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World Journal of Orthopedics logoLink to World Journal of Orthopedics
. 2021 Aug 18;12(8):584–603. doi: 10.5312/wjo.v12.i8.584

Complications in growth-friendly spinal surgeries for early-onset scoliosis: Literature review

Michał Latalski 1, Marek Fatyga 2, Ireneusz Sowa 3, Magdalena Wojciak 4, Grzegorz Starobrat 5, Anna Danielewicz 6
PMCID: PMC8384615  PMID: 34485105

Abstract

BACKGROUND

The treatments for early-onset scoliosis (EOS), defined as curvature of the spine with onset before 10 years of age, continue to pose a great challenge for pediatric orthopedics. The treatment goals for EOS include minimizing spinal deformity while maximizing thoracic volume and pulmonary function. Different surgical techniques have different advantages and drawbacks; however, the two major concerns in the management of EOS are repeated surgeries and complications.

AIM

To review the current literature to assess the safety of EOS surgical treatment in terms of the rate of complications and unplanned surgeries.

METHODS

In January 2021 two independent reviewers systematically searched three electronic medical databases (PubMed, the Cochrane Library, and Embase) for relevant articles. Every step of the review was done according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Due to the heterogeneity of articles and topics after data analysis, a descriptive (synthetic) analysis was performed.

RESULTS

A total of 2136 articles were found. Forty articles were included in this systematic review, after applying our inclusion and exclusion criteria. EOS surgery has a varying but high rate of complications. The most frequent complications were categorized as implant (54%), general (17%), wound (15%) and alignment (12%). The rate of complications might have been even higher than reported, as some authors do not report all types of complications. About 54% of patients required unplanned surgeries due to complications, which comprised 15% of all surgeries.

CONCLUSION

The literature concerning the definitions, collection, and interpretation of data regarding EOS surgery complications is often difficult to interpret. This creates problems in the comparison, analysis, and improvement of spine surgery practice. Additionally, this observation indicates that data on the incidence of complications can be underestimated, and should be interpreted with caution. Awareness of the high rate of complications of EOS surgery is crucial, and an optimal strategy for prevention should become a priority.

Keywords: Scoliosis, Spine, Growth-friendly implant, Surgery, Complications, Treatment


Core Tip: Early-onset scoliosis (EOS) is defined as curvature of the spine ≥ 10° with onset before 10 years of age, regardless of etiology. The treatment for EOS is still a great challenge for pediatric orthopedics, and surgery is often necessary. Repeated surgeries and complications are two major concerns in EOS management. The literature on the definitions, collection, and interpretation of data regarding EOS surgery complications is often difficult to interpret. This creates problems in the comparison, analysis, and improvement of spine surgery practice. Data on the incidence of complications can be underestimated, and should be interpreted with caution.

INTRODUCTION

Early-onset scoliosis (EOS) is defined as curvature of the spine ≥ 10° in the frontal plane with onset before 10 years of age[1]. EOS is not a diagnosis, but can rather be defined as the age of onset of a coronal plane spinal deformity. As such, EOS includes spinal deformities resulting from congenital malformations, neuromuscular conditions, inherited bone dysplasias and syndromes, and, in idiopathic cases, with no underlying disorder. As EOS has such a wide variety of etiologies, its natural history varies widely, and in many cases is established at the time of the child’s diagnosis which reveals the spinal deformity[2]. The natural history of untreated progressive EOS was reported on by Scott and Morgan in 1955[3]. They documented the progression of curves from 30 to 100 degrees. Moreover, 4 patients out of 28 died before the age of 20 years, of cardiorespiratory disease. Relentless curve progression, in the absence of treatment, results in increasing chest wall deformity. Rib rotation and curve progression produce restrictive pulmonary disease, with worsening pulmonary function, as documented by diminishing forced vital capacity and total lung volume. If left untreated, the spinal deformity produces chest wall rotation, which obliterates the space available for the lungs[4]. The treatment for EOS remains a great challenge for pediatric orthopedics. The treatment goals for EOS, regardless of the diagnosis, are the same: minimizing spinal deformity while maximizing thoracic volume and pulmonary function[5]. When conservative treatment is ineffective, the option is surgery[6]. Different techniques have different advantages and drawbacks. Those most often used are traditional growing rods (TGR), vertical expandable prosthetic titanium ribs (VEPTR), magnetically controlled growing rods (MCGR), and the Shilla growth guidance system (SGGS). Repeated surgeries and complications are two major concerns in EOS management. The aim of the study was to review the current literature to assess the safety of EOS surgical treatment in terms of the rate of complications and unplanned surgeries.

MATERIALS AND METHODS

Literature search strategy

The systematic review was conducted according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)[7] (Figure 1). In January 2021, a search of three electronic medical databases (PubMed, the Cochrane Library, and Embase) was performed by three independent authors. We combined the terms: “early-onset scoliosis” OR “eos” OR “juvenile scoliosis” OR “infantile scoliosis” OR “tgr” OR “veptr” OR “MCGR” OR “Shilla” OR “growth-friendly” AND “complication”. The reference lists of all retrieved articles were reviewed for the further identification of potentially relevant studies, and assessed using the inclusion and exclusion criteria.

Figure 1.

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart of the method of selection and screening.

Selection criteria

The eligible studies for the reference review included those dealing with complications in the operative treatment of EOS. The initial screening of titles and abstracts was made using the following inclusion criteria: studies of any level of evidence, reporting clinical results, published in peer review journals, and dealing with complications in operative EOS treatment. Exclusion criteria were: studies with complications in the non-operative treatment of EOS, in vitro, or animal model studies. We also excluded all the remaining duplicates, articles dealing with other topics, and those with poor scientific methodology, or without an accessible abstract. Reference lists were also manually searched for further relevant studies. Reviews, abstracts, case reports, conference presentations, and expert opinions, were excluded.

All papers were tagged: (1) according to the system used: TGR, VEPTR, MCGR, Shilla (guided growth); (2) the number of cases as a “big group” – more than 30 cases, “medium group” – 10-29 cases, and “small group” – less than 10 cases; and (3) the time of follow-up – “short” – less than 2 years, “minimum” – more than 2 years, and “optimum” – more than 5 years. The final inclusion criteria were primarily limited to “big group” and “optimum follow-up”. During the paper extraction, no papers with VEPTR, and only one with Shilla and MCGR, were found, so that the groups’ extracted papers had to be extended with “medium group” and “minimum” follow-up.

