Perioperative neurologic injury associated with rib-based distraction surgery

Study Design Retrospective, comparative case series from the study group database.

Objectives The primary objective was to report the neurologic injury rate for rib-based distraction surgery and determine whether preoperative diagnosis affects this rate. The secondary objective was to describe these injuries and outcome.

Summary of Background Data Posterior distraction-based systems are commonly used to treat early-onset scoliosis. General complication rates for these surgeries are high; however, there are few reports in the literature on neurologic injury after rib-based distraction surgery.

Methods This was a retrospective review of the Children's Spine Study Group database from 2004 to 2013. The researchers used the chi-square test to compare the distributions of proportions between diagnoses.

Results A total of 524 patients were identified and treated with rib-based distraction surgery. The preoperative diagnoses consisted of 222 congenital/structural, 163 neuromuscular, 63 syndromic, 67 idiopathic, and 9 unknown. There were 9 neurologic injuries (7 clinical and 2 neuromonitoring alerts) for a neurologic injury rate of 1.7%. Using the Classification for Early-Onset Scoliosis, 8 patients were classified as congenital and 1 as neuromuscular. The neurologic injury rate in the congenital curves group was 3.6% and was 0.34% in non-congenital curves (p =.005). The proportion of injured patients with an additional secondary diagnosis was 3.82%, compared with 0.82% patients with only a primary diagnosis (p =.01). Eight injuries occurred at initial implantation and 1 at revision surgery. Most were brachial plexus (n = 5) with no complete spinal cord injuries. Four patients required return to surgery and 1 needed intraoperative intervention. At 4.2 years' follow-up, 7 of 9 patients had full resolution of symptoms and 2 patients had residual upper extremity weakness.

Conclusions The rate of neurologic injury for patients treated with rib-based distraction surgery was 1.7%. Most injuries occurred with congenital diagnoses and they were more likely in patients with additional secondary diagnoses. These injuries were predominantly to the brachial plexus and generally resolved.