients with 2 pulmonary complica- Fig. 1, and the area under the curve was 0.903 (95% CI, tions, 6 patients with 3 pulmonary complications, and 1 0.853 to 0.952). The coefplot of the regression coefficients patient with 4 pulmonary complications). was shown in Fig. 2. Univariate analysis Nomogram Compared with patients without postoperative pulmonary Through the logistic regression model, we built a prog- complications, patients with postoperative pulmonary nostic nomogram incorporating the above independent complications were significantly older (P < 0.001), in- prognostic factors for visualization and facilitating clin- cluded a greater proportion of females (P = 0.013), ical practice as shown in Fig. 3. and had a longer duration of symptoms (P < 0.001). The incidence of thoracic scoliosis (P =0.006), reoper- Discussion ation (P = 0.037) and preoperative pulmonary disease Congenital scoliosis (CS) may result in thoracic de- (P < 0.001) was significantly higher in patients with formity that limits normal respiration and lung postoperative pulmonary complications than in those growth [3]. Many patients with CS have progressive without. The preoperative Cobb angle (P < 0.001) was restrictive lung disease, which increases the risks of lager in patients with postoperative pulmonary com- pulmonary complications after surgical correction plications than in those without. RV/TLC value was [12]. Pulmonary complications are often cited as the also significantly higher in patients with postoperative pulmonary complications than in those without these Table 3 Logistic regression of pulmonary complication and clinical variables complications (P = 0.040). More vertebral levels were fused in patients with postoperative pulmonary Variables OR P value 95% CI complications than in those without (P < 0.001). The Age, years 1.088 0.038 1.005–1.179 rate of thoracoplasty (P < 0.001), and upper thoracic Reoperation, no. (%) 5.150 0.012 1.443–18.384 (P < 0.001), middle thoracic (P < 0.001), and lower Preoperative pulmonary disease, no (%) 10.504 0.004 2.114–52.198 thoracic screw-setting (P = 0.015) was significantly higher Correction rate, % 1.088 0.001 1.034–1.145 in postoperative pulmonary complications group. The Middle thoracic screw-setting, no (%) 12.690 0.043 1.089–147.945 operation time was longer (P < 0.001), and the blood Thoracoplasty, no (%) 5.802 0.001 2.065–16.303 transfusion volume was also higher (P < 0.001) in the post- operative pulmonary complications group. The Cobb Abbreviations: No. Number, RV Residual volume, TLC Total lung capacity Wu et al. BMC Musculoskeletal Disorders (2019) 20:331 Page 5 of 8 Fig. 1 The ROC curve using predicted probability values from the logistic regression most frequent problems after correction of scoliosis; pulmonary disease, reoperation, correction rate, middle the identification of risk factors for pulmonary com- thoracic screw-setting, and thoracoplasty are independent plications in CS patients improves surgical safety. In predictive factors for postoperative pulmonary complica- our study, the incidence of postoperative pulmonary tions in CS patients. complications after posterior spinal instrumentation and Our study showed that age was an independent risk fusion in the treatment of CS is 13.9%. Age, preoperative factor for the development of postoperative pulmonary Fig. 2 Coefplot of the Logistic regression coefficient. Abbreviation: No. number, RV residual volume, TLC total lung capacity Wu et al. BMC Musculoskeletal Disorders (2019) 20:331 Page 6 of 8 Fig. 3 Nomogram for pulmonary complication using the independent prognostic factors complications. Our result is consistent with that of pre- with postoperative pulmonary complications in the vious studies [12–14]. Yuan et al. [12] reported that surgical treatment of scoliosis. Although the results of older patients (> 13 years) required prolonged postopera- previous studies were controversial, knowledge of pul- tive mechanical ventilation after scoliosis repair surgery. monary comorbidity provided the identification of a Patil et al. [13] found that in idiopathic scoliosis patients, patient with high risk for postoperative pulmonary older ones (> 18 years) were more likely to develop post- complications. operative complications that included pulmonary prob- Our results demonstrated that the history of previ- lems. Shaw et al. [14] concluded that increasing age was ous operations was an independent risk factor for the correlated with higher rates of major short-term compli- development of postoperative pulmonary complica- cations (including pulmonary complications) in adult tionsinCSpatientsand more attentionshould be scoliosis surgery. A possible reason for the association of paid to reoperation patients. Sansur et al. [17] age with pulmonary complications is that restrictive ven- reported