Data extraction and criteria appraisal

Three investigators independently reviewed each article. Discrepancies between the reviewers were resolved by discussion and consensus. All data were extracted from article texts, tables, and figures, and put into tables in an Excel sheet.

Complications were categorized as wound-related, implant-related, alignment-related, and general (surgical or medical). Surgical procedures were classified as planned [implantations, lengthenings, final fusions (FF)], and unplanned (revisions). Implantation procedures were included as equal to the number of patients. Not-given information was calculated using specific formulas based on the known data, i.e., the mean number of operations per patient, the number of patients, and the number of operations. Some data – especially in TGR-group patients - like the number of lengthenings and derived information – were estimated based on the mean duration between lengthenings, using formulas, i.e., the mean duration between lengthenings, and follow-up, i.e. the number of lengthenings. The mean durations between lengthenings, if not specified, were taken as the mean value of durations between lengthenings specified in other papers. These data were marked in the table with the symbol “1”. In some papers the number of unplanned surgeries was not provided. In those cases, such complications as deep infections and implant fractures were estimated as an indication of at least one revision/unplanned surgery. Some fields were left empty when there were not enough data to estimate the value. When the data in the main text and the tables did not match, the higher value was taken.

RESULTS

Included studies

A total of 2136 articles were found. After the exclusion of duplicates, 1300 articles were selected. At the end of the first screening, following the previously described selection criteria, we selected 615 articles eligible for full-text reading. Ultimately, after full-text reading and reference-list checks, we selected n = 40 articles, following previously adopted criteria. A PRISMA flowchart of the method of selection and screening is presented in Figure 1. The included articles focus on complications in the most commonly used systems – TGR (17 papers), VEPTR (13 papers), MCGR (8 papers), and Shilla (guided growth) (7 papers). Data extracted from these papers were assigned to the appropriate system. Harris et al[8], 2020, in their paper analyzed the impact of patient and surgical factors on the proximal complications and revision rates of early-onset scoliosis patients using a multicenter database. Total 353 patients met the inclusion criteria: growing rods = 318 and VEPTR = 35. Helenius et al[9], 2018, analyzed the outcomes of surgeries using growing rods in patients with severe vs moderate early-onset scoliosis. From the group of 214 patients, 198 were treated with TGR and 14 with MCGR. As in the main texts, the data were not separated out, so we included them in the TGR group, as the vast majority were treated with this system. Papers by Akbarnia et al[10], Bachabi et al[11], Haapala et al[12], Andras et al[13], and Luhmann et al[14], dealt with comparisons between TGR and MCGR, TGR, and VEPTR, Shilla and MCGR, and TGR and Shilla, respectively, so they appear in the table for the applicable system. The demographic findings of the included articles are summarized in Table 1.

Table 1.

