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Although a multitude of optionsexistfor the management of osteoporosis, only one
anabolictherapyexists,teriparatide(Forteo,EliLilly,Indianapolis,IN).
8
Teriparatideisa
recombinant form of a portion of the parathyroid hormone (PTH). Although PTH
increases osteoclastic activity, via osteoblast signaling, pulsatile administration of
teriparatideincreasesosteoblasticactivitytoagreaterdegree,increasingbone formation.
Anadverseeffectofteriparatideobservedinanimalmodelswasosteosarcomaformation,
however,and patients with risk factors for osteosarcoma, including Paget’s diseaseand
priorradiationtherapy,should avoidteriparatideexposure.Incasesof acontraindication
to teriparatide,we often employ denosumab,a monoclonal antibodythatbinds receptor
activator of nuclear-κB (RANK) ligand (RANKL). The binding of RANKL prevents
RANK activations,thereby suppressing osteoclastactivation. This isan “anti-catabolic”
mechanism of osteoporosis management, however, similar to bisphosphonates. Both
denosumabandbisphosphonatesdelaycallusmaturationinfracturemodels,whichlikely
behave similarly to a fusion model, but there is no human evidence to support a
correlation between exposure to these anti-catabolic medications and pseudarthrosis.
8
Nonetheless, we attempt to avoid bisphosphonate exposure early in the spine fusion
process,asthereareanimaldatatosupportanegativeeffectofbisphosphonates.Thereis
some evidence,however, thata combination of teriparatide andbisphosphonate therapy
may be ideal to maximize callus formation and rigidity, with early teriparatide
administrationfollowedbyconversiontobisphosphonatetherapy.
Surgical techniques may play a role in instrumenting the osteoporotic spine as well.
Speciallydesigned screwthreads havebeen shownto increaseinsertional torque,which
maybenefitthedurabilityofaconstructinosteoporoticbone.Hydroxyapatitecoatinghas
also been shown to increase screw purchase. As the pedicle is often patulous in the
osteoporoticspine,onemay choosetoavoidtappingthechannel ofthepediclescrew.If
tappingisperformed,itshouldundersizetheanticipatedscrewdiameterby1mmormore.
Screw diameters should be maximized, at least 70% of pedicle diameter, to ensure an
appropriateinterferencefitwithinthepedicle.Screwlengthshouldbemaximizedand,in
extremecases,onemaychoosetotaptheanteriorcortexandachievebicorticalpurchase
of the screw, as this will significantly improve pullout strength. One should attempt to
leavethedorsalcortexintactaswell,asthismayminimizescrewtogglingandloosening.
Implantmaterials areamatter ofpreference andare debatedamong spinaldeformity
surgeons.Weprefertouse5.5-mmcobalt-chromium(Co-Cr)rodsincasesofdegenerative
scoliosiswithpoorbonequality.Inlarger,stifferreconstructions,wecommonlyusea6.0-
mmCo-Crrodonthe“workingside,”andplacea5.5-mmCo-Cronthecontralateralside.
Somesurgeonsprefercommerciallypuretitaniumrods,whichareabitlessstiffthanCo-
Cr,believingthat thiswillstress thebone–implantinterface less,thereby decreasingthe
incidence of adjacent segment problems. Conversely, some surgeons prefer 6.35-mm
stainless steel (SS) rods, believing this is the most durable metal for spinal deformity
surgery.Inaseriesofspinaldeformitypatients,implantfracturewaslesscommonamong
thosefixedwithCo-Crrods.
9
Incasesofthree-columnosteotomy(i.e.,pediclesubtraction
osteotomy, vertebral column resection), dominoes are used to span the osteotomylevel
withmorethantworods,increasingtherigidityoftheconstructattheosteotomysiteand
decreasingmicromotion. In anycase, securefixation, withaccurate screwplacement,is
required along the length of the deformity. This increases the rigidity of the construct,
decreasingnonunionrates.Weperformhigh-densityinstrumentation(1.8screws/level)in
thevastmajority ofASD surgeries.Although thisissue is debatedregarding adolescent
idiopathicscoliosis,wefeelstronglythathigh-densityinstrumentationisneededinASD.
Inall cases instrumentedto S1,we placedistal supportingscrews, oftenS2-alar-iliac
(S2AI)oriliacscrews.