that patients with a previous history of tilatory impairment and pulmonary function damage spinal surgery were significantly more likely to have caused by scoliosis are progressive with age. complications than patients undergoing initial correc- In our study, CS patients with pulmonary comorbidity tions through adult scoliosis surgery. Toll et al. [15] were more likely to have postoperative pulmonary complica- showed that having previous operations had a strong tions than those without pulmonary comorbidity. Pulmonary association with infectious complications, including comorbidity in CS patients, which was probably associated pulmonary ones. with impaired lung function, increased the risk of pulmonary According to our logistic regression analysis, the cor- complications following surgical correction. Patil et al. rection rate is an independent risk factor for the devel- [13] reported that patients with preoperative pulmon- opment of postoperative pulmonary complications. ary comorbidities were more likely to develop However, little has been reported about correction rate pulmonary complications after surgical correction of as an independent risk factor for pulmonary complica- idiopathic scoliosis. Toll et al. [15] also identified tions in CS patients. In our univariate analysis study, the pulmonary comorbidity in neuromuscular scoliosis preoperative Cobb angle (P < 0.001) is also larger in patients as a risk factor for perioperative infection patients with postoperative pulmonary complications following surgical deformity correction. On the other than in those without. After the test of the collinearity side, Zhang et al. [16] found that preoperative pul- diagnostics, we included all the risk factors in the logistic monary symptoms usually predicted abnormal results regression model. We found that the Cobb angle correc- of pulmonary function tests but had no correlation tion rate (OR = 1.086, P = 0.002) was an independent risk Wu et al. BMC Musculoskeletal Disorders (2019) 20:331 Page 7 of 8 factor of postoperative pulmonary complications, but, pulmonary complications before surgery; rather than add- the preoperative Cobb angle (OR = 1.012, P = 0.246) was ing thoracoplasty whenever indicated, we can instead per- not. In other words, the Cobb angle correction rate is a form it in one-stage with posterior spinal instrumentation better predictor of postoperative pulmonary complica- and fusion surgery. tions than the preoperative Cobb angle. A possible ex- This study has several limitations. First, this is a single planation is that the degree of Cobb angle correction is center retrospective study. Second, we did not consider more difficult for the lung and pleura to accommodate the postoperative pulmonary function and the outcomes than the preoperative Cobb angle. of pulmonary complications, such as mechanical ventila- It is well known that thoracic pedicle screw fixation tion time, postoperative analgesia, hospital cost, and which has excellent deformity correction and a high mortality. Third, we derived six independent risk factors margin of safety, is a reliable method of treating spinal of postoperative pulmonary complications, and built a deformities [18]. Yet, pulmonary complications have also nomogram for visualization and facilitating clinical prac- been reported after thoracic pedicle screw fixation [18– tice. However, we did not validate the nomogram in a 20]. In our univariate analyses, the rates of upper, new database. A prospective, multicenter study is needed middle, and lower thoracic screw-settings were all sig- to address these issues and validate our findings. nificantly higher in the postoperative pulmonary compli- cations group than in the group without complications, Conclusions while the rate of lumbar screw-setting showed no signifi- We conclude that it is important for surgeons to predict cant difference between the two groups. However, in postoperative pulmonary complications in CS patients multivariate analysis, only middle thoracic screw-setting before surgery. Logistic regression analysis shows that was the independent predictive factor for postoperative the independent risk factors to develop pulmonary com- pulmonary complications. This may be attributed to the plications after posterior spinal instrumentation and fu- anatomic characteristics of the middle thoracic spine, sion in CS patients are age, preoperative pulmonary which is located at the apex of the kyphosis of the thor- disease, reoperation, correction rate, middle thoracic acic spine. Therefore, because the middle thoracic screw-setting, and thoracoplasty. screw-setting approach is more likely to cause injury to the lungs and pleura, greater care must be given to this Additional file procedure. Thoracoplasty by means of multiple rib resections is Additional file 1: Multicollinearity