Demographic data from the reviewed articles

Ref.
Construct
Subject
Sex (male/female)
Age at IP
Follow up
Diagnosis
No of patient with final spinal fusion
Comments, kind of complication analyzed
1 Bess et al[15], 2010 TGR 140 71/59 6 5.0 Neuromuscular (n = 52), idiopathic (n = 40), congenital (n = 24), and other (n = 24) 50 W, I, A, M
2 Du et al[16], 2020 167 69/98 7,2 10.7 Idiopathic (n = 45), neuromuscular (n = 56), syndromic (n = 43), congenital (n = 21), other (n = 2) 167 Analyzed patients who had undergone a FF after growing-rod treatment, W, I, A, M
3 Andras et al[13], 2015 36 nd 6.1 4.3 Syndromal (n = 10), idiopathic (n = 11), congenital (n = 2), neuromuscular (n = 13) nd I, M
4 Myung et al[17], 2014 159 nd 5 4.7 Neuromuscular (n = 46), congenital (n = 42), idiopathic (n = 37), syndromal (n = 34) nd I
5 Arandi et al[18], 2014 175 78/97 5.9 5.2 Idiopathic (n = 69), syndromal (n = 62), neuromuscular (n = 44) nd I
6 Liang et al[19], 2015 55 16/39 6.8 38.4 Congenital (n = 28), idiopathic (n = 6), syndromal (n = 8), neuromuscular (n = 6) and miscellaneous disorders (n = 7) 10 W, I, A, M
7 Ramirez et al[20], 2020 67 32/35 6 4.1 Only non-ambulatory neuromuscular early-onset scoliosis nd W, I, M
8 Yamaguchi et al[21], 2014 176 nd nd 4.7 Congenital (n = 48), neuromuscular (n = 42), syndromal (n = 37), idiopathic scoliosis (n = 32) and miscellaneous (n = 17) nd I
9 Poe-Kochert et al[22], 2016 100 42/58 7 4.3 Neuromuscular (n = 38), syndromic (n = 31), idiopathic (n = 22), congenital (n = 9) 100 Analyzed patients who had undergone a FF after growing-rod treatment; W, I
10 Kabirian et al[23], 2014 379 177/202 6.3 5.3 nd nd Only deep infection analyzed
11 Hosseini et al[24], 2018 274 114/160 6.7 6.3 Neuromuscular (n = 84), congenital (n = 43), syndromic (n = 89), idiopathic (n = 58) nd I
12 Johnston et al[25], 2013 27 nd 5.3 4.5 Neuromuscular (n = 6), idiopathic (n = 11), syndromic (n = 10) 6 Comparing with cast treatment, complications in total
13 Bachabi et al[11], 2020 50 nd 5.5 8.3 nd nd W, I, A, M
14 Luhmann et al[14], 2017 18 18 7.7 7.4 Idiopathic (n = 9), neuromuscular (n = 7), syndromic (n = 1), congenital (n = 1) 17 W, I, M
15 Akbarnia et al[10], 2014 12 5 6.5 4.1 Not given nd W, I, M
16 Harris et al[8], 2020 353 nd 6 6.0 Not given nd I, TGR -318 cases, 35 -VEPTR cases
17 Helenius et al[9], 2018 214 94/120 5.6 6.0 Neuromuscular (n = 68), congenital (n = 28), syndromic (n = 74), idiopathic (n = 44) 49 W, I, M TGR cases 198) MCGR cases 16
18 Gadepalli et al[26], 2011 VEPTR 26 16/10 7.58 7.0 Congenital or infantile scoliosis (n = 12), neuromuscular scoliosis (n = 5), unspecified structural thoracic disorder (n = 7), Jeune syndrome (n = 2) nd W, I, M
19 Bachabi et al[11], 2020 22 nd 4.3 7.7 nd nd W, I, M
20 Crews et al[27], 2018 151 16/6 7.1 3+ nd nd Only SSIs following VEPTR implant or revision surgeries were identified
21 Murphy et al[28], 2016 25 12/13 5.7 4.5 Congenital (n = 25) nd W, I, M
22 Berger-Groch et al[29], 2020 13 7/6 2.2 7.6 Congenital (n = 13) nd W, I, M
23 Hasler et al[30], 2010 23 8/15 6.5 3.6 Early onset idiopathic scoliosis (n = 1), neuromuscular (n = 11), post-thoracotomy scoliosis (n = 2), Sprengel deformity (n = 1), hyperkyphosis (n = 2), myopathy (n = 1), syndromic (n = 5) nd W, I, A, M
24 Latalski et al[31], 2011 12 nd 5.25 2.5 Congenital (n = 3), neuromuscular (n = 9) 0 W, I, A, M
25 Hell et al[32], 2005 15 8/7 6 nd Congenital (n = 9), neuromuscular (n = 6) 0 W, I, M
26 Garg et al[33], 2014 103 57/46 5.3 Neuromuscular (n = 30), congenital (n = 44), syndromic (n = 18), idiopathic (n = 11) Only wound complications following VEPTR implant or revision surgeries were identified
27 Waldhausen et al[34], 2016 65 nd 6.9 6.9 Congenital (n = 23), neuromuscular (n = 12), syndromic (n = 14), idiopathic (n = 2), other (n = 14) 28 W, I, M
28 Striano et al[35], 2019 166 6.81 Neuromuscular (n = 61), syndromic (n = 38), congenital (n = 64), idiopathic (n = 3) nd Only wound complications following VEPTR implant or revision surgeries were identified
29 Lucas et al[36], 2013 54 21/33 7 2.0 Neuromuscular (n = 19), congenital (n = 30), syndromic (n = 7), idiopathic (n = 3) nd W, I, A, M
30 Garg et al[37], 2016 38 22/16 5.51 4.1 Neuromuscular (n = 18), congenital (n = 13), syndromic (n = 5), idiopathic (n = 2) nd Only wound complications following VEPTR implant or revision surgeries were identified
31 Subramanian et al[38], 2018 MCGR 31 15/16 7.7 3.9 Neuromuscular (n = 4), syndromic (n = 19), idiopathic (n = 6), congenital (n = 2) nd W, I, A, M
32 Urbański et al[39], 2020 47 14/18 8.8 1-2.5 Neuromuscular (n = 10), syndromic (n = 11), idiopathic (n = 20), congenital (n = 6) 0 W, I, A, M
33 Akbarnia et al[10], 2014 12 5/7 6.8 2.5 Neuromuscular (n = 4), syndromic (n = 4), idiopathic (n = 3), congenital (n = 1) nd I, M
34 Studer et al[40], 2019 30 10/20 9.4 2.1 Congenital (n = 11), neuromuscular (n = 10), syndromic (n = 4), idiopathic (n = 5) nd W, I, A
35 Kwan et al[41], 2017 30 11/19 7.3 3.0 Syndromal (n = 8), idiopathic (n = 8), congenital (n = 6), neuromuscular (n = 8) 5 W, I, A,
36 Obid et al[42], 2020 22 4/18 9.5 4.0 Idiopathic (n = 14), neurofbromatosis (n = 2), neuromuscular and syndromic (n = 6) 9 W, I, A, M
37 Lampe et al[43], 2019 24 7/17 10.5 3.5 Syndromal (n = 4), idiopathic (n = 9), congenital (n = 1), neuromuscular (n = 10) nd W, I, A, M
38 Haapala et al[12], 2020 18 11/7 6.8 3.2 Neuromuscular (n = 12) II, syndromic (n = 8) EOS two NFI (n = 2) 5 I, A, M
39 Haapala et al[12], 2020 Shilla 13 8/5 6 4.0 Neuromuscular (n = 11), syndromic (n = 2) 4 W, I, M
40 Andras et al[13], 2015 Shilla 36 nd 6.1 4.6 Syndromal (n = 10), idiopathic (n = 11), congenital (n = 2), neuromuscular (n = 13) nd I, M
41 Nazareth et al[44], 2020 Shilla 20 10/10 5.7 5.2 Syndromic (n = 9), neuromuscular (n = 5), idiopathic (n = 3), congenital (n = 3). 7 W, I, M
42 Miękisiak et al[45], 2019 GGS 57 13/44 9.8 2+ Not given nd GGS – the same principle as Shilla. System made of Ti. W, I, A, M
43 McCarthy et al[46], 2014 Shilla 10 2/8 7.5 2.0 Idiopathic (n = 3), congenital scoliosis (n = 1), syndromic (n = 2), neuromuscular scoliosis (n = 4) nd W, I
44 Luhmann et al[14], 2017 Shilla 18 nd 7.9 6.1 Idiopathic (n = 8), neuromuscular (n = 7), syndromic (n = 3) 15 and 3 implant removals W, I, M
45 McCarthy et al[47], 2015 Shilla 40 17/23 6.11 5.0 Idiopathic (n = 9), congenital (n = 1), neuromuscular (n = 16), syndromic (n = 14) 15 and 3 Implant removals W, I, A

Type of complications: Wound (W), implant-related (I), alignment (A), and medical/surgical complications (M). FF: Final fusions; GGS: Growth guidance system; VEPTR: Vertical expandable prosthetic titanium ribs; TGR: Traditional growing rods; MCGR: Magnetically controlled growing rods.