10
IliacscrewsdistaltoS1decreasestrainonS1fixationinflexion,
minimizingmicromotionatthelumbosacraljunction.S2AIscrewshavebeenproposedas
analternativetoiliacscrews,withamoreventralstartingpointand“in-line”tulipheads,
facilitating rod placement. Midterm results of S2AI screws are encouraging, and we
employthistechniquefrequently.AthirdoptionfordistalfixationisS2-alarscrews.These
screwsoffersupporttoS1pullout,withoutcrossingorimmobilizingthesacroiliacjoint.If
onechoosestousethismethod,attentionmustbepaidtothecourseoftheL5root,as it
courses over the front of the sacral ala. Bone graft materials should consist of locally
obtainedautograft,allograft,andiliaccrestbonegraft(ICBG)orrbBMP-2.Weroutinely
usefresh-frozencancellousallograft,asitsosteoinductivepropertiesarelikelybetterthan
thoseofcorticalchips.Inlongfusions,inadequatevolumesofICBGmayindicatetheuse
of rh-BMP2 in an off-label fashion. We have shown this to be an effective method of
improving fusion rates. We neither use nor advocate other so-called osteobiologic
products, as the evidence to support their use is weak. The dorsal elements should be
decorticated,usinggaugesorburs,tofreshbleedingbone.Bleedingboneisarequisitefor
competitivefusion rates.Ifusing morethan tworodsor cross-links,they arefixedafter
bonegraftplacement,tominimizedisruptionandinterferencewithcontiguousgrafting.
Inthevastmajorityofcases,thediagnosisofpseudarthrosisismadewiththepresence
oflooseor fracturedimplants.Weintervenewhenthere isaprogressionofdeformity or
pain.Intheabsenceofprogression,weoftenobserveunilateralrodfractures.Whenboth
rodshavefractured,weusuallyrecommendrevisionsurgery.Inasmallnumberofcases,a
pseudarthrosismaypresentassymptomsconsistentwithneuralelementcompression(e.g.,
radiculopathy, claudication) due to scar tissue/fibrous callus accumulation (Fig. 11.3).
Computedtomography(CT),withfinecutsandmetalsubtraction,isthepreferredimaging
modalityfordiagnosingpseudarthrosis.
11
Flexion/extension radiographshavebeen used,
thoughtheyarenotassensitiveasCTscanning.
Management of pseudarthrosis consists of revision surgery. The use of rh-BMP2 in
posterolateral fusion revisions has received Food and Drug Administration (FDA)
approval. When revising a pseudarthrosis case, inspection of the entire fusion mass is
recommended, as one pseudarthrosis may beget another.
12
In our experience, most
pseudarthrosispresentsatL5-S1,L4-L5,andatthethoracolumbarjunction,inthatorder.
Revision surgery often consists of anterior column support, if not already done, in the
formofaTLIF,ALIF,ortranspsoasinterbodyfusion.Optionsfor graftmaterialinclude
titanium,polyetheretherketone(PEEK),andallograft.Ourpreferenceistousetitanium,as
itbondstobone,increasingthestabilityoftheconstructandlikelyimprovingfusionrates.
The pseudarthrosis tissue should be debrided, as these tissues are unable to undergo
mineralization and must be removed to achieve union. In the lumbar spine, we often
perform a posterior column osteotomy through the pseudarthrosis tissue and compress
through the pseudarthrosis. In addition to encouraging fusion by exposure of bleeding
cancellous bone, the osteotomyaids in restoration of lordosis, taking tension offof the
fusion mass and promoting compression at the pseudarthrosis level. If rh-BMP2 is not
used, we use autogenous iliac crest graft, as the biologic activity of allograft is not
sufficient to create a competitive environment for fusion in the setting of a previous
pseudarthrosis.Forcasesoflumbosacraljunctionpseudarthrosis,weensurethatwehave
adequatedistalfixation, consistingofpedicle screwsatthefirstsacralvertebraand iliac
screws below that. In the case of patulous, eroded S1 pedicles, we place multiple iliac
screwsoneachside.
Fig.11.3A61-year-oldmanpresentedwithasagittalplanemalalignmentandL4radiculopathyduetopseudarthrosis.
Notethevacuumdiskwithintheinstrumentedlevels,indicativeofapseudarthrosis.
The postoperative routine is unchanged in the management of pseudarthrosis. No
bracing is used and the patients are mobilized on postoperative day 1. Strict activity
precautions are established, however, and patients are instructed on how to safely rise
frombedandaregivenafront-wheeledwalkertousefor6weekstoencourageanupright
posture, discouraging flexion through the revision fusion mass. Teriparatide therapy is
continuedforaminimumof3monthsaftersurgery.WedonotperformCTscanningfor
evaluation of fusion masses,as the exposure to radiation is excessive, andfindings are
unlikelytoaffectourmanagementofthepatient.
Careful attention to detail in preoperative planning, intraoperative performance, and
postoperative rehabilitation helps surgeons minimize pseudarthrosis in their practice.
