Safety and Outcome in the Surgery of Adolescent Idiopathic Scoliosis

The goal of surgery in adolescent idiopathic scoliosis (AIS) is to achieve the desired outcome with utmost safety. This review article will discuss safety in AIS surgery and the expected outcome of the surgery. Safety in surgery is to avoid our most feared complication of neurologic deficit while also mitigating the likelihood of having a subsequent infection, pseudoarthrosis, or implant failure. SRS morbidity and mortality data over last 40 years showed that, the incidence of new neurologic deficits has remained fairly consistent below 1% and when cord deficits occur, the likelihood of some recovery is very high with a relatively high probability of complete recovery. Safe surgery starts long before surgery itself; appropriate history, physical examination, radiographic interpretation and appropriate investigation, all will lead to a safer surgical procedure. Detailed open and transparent discussion with the family is mandatory. Maintaining intraoperative neurologic safety begins with the skin incision and ends when the patient awakens. Continuous Intraoperative neuromonitoring (IONM), appropriate screws placement, carefully performed osteotomies, and correction maneuvers, all are major contributing factors to the safety of surgery in AIS. Should intraoperative monitoring change, surgeon should follow a well-planned algorithm for managing potential neurologic complication. Surgical complications can't be eliminated but better appropriate preparation and timely response can significantly decrease complications incidence. Patients, parents and surgeons generally desire similar outcomes for the surgical correction of AIS, yet their priorities of outcome may differ. The expectations are: The patient will survive the surgery, the patient will have normal neurologic function (assuming normal preoperative—AIS), the correction will be lasting without need for additional procedure, the patient will have pain free “normal” function, and the patient's body/trunk shape will be “norma.” Patients' perception of the outcome can be reliably charted through the validated outcome instruments (SRS24, SRS22, SRS22r). Modern techniques and implants improve the outcome through significant reduction in the incidence of further surgery and pseudoarthrosis. Opinions are differ on fusion and instrumentation levels but the goal is to have best correction and a balanced trunk. Quantification of process measures is also valuable in assessing functional outcome (eg, pulmonary function testing, spinal motion studies and radiographic measurements). The outcome of truncal appearance and spinal balance will be better evaluated in the future with 3D imaging. Surgeons must use all available data combined with thoughtful assessment of the risk and benefits to be able seek the best outcome for the patients with adolescent idiopathic scoliosis.