Tables 2-5 present the number of surgical procedures (planned and unplanned). The number of patients is re-listed for easier reference to the remaining data. As the quantitative data depends on the number of analyzed patients, the second part of the table presents the percentage data. It shows the percentage of unplanned surgeries, the percentage of unplanned surgeries to all surgeries, the percentage of unplanned surgeries to patients with at least one complication, and the ratio of planned to unplanned surgeries. Eight papers were excluded from these tables, as there were no data on unplanned surgeries. Some fields were left empty if there were insufficient data. From the 40 analyzed papers 12 described all 4 complications (wound and implant-related, alignment, and medical/surgical). These data are marked in the table with the symbol “2”. In the others, some of these complications were not described. It probably means that the number of unplanned surgeries was understated.

Table 2.

The number of planned and unplanned surgical procedures in the traditional growing rods group

Ref.
Subject
Surgical procedures (n)
Planned surgical procedures (n)
Unplanned surgical procedure
% unplanned surgeries to all surgeries
% unplanned surgery to patients with at least one complication
Ratio of planned to unplanned surgery
n
%
Bess et al[15], 2010 140 897 823 74 52.92 8.22 91.42 11.12
Du et al[16], 2020 167 199 167 32 19.23 16.13 100.03 5.22
Andras et al[13], 2015 36 288 259 29 80.6 10.1 100.0 8.9
Myung et al[17], 2014 159 10811 10501 311 19.5 2.9 83.8 33.87
Arandi et al[18], 2014 175 12471 1190 571 32.6 4.6 71.3 20.88
Liang et al[19], 2015 55 272 263 231 41.82 8.52 100.02 11.43
Ramirez et al[20], 2020 67 4631 3961 67 100 14.5 163.4 5.91
Poe-Kochert et al[22], 2016 100 1571 1001 57 573 36.33 285.03 1.75
Kabirian e et al[23], 2014 379 2344 22741 70 18.5 3.0 166.7 32.49
Luhmann et al[14], 2017 18 167 141 26 144.4 15.6 5.42
Akbarnia et al[10], 2014 12 73 68 5 41.7 6.8 45.5 13.6
Harris et al[8], 2020 353 31411 28951 246 69.7 7.8 174.5 11.77
Helenius et al[9], 2018 214 1971 1836 133 62.1 6.7 137.1 13.8
1

Data estimated based on the mean values of duration between lengthenings.

2

The values of the % of unplanned surgeries in which all four complications were analyzed in the paper.

3

Corresponds to the papers in which all the patients were after the final fusion.

Table 5.

The number of planned and unplanned surgical procedures in guided growth group – the Shilla and growth guidance system groups

Ref.
Subject
Surgical procedures (n)
Planned surgical procedures (n)
Unplanned surgical procedure
% unplanned surgeries to all surgeries
% unplanned surgeries to patients with at least one complication
Ratio of planned to unplanned surgery
n
%
Haapala et al[12], 2020 13 19 17 2 15.4 10.5 40.0 8.5
Andras et al[13], 2015 36 101 36 65 180.6 64.4 224.1 0.55
Nazareth et al[44], 2020 20 41 20 21 105 51.2 140.0 0.95
Miękisiak et al[45], 2019 57 82 57 25 43.92 30.52 2.28
McCarthy et al[46], 2014 10 15 10 5 50 33.3 100.0 2
Luhmann et al[14], 2017 18 56 36 20 111.1 1.8
McCarthy et al[47], 2015 40 109 58 51 127.5 1.14
2

The values of the % of unplanned surgeries in which all four complications were analyzed in the paper.

Table 3.

The number of planned and unplanned surgical procedures in the vertical expandable prosthetic titanium ribs group

Ref.
Subject
Surgical procedures (n)
Planned surgical procedures (n)
Unplanned surgical procedure
% unplanned surgeries to all surgeries
% unplanned surgery to patients with at least one complication
Ratio of planned to unplanned surgery
n
%
Murphy et al[28], 2016 25 232 188 40 160 17.2 266.7 4.69
Gadepalli et al[26], 2011 26 100 86 14 53.8 14.0 6.14
Berger-Groch et al[29], 2020 13 182 178 5 38.5 2.7 35.6
Hasler et al[30], 2010 23 187 172 15 65.22 8.02 166.72 11.47
Latalski et al[31], 2011 12 44 38 6 502 13.62 75.02 6.33
Striano et al[35], 2019 166 670 560 110 66.3 16.4 275.0 5.09
Lucas et al[36], 2013 54 184 152 30 55.62 16.32 83.32 5.07
Garg et al[37], 2016 38 410 3501 601 157.9 14.6 5.83
1

Data estimated based on the mean values of duration between lengthenings.

2

The values of the % of unplanned surgeries in which all four complications were analyzed in the paper.

Table 4.

The number of planned and unplanned surgical procedures in the magnetically controlled growing rods group

Ref.
Subject
Surgical procedures (n)
Planned surgical procedures (n)
Unplanned surgical procedure
% unplanned surgeries to all surgeries
% unplanned surgery to patients with at least one complication
Ratio of planned to unplanned surgery
n
%
Subramanian et al[38], 2018 31 53 31 22 712 41.52 104.8 1.41
Urbański et al[39], 2020 47 60 47 13 27.72 21.72 81.3 3.62
Akbarnia et al[10], 2014 12 16 12 4 33.3 25.0 100.0 3
Studer et al[40], 2019 30 43 30 13 43.3 30.2 118.2 2.31
Kwan et al[41], 2017 30 44 30 14 46.7 31.8 100.0 2.14
Obid et al[42], 2020 22 46 19 5 22.72 10.92 41.72 3.8
Lampe et al[43], 2019 24 43 24 19 79.22 44.22 172.72 1.26
2

The values of the % of unplanned surgeries in which all four complications were analyzed in the paper.

Excluded from these tables were papers in which the number of unplanned surgeries was not specified, and were not calculated; some cases referred to final fusion, but it was not specified when, so the total number based on the duration between lengthenings was not possible to estimate.

