Pediatric revision spinal deformity surgery: Issues and complications

Study Design: A review of issues and concerns associated with pediatric revision surgery. Objectives.: To describe: (1) the incidence, causes, and prevention of spine revision surgery in the pediatric population; and (2) the preoperative planning and imaging necessary for such surgeries and the associated intraoperative and technical complications (e.g., infection, blood loss, and incomplete deformity correction). Summary of Background Data.: Revision surgery may be needed for pediatric spinal deformity because of many factors. This article describes the assessment and performance of revision surgery to optimize results. Methods.: The literature and the author s personal experience were reviewed. Results.: Rates of reoperation range from 4% to 25% for adolescent idiopathic scoliosis and are higher for neuromuscular or syndromic diagnoses. The most common indications for revision are infection, increased deformity, late operative site pain, pseudarthrosis, and implant dislodgement. Because revision cases are unique, preoperative planning should include a review of previous records and imaging for a thorough understanding of the bony and neurologic anatomy and instrumentation. Preoperative discussion with colleagues may help prevent the need for additional revision. Measures to minimize blood loss should be taken. Deformity correction may include mobilization by multiple osteotomies for long sweeping curves, or focal osteotomies (e.g., vertebral column resection or pedicle subtraction osteotomies) for focal deformity. If fusing additional levels, instrumentation should have adequate fixation and should connect to existing anchors so that the corrective force can be applied to the site of deformity. The possibility of occult infection should be considered; in the event of a late deep infection, options include removing implants and debriding the spine. However, there is a risk of increased deformity in the coronal and sagittal planes after implant removal. Because revision surgery itself may have a higher subsequent reoperation rate, thorough preparation should be done to ensure success. CONCLUSION.: Cases of spine revision surgery in the pediatric population are best undertaken by an experienced surgeon and should involve thorough preoperative planning, proper equipment, and skilled assistance.