test of risk factors of pulmonary complications (DOCX 15 kb) used to treat the rib cage deformity in thoracic scoli- osis and has been regarded as an important factor for Abbreviations the patient’s satisfaction [21]. Thoracoplasty in com- BMI: Body mass index; CS: Congenital scoliosis; CT: Computed tomography; bination with spine fusion is an established method FEV1/FVC: Forced expiratory volume in 1 s/forced vital capacity; to address the rib cage deformity in scoliosis surgery MR: Magnetic resonance; OR: Odds ratio; PFTs: Pulmonary function tests; ROC: Receiver operating characteristic; RV/TLC: Residual volume/total lung [22]. With respect to the impact of postoperative pul- capacity; VIF: Variance inflation factor; WBC: White blood cell monary complications on thoracoplasty after scoliotic surgery, Liang et al. [23]demonstratedthatperform- Acknowledgements We would like to acknowledge the significant contribution of the patients, ance of a thoracoplasty was the only risk factor for families, researchers, clinical staff, and sponsors included in this study. postoperative pulmonary complications in patients undergoing posterior spinal fusion. However, Suk et Authors’ contributions al. [21] reported that thoracoplasty showed satisfac- LW contributed to the conception and design of this manuscript, the acquisition of the data, the analysis and the interpretation of the data and tory clinical outcomes without pulmonary function the drafting of the manuscript. XNZ and YZL followed up and collected the compromise in the treatment of thoracic adolescent data. YSW was responsible for the data collection and radiographic idiopathic scoliosis. Hod-Feins et al. [8] suggested that measurements. YH conceived of the study and participated in its design and coordination, revised the manuscript critically for important intellectual thoracoplasty could be added whenever indicated content, and gave final approval of the version to be published. All authors because thoracoplasty did not correlate with postoper- read and approved the final manuscript. ative pulmonary complications. In our study, CS pa- Funding tients who underwent thoracoplasty were more likely This study was supported partially by research fund provided by National to have postoperative pulmonary complications than Natural Science Foundation of China (NSFC) No. 81772421. those who did not. According to our logistic This funding was not involved in the data collection, data analysis, or the preparation or editing of the manuscript. regression analysis, thoracoplasty is an independent predictive factor-but no the only one for postoperative Availability of data and materials pulmonary complications in CS patients. We could use The datasets used and analyzed during the current study are available from nomogram to evaluate the risk of postoperative the corresponding author on reasonable request. Wu et al. BMC Musculoskeletal Disorders (2019) 20:331 Page 8 of 8 Ethics approval and consent to participate 18. Suk SI, Kim WJ, Lee SM, Kim JH, Chung ER. Thoracic pedicle screw fixation in The study was approved by Ethics Committee of Chaoyang Hospital. This spinal deformities: are they really safe? Spine (Phila Pa 1976). 2011;26:2049–57. study was in accordance with the ethical standards of the institutional 19. Jin M, Liu Z, Qiu Y, Yan H, Han X, Zhu Z. Incidence and risk factors for the research committee, the 1964 Helsinki declaration, and its later amendments. misplacement of pedicle screws in scoliosis surgery assisted by O-arm For this type of study formal consent is not required. navigation-analysis of a large series of one thousand, one hundred and forty five screws. Int Orthop. 2017;41:773–80. 20. Li G, Lv G, Passias P, Kozanek M, Metkar US, Liu Z, et al. Complications Consent for publication associated with thoracic pedicle screws in spinal deformity. Eur Spine J. Not applicable. 2010;19:1576–84. 21. Suk SI, Kim JH, Kim SS, Lee JJ, Han YT. Thoracoplasty in thoracic adolescent Competing interests idiopathic scoliosis. Spine (Phila Pa 1976). 2008;33:1061–7. The authors declare that they have no competing interests. 22. Min K, Waelchli B, Hahn F. Primary thoracoplasty and pedicle screw instrumentation in thoracic idiopathic scoliosis. Eur Spine J. 2005;14:777–82. Author details 23. Liang J, Qiu G, Shen J, Zhang J, Wang Y, Li S, et al. Predictive factors of Department of Orthopedics, Beijing Chaoyang Hospital, Capital Medical postoperative pulmonary complications in scoliotic patients with moderate University, No. 8 Gongti South Rd, Beijing 100043, China. Department of or severe pulmonary dysfunction. J Spinal Disord Tech. 2010;23:388–92. 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BMC Musculoskeletal DisordersSpringer Journals

Published: Jul 16, 2019

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