Unplanned surgeries are due to complications which cannot be resolved conservatively. The total number of complications is much higher. Table 6 presents the total number of complications, the number of patients with a minimum of one complication, the percentage of complications in all patients, the percentage of patients with a minimum of one complication, the number of complications in complicated patients, the complication rate per surgical procedure in percentage terms, and the percentage complications requiring surgical procedures. Some cells in the table are empty because of insufficient data in the corresponding papers.

Table 6.

Number of complications analyzed in extracted papers

Ref.
Subject
Total No. of complications
No. of patients with a minimum of one complication
% of complications in all patients
% of patients with a minimum one complication
No. of complications in complicated patients
Complication rate per surgical procedure (%)
% complications requiring surgical procedures
TGR
Bess et al[15], 2010 140 171 81 122.12 57.92 2.12 19.12 43.32
Du et al[16], 2020 167 49 32 29.32,3 19.23 1.53 nd nd
Andras et al[13], 2015 36 47 29 130.6 80.6 1.6 16.3 61.7
Myung et al[17], 2014 159 64 37 40.3 23.3 1.7 5.9 48.4
Arandi et al[18], 2014 175 146 80 83.4 45.7 1.8 11.7 39.0
Liang et al[19], 2015 55 42 23 76.42 41.82 1.82 15.42 54.82
Ramirez et al[20], 2020 67 92 41 137.3 61.2 2.2 19.9 72.8
Yamaguchi et al[21], 2014 176 44 26 25.0 14.8 1.7
Poe-Kochert et al[22], 2016 100 30 20 30.03 20.03 1.53 19.13 190.0
Kabirian et al[23], 2014 379 70 42 18.5 11.1 1.7 3.0
Johnston et al[25], 2013 27 23 12 85.2 44.4 1.9 12.8
Bachabi et al[11], 2020 50 45 33 90.02 66.02 1.42 9.42
Luhmann et al[14], 2017 18 26 144.4 nd 15.6
Akbarnia et al[10], 2014 12 25 11 208.3 91.7 2.3 34.2
Harris et al[8], 2020 353 264 141 74.8 39.9 1.9 nd 93.2
Helenius et al[9], 2018 214 216 97 100.9 45.3 2.2 11.0 61.6
VEPTR
Bachabi et al[11], 2020 22 26 18 118.2 81.8 1.4 7.9
Crews et al[27], 2018 151 26 22 17.2 14.6 1.2 8.0
Murphy et al[28], 2016 25 41 15 164.0 60.0 2.7 17.7 97.6
Gadepalli et al[26], 2011 26 36 nd 138.5 nd nd 38.9
Berger-Groch et al[29], 2020 13 21 nd 161.5 nd nd 11.5 23.8
Hasler et al[30], 2010 23 31 9 134.82 39.12 3.4 16.62 48.4
Latalski et al[31], 2011 12 15 8 125.02 66.72 1.9 34.12 40.0
Hell, et al[32]. 2005 15 3 3 20.0 20.0 1.0 10.7
Garg et al[33], 2014 103 33 25 32.0 24.3 1.3 nd
Waldhausen et al[34], 2016 65 37 22 56.9 33.8 1.7
Striano et al[35], 2019 166 47 40 28.3 24.1 1.2 7.0 234.0
Lucas et al[36], 2013 54 74 36 137.02 66.72 2.12 40.22 40.5
Garg et al[37], 2016 38 86 226.3 nd 69.8
MCGR
Subramanian et al[38], 2018 31 25 21 80.62 67.72 1.22 47.22 88.0
Urbański et al[39], 2020 47 17 16 36.22 34.02 1.12 28.32 76.5
Akbarnia et al[10], 2014 12 12 4 100.0 33.3 3.0 75.0 33.3
Studer et al[40], 2019 30 12 11 40.0 36.7 1.1 27.9 108.3
Kwan et al[41], 2017 30 15 14 50.0 46.7 1.1 34.1 93.3
Obid et al[42], 2020 22 12 12 54.52 54.52 1.02 26.12 41.7
Lampe et al[43], 2019 24 20 11 83.32 45.8 1.8 46.5 95.0
Haapala et al[12], 2020 18 10 6 55.6 33.3 1.7 20.0
Shilla
Haapala et al[12], 2020 13 5 5 38.5 38.5 1.0 26.3
Andras et al[13], 2015 36 69 29 191.7 80.6 2.4 68.3
Nazareth et al[44], 2020 20 31 15 155.0 75.0 2.1 75.6
Miękisiak et al[45], 2019 57 57 100.02 0.0 69.5
McCarthy et al[46], 2014 10 5 5 50.0 50.0 1.0 33.3
Luhmann et al[14], 2017 18 20 111.1 0.0 35.7
McCarthy et al[47], 2015 40 59 38 147.5 95.0 1.6 54.1
2

The values of the % of unplanned surgeries in which all four complications were analyzed in the paper.

3

Corresponds to the papers in which all patients were after final fusion.

TGR: Traditional growing rods; VEPTR: Vertical expandable prosthetic titanium ribs; MCGR: Magnetically controlled growing rods.

In Table 7 the total number of complications are divided into wound-related, implant-related, alignment, and surgical/medical-related. Only 12 out of 40 papers include analyses of all these types. The paper by Johnston et al[25], 2013, did not differentiate the types of complications, so this reference was excluded from Table 7.

Table 7.

Total number of complications divided into wound-related, implant-related, alignment and surgical/medical related

Ref.
Total No. of complications
Wound complications total/infection
Implant complications mechanical complication
Alignment complications
Surgical or medical complications
n
%
n
%
n
%
n
%
TGR
Bess et al[15], 2010 171 34 20 105 61 10 6 22 13
Du et al[16], 2020 49 19 39 13 27 9 18 8 16
Andras et al[13], 2015 32 24 75 8 25
Myung et al[17], 2014 64 64 100
Arandi et al[18], 2014 146 146 100
Liang et al[19], 2015 42 5 12 25 60 4 10 8 19
Ramirez et al[20], 2020 92 49 53 30 33 13 14
Yamaguchi et al[21], 2014 44 44 100
Poe-Kochert et al[22], 2016 29 16 55 13 45
Kabirian et al[23], 2014 70 70 100
Hosseini et al[24], 2018 134 134 100
Bachabi et al[11], 2020 45 7 16 28 62 2 4 8 18
Luhmann et al[14], 2017 26 9 35 11 42 6 23
Akbarnia et al[10], 2014 25 4 16 13 52 8 32
Harris et al[8], 2020 264 264 100
Helenius et al[9], 2018 216 40 19 127 59 49 23
VEPTR
Bachabi et al[11], 2020 26 9 35 15 58 2 8
Crews et al[27], 2018 26 26 100
Murphy et al[28], 2016 57 16 28 28 49 13 23
Gadepalli et al[26], 2011 25 6 24 3 12 16 64
Berger-Groch et al[29], 2020 24 1 4 2 8 21 88
Hasler et al[30], 2010 31 16 52 7 23 7 23 1 3
Latalski et al[31], 2011 15 1 7 7 47 1 7 6 40
Hell, et al[32], 2005 3 1 33 1 33 1 33
Garg et al[33], 2014 34 34 100
Waldhausen et al[34], 2016 37 12 32 21 57 4 11
Striano et al[35], 2019 47 47 100
Lucas et al[36], 2013 49 11 22 28 57 7 14 3 6
Garg et al[37], 2016 86 86 100
MCGR
Subramanian et al[38], 2018 24 6 25 16 67 1 4 1 4
Urbański et al[39], 2020 16 2 13 8 50 1 6 5 31
Akbarnia et al[10], 2014 12 8 67 4 33
Studer et al[40], 2019 12 3 25 6 50 3 25
Kwan et al[41], 2017 15 2 13 12 80 1 7
Obid et al[42], 2020 12 1 8 3 25 7 58 1 8
Lampe et al[43], 2019 20 3 15 7 35 6 30 4 20
Haapala et al[12], 2020 10 6 60 1 10 3 30
Shilla
Haapala et al[12], 2020 5 1 20 3 60 1 20
Andras et al[13], 2015 56 55 98 1 2
Nazareth et al[44], 2020 31 4 13 26 84 1 3
Miękisiak et al[45], 2019 57 3 5 34 60 10 18 10 18
McCarthy et al[46], 2014 5 2 40 3 60
Luhmann et al[14], 2017 20 6 30 13 65 1 5
McCarthy et al[47], 2015 59 6 10 42 71 11 19

TGR: Traditional growing rods; VEPTR: Vertical expandable prosthetic titanium ribs; MCGR: Magnetically controlled growing rods.

Smith et al[48] published in 2015 a New Classification System to Report Complications in Growing Spine Surgery, and only 4 out of 23 papers published in 2016 used this system (Table 8).

Table 8.

Complication grades according to Smith

Ref.
Total No. of complications
Related to disease
Related to device
Complication grade I
Complication grade II
Complication grade III
Complication grade IV
Complication grade I
Complication grade IIA
Complication grade IIB
Complication grade III
Complication grade IV
Ramirez et al[20], 2020 92 8 8 17 4 4
Murphy et al[28], 2016 57 5 6 2 1 13 8 3 4
Studer et al[40], 2019 12 2 7
Miękisiak et al[45], 2019 57 32 17 8 0

DISCUSSION

Currently there is great interest in the concept of the continued growth of the spine and chest while treating spinal deformity in EOS patients. The risk of complications is inherent in correction surgeries, regardless of etiology. Many studies agree that in the case of neuromuscular scoliosis the probability of a complication is 35%, while for EOS the probability increases to 48%[49]. Watanabe et al[50] identified risk factors for complications in the treatment of early-onset scoliosis using the dual growing rod technique. Postoperative complications occurred after 119 out of 538 procedures (22%) and affected 50 patients (57%). Complications mostly included implant-related failures (72%), and infections (16%). The authors suggested that independent risk factors for postoperative complications included an increase of every 20° in the proximal thoracic Cobb angle, an increase of every 20° in the thoracic kyphosis angle, and 6 or more rod-lengthening procedures. According to Bess et al[15], the patients’ early age when carrying out the index surgery influenced the incidence of complications, but Watanabe did not confirm this. He believed that a patient’s being young at the time of the index surgery significantly reduced the risk of the child’s developing a significant deformity, the degree of which at the start of the treatment significantly affects the risk of its course. However, one should be aware of the inverse relationship between the age of the index surgery and the number of lengthenings in distraction-based methods[4].

Bess, and the Growing Spine Study Group, stated in publications that there was a 24% complication rate each time a growing-rod construct was surgically lengthened, and a 13% decrease in complications for each additional year of age at the time of the initial growing rod implantation[15]. Rod implantation below age 7 years, increasing kyphosis, and more severe major curve magnitude, have been shown to correlate with a higher rate of complications overall[51].

Surgical difficulties, as well as the potentially harmful effect of repeated anesthesia, have led to the adoption of magnetically controlled growing rods, and guided growth systems like Shilla. However, problems with the loss of fixation and failure of the implants in some cases persist[10,47]. Some authors have pointed out an additional problem connected with metal debris which appears in the serum and surrounding tissues[52]. Although it does not directly affect the outcome of the treatment, it is worth considering this occurrence as undesirable/a complication.

The most important issue is that authors define complications in different ways. In Andras et al[13], major complications are defined as any neurological injury and any issue requiring surgery for implant revision or infection. In Ramirez et al[20], complications are defined as any change from the normal postoperative course which occurred from the time of the surgery until the most recent follow-up visit. In McCarthy et al[47], 2015, complications are defined as any problem requiring a return to the operating room, so all returns to the operating room were considered unanticipated. Some authors report major complications and some report the whole range of general complications.

For this study, complications were categorized as wound, implant, alignment, or general [surgical or medical]. Wound problems were classified as either superficial or deep infections, and other wound-related problems, such as painful scars. Implant complications included rod breakage, failure of foundation fixation such as hook or screw pullout, and implant prominence. Alignment complications included junctional kyphosis (proximal or distal), curve progression above or below the instrumented levels, and curve progression after definitive fusion. General complications included, but were not limited to, dural tears, hematomas, and postoperative cardiopulmonary and gastrointestinal complications. Unfortunately, not all authors evaluated all these kinds of complications together – 4 out of 17 in TGR, 3 out of 13 in VEPTR, 4 out of 8 in MCGR, and 1 out of 7 in Shilla. Only 16 out of 44 papers (36%) referred to alignment complication in the evaluation – mostly in MCGR (88%), and conversely to VEPTR (23%). Five papers (11%) (TGR) described only implant-related complications, and 5 only wound-related (4 VEPTR and 1 TGR). The most frequently evaluated set of complications were wound, implant, and medical-related – 13 papers (30% of the papers). The original idea of the paper was to evaluate the number of procedures used to treat complications categorized as either planned or unplanned. Planned procedures were defined as procedures which were scheduled as part of the routine growing-rod-treatment protocol. Unplanned procedures were defined as unscheduled surgical procedures performed to manage a complication. Unfortunately, there was no division into such treatments, so the data were simplified and surgical procedures were classified as planned (implantations, lengthenings, final fusions) and unplanned (revisions). In that case, the number of complications requiring surgical treatment could have been greater, as some of them could have been repaired during the planned lengthening procedure. Only 10 papers (23%) (2 TGR, 3 VEPTR, 4 MAGEC, 1 Shilla) included data with unplanned surgeries, and all described complications concurrently. FF significantly influenced the number of surgeries. Despite the number of patients with FFs being known, there were no data about the time of the FFs – so estimated data based on the mean follow-up times and durations between lengthening procedures were understated. Deleting these references from the statements in question leaves 6 papers with no TGR patients. Adding Smith's classification for evaluation as a criterion further reduces the number of papers to only one. That is why the analysis had to be simplified.

TGRs constitute the most commonly applied technique, and are considered the gold standard for EOS with long curves[53]. In the reviewed papers, the complication rate per patient of the growing rod technique was very high and ranged from 19% to 208% (median 84%). Interestingly, Akbarnia et al[10], presented a complication rate of 208% (wound, implant-related and medical) in only 12 patients, whereas the rate for deep infections was 19% in 379 cases[23]. Comparing only implant-related complications, this parameter varied from 25%[21] to 40%[17], to 83%[18] – the authors analyzed a similar group of approximately 160 patients. The complication rate per surgical procedure varied from 3% to 34% (median 15%). There were two complications in complication-affected patients. In the analyzed papers, an average of 946 surgical procedures were performed. The incidence of unplanned surgeries in all patients varied from 19% to 144% (median 53%). The percentage of unplanned surgeries for all surgeries was 8% (3%-36%). The ratio of planned to unplanned surgeries was 11.6% (1.8%-33.9%). The most frequent complications were implant-related (61%) and wound-related (27%), while medical complications and alignments accounted for 19% and 8%, respectively. The most concerning problem related to TGRs is the high complication rate. The risks for implant failure, infections, and wound healing problems are significantly increased as a consequence of the repeated lengthening procedures and an unfused spine. If rod breakage or screw displacement occurs, revision surgeries are indicated to change the rod or extend the instrumented segments. Additionally, repeated general anesthesia can pose a threat to mental health. Adequate informed consent and close follow-ups are necessary.

VEPTR was developed for patients with thoracic insufficiency syndrome (TIS), but it is sometimes indicated for individuals with EOS who are at risk of secondary TIS[54,55]. The complication rate per patient was as high as 125% (17%-226%) with a 9% rate per surgical procedure (7%-18%). Such a discrepancy is very confusing. Garg et al[37] identified only wound complications following VEPTR implant or revision surgeries. If so, adding implant, alignment, and medical-related complications, the final percentage of complications should be expected at a much higher level. On the other hand, Crews et al[27] analyzed wound, implant, and general complications at the level of 17%. The most frequent complications were implant-related 48%, and wound-related 33%, while medical complications and alignments accounted for 23% and 11%. respectively. which limits their applications. In the analyzed papers, an average of 251 surgical procedures were performed. The percentage of unplanned surgeries in all patients varied from 39% to 160% (median 60%). The percentage of unplanned surgeries to all surgeries was 14% (3%-17%). The proportion of planned to unplanned surgeries was 6% (4.7%-35.6%).

MCGRs were introduced by Takaso et al[56] in 1998 as remote-controlled growing-rod spinal instrumentation. The system did not require open lengthening as TGRs did, and the effect could instead be achieved by external remote control without repeated anesthesia. The complication rate of the magnetically controlled growing rod technique per patient varied from 36% to 100% (median 55%). In this group of patients, the distribution of complications is fairly homogeneous. Only Akbarnia et al[10] described such a high level of complications while omitting wound-related and alignment problems. The complication rate per surgical procedure varied from 20% to 75% (median 31%). In the analyzed papers, an average of 44 surgical procedures were performed. The percentage of unplanned surgeries in all patients varied from 23% to 79% (median 43%). The percentage of unplanned surgeries in all surgeries was 30% (11%-34%). The ratio of planned to unplanned surgeries was 2.3 (1.3-3.8). The most frequently occurring complication was implant-related – 55%, then general (25%), wound (14%), and alignment (10%). La Rosa et al[57] stated that MCGRs can prevent surgical scarring, surgical site infections, and psychological distress, which occur in patients with TGRs and VEPTR due to the multiple surgeries. The decreased rate of infections and wound healing problems in patients who received MCGRs is of great benefit to patients. However, Aslan et al[58] used psychosocial tools to compare the mental state of patients receiving MCGRs and TGRs. He affirmed that if the patient noticed benefit from the growing rods, and did not experience major complications, the non-invasiveness of the lengthening procedures did not show an advantage on the patients’ psychosocial state. Besides, although MCGRs were associated with a lower rate of infections [both deep and superficial], they were associated with a significantly increased risk of metalwork problems and unplanned revisions[59].

The Shilla technique guides spinal growth towards a normal alignment[60]. The technique first corrects the apical deformity towards a neutral alignment. Then the upper and lower growth guidance portions extend into the distal and proximal areas of the curve, using special screws and caps, allowing the rod to slide with growth in a longitudinal direction. Multiple open lengthening surgeries are avoided, as in MCGRs. The complication rate was as high as 111% of the patients (39%-192%), and the complication rate per surgical procedure was 54%. Haapala et al[12] showed the fewest complications – 39%. The remaining authors assessed the number of complications at a similar level. The most frequently appearing complications were implant-related (65%). Wound-related and alignment problems were 16% and 18%, respectively. General complications were only 5%. The percentage of unplanned surgeries in all patients varied from 15% to 181% (median 105%). The percentage of unplanned surgeries to all surgeries was 33% (11%-64%). The ratio of planned to unplanned surgeries was 1.8 (0.6-8.5). Luhmann et al[14] found that the Shilla growth guidance system compared favorably with TGRs in terms of the degree of correction of the major curve, spinal length, and growth, and the maintenance of the sagittal alignment. Looking at these data the benefits are not so obvious. Similar to MCGR and TGR, the SGGS is associated with a very high rate of implant-related complications, which usually results in revision surgery. Additionally, for patients with great growth potential, the distal and proximal screws can slide off the rod, requiring the rods to be changed.

EOS surgery has a varying but high rate of complications. Based on this review of 40 papers, 3249 cases, and 15037 surgical procedures, the most-frequent implant complications (total 54%), the general, wound, and alignment were 17%, 15%, and 12%, respectively. These data are simplified and certainly underestimated, because of the reasons described earlier. The rate of complications might have been higher than reported, as some authors did not report every type of complication. Due to complications, 54% of the patients required unplanned surgeries, which equated to 15% of all surgeries.

The long-term risks of EOS surgery have not yet been reported on in research. There is a lack of papers with homogenous cases, long-term follow-up, all revision surgeries, and complication data.

One would expect that successful treatment which encourages the growth of the spine and chest would lead to favorable outcomes in patients with early-onset idiopathic scoliosis. But it is not unambiguous with patients with, e.g., progressive neuromuscular conditions such as congenital muscular dystrophies and spinal muscular atrophy. Surgery can effect spinal growth with expandable instrumentation, but worsening muscle weakness can negate the positive effects of growth-friendly procedures[2]. Tsirikos et al[61] showed that the life expectancy of patients with cerebral palsy and other neurogenic deformities subjected to deformation correction does not change, but only an additional source of data such as the number of days in the intensive care unit after surgery, and the presence of severe preoperative thoracic hyperkyphosis, were the only factors affecting survival rates.

As highlighted by Hawes[62], the complexity of spinal surgery is reflected in the diversity of complications which might occur months or even years later. Given the time delay and difficulty in diagnosis, it is likely that some of the events are not recognized as surgical complications. Therefore, clear uniformity of definitions and the carefulness of the surgeon are important in assessing patient follow-up and treatment outcomes.

CONCLUSION

The literature concerning the definitions, collection, and interpretation of data regarding EOS surgery complications is often difficult to interpret. This causes problems in the comparison, analysis, and improvement of spine surgery practice. Additionally, this observation indicates that data on the incidence of complications can be underestimated and should be interpreted with caution. Awareness of the high rate of complications of EOS surgery is crucial, and an optimal strategy for prevention should become a priority.

ARTICLE HIGHLIGHTS

Research background

The treatment for early-onset scoliosis (EOS) remains a great challenge for pediatric orthopedics. The treatment goals for EOS, regardless of the diagnosis, are the same: minimizing spinal deformity while maximizing thoracic volume and pulmonary function. When conservative treatment is ineffective, the option is surgery.

Research motivation

Different surgical techniques have different advantages and drawbacks. Those most often used are traditional growing rods (TGR), vertical expandable prosthetic titanium ribs (VEPTR), magnetically controlled growing rods (MCGR), and the Shilla growth guidance system (SGGS). Repeated surgeries and complications are two major concerns in EOS management.

Research objectives

The aim of the study was to review the current literature to assess the safety of EOS surgical treatment in terms of the rate of complications and unplanned surgeries.

Research methods

The systematic review was conducted according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. In January 2021, a search of three electronic medical databases (PubMed, the Cochrane Library, and Embase) was performed by three independent authors. We combined the terms: “early-onset scoliosis” OR “eos” OR “juvenile scoliosis” OR “infantile scoliosis” OR “tgr” OR “veptr” OR “MCGR” OR “Shilla” OR “growth-friendly” AND “complication”.

Research results

EOS surgery has a varying but high rate of complications. The most frequent complications were categorized as implant, general, wound and alignment. The rate of complications might have been even higher than reported, as some authors do not report all types of complications.

Research conclusions

The literature concerning the definitions, collection, and interpretation of data regarding EOS surgery complications is often difficult to interpret. This creates problems in the comparison, analysis, and improvement of spine surgery practice. Awareness of the high rate of complications of EOS surgery is crucial, and an optimal strategy for prevention should become a priority.

Research perspectives

This observation indicates that data on the incidence of complications can be underestimated, and should be interpreted with caution. Further studies are needed to confirm the study results, especially concerning longitudinal data.

Footnotes

Conflict-of-interest statement: The authors declare that there is no conflict of interest.

PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.

Manuscript source: Invited manuscript

Corresponding Author's Membership in Professional Societies: European Paediatric Orthopaedic Society; Eurospine.

Peer-review started: February 25, 2021

First decision: March 31, 2021

Article in press: August 2, 2021

Specialty type: Orthopedics

Country/Territory of origin: Poland

Peer-review report’s scientific quality classification

Grade A (Excellent): A

Grade B (Very good): 0

Grade C (Good): 0

Grade D (Fair): 0

Grade E (Poor): 0

P-Reviewer: Liu HQ S-Editor: Wang JL L-Editor: A P-Editor: Li JH

Contributor Information

Michał Latalski, Children Orthopaedic Department, Medical University of Lublin, Lublin 20-093, Poland. michallatalski@umlub.pl.

Marek Fatyga, Children Orthopaedic Department, University Hospital for Children, Lublin 20-093, Poland.

Ireneusz Sowa, Department of Analytical Chemistry, Medical University of Lublin, Lublin 20-093, Poland.

Magdalena Wojciak, Department of Analytical Chemistry, Medical University of Lublin, Lublin 20-093, Poland.

Grzegorz Starobrat, Children Orthopaedic Department, University Hospital for Children, Lublin 20-093, Poland.

Anna Danielewicz, Children Orthopaedic Department, Medical University of Lublin, Lublin 20-093, Poland.

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