Smoking cessation is absolutely mandatory to ensure competitive results. Appropriate
choicesofbiologicsandinstrumentationhelpincreasefusionrates.However,anonunion
rate of 0% is not realistic, and the informed decision-making process should include
discussionoftheriskofreoperationfornonunioninASDsurgery.
Infection
Perioperative surgical-site infection (SSI) is a significant cause of morbidity in ASD
surgery, with reported rates ranging from 0.3% to 20%.
1,2,13
These rates include both
superficialanddeepwoundinfections;thetreatmentsandimplicationsforeachdiffer.In
manyinstances, asuperficialinfection canbemanaged onanoutpatient basis,withoral
antibioticsalone.Conversely,adeepwoundinfectionisacatastrophe,nearlyuniversally
managed with rehospitalization, revision surgery, and prolonged intravenous antibiotics
followedbyoralantibiotics.
A review of the Scoliosis Research Society (SRS) Morbidity and Mortality database
revealedanoverallinfectionrateof2.1%incasesperformedbyparticipatingmembers.
13
This cohort included a heterogeneous mix of procedures, including noninstrumented
degenerative lumbar surgeries, in addition to instrumented ASD procedures. Not
surprisingly, less extensive surgeries, including lumbar diskectomies and minimally
invasiveTLIFprocedureswereassociatedwithlowerratesofinfection.Thosecasesthat
were associated with instrumented spinal fusions had higher rates of infection.
Neuromuscular scoliosis (14%) and postlaminectomy kyphosis (5.1%) had the highest
ratesofpostoperativewoundinfection.Revisionsurgeriesweremorecommonlyaffected
byinfections(3.3%vs2.0%),anddeepinfectionsweremorecommoninthissituationas
well.
Although the SRS database provides good epidemiological data regarding rates of
infections,itdoesnotprovidethegranulardatathatallowforfinerconclusionsregarding
postoperativeinfectionsintheASDpopulation.Severalsmallerserieshavereviewedthe
rates of reoperation for patients undergoing ASD reconstructions. Pichelmann et al
1
publishedourgroup’sexperiencewithprimaryASDsurgeries,notingarateofreoperation
forinfectionof1.4%andaccountingfor15.5%ofrevisionsurgeries.Onemustnotethat
thisrateis likelylowerthanthe truevalue,as superficialinfectionsareunlikely tohave
undergone reoperation. As a follow-up study, we reviewed the rates of unanticipated
reoperation for revision ASD procedures, noting infection in 14% of revision surgeries
performed.
2
Theseratesaresimilartothosepresentedbyothers,withinfectionaccounting
for15%ofrevisionsurgeriesinASD.
3
Adultspinaldeformitysurgeriesareathigherriskforperioperativeinfectionthanother
orthopedic or neurologic surgeries because of the long duration, high estimated blood
losses, large surface areas, and extensive use of implants. It stands to reason that the
longera wound isexposed toair,the more likelysome contaminationmay occur.High
estimated blood losses are often associated with the need for perioperative allogeneic
transfusions. Although allogeneic transfusions are associated with major complications,
such as transfusion-related acute lung injury (TRALI), more common are perioperative
infections, includingSSI, urinary tract infections,and respiratory tractinfections.
14
The
exposuretoallogeneicbloodandproteinsisassociatedwithanimmunomodulatoryeffect
that may depress the immune response to pathogens, making the patient susceptible to
SSI. This relationship has been shown in less extensive lumbar degenerative fusion
proceduresandthesameislikelytrueinASD.
Implants render patients susceptible to deep wound infections, as there is a race
between nativecells and bacteriato the implantsurface. Bacteria forma glycocalyx on
implants,whichhelpsthemadheretothesurface.The glycocalyx“protects” thebacteria
from antibiotics, duetopoor penetrance by antibiotics, and also decreases thevalue of
woundculture,asbacteriabecomeadherenttotheglycocalyxandarenoteasilyshedinto
the wound bed. There is evidence that titanium and cobalt chromium implants are less
susceptible toglycocalyx formation than stainlesssteel. Our preference isto use Co-Cr
rodsfortheirmaterialpropertiesinASD.
PatientdemographicscertainlyhelpidentifythoseatriskfordevelopingSSI.Thus,as
withpseudarthrosis,itisimperativethatthesepatientsareidentifiedandthatappropriate
stepsaretakentominimizetheriskofSSI.Acomprehensivereviewofpatientstreatedat
our institution, with an overall deep infection rate of 2.0%, found that a concomitant
diagnosis of diabetes had the strongest association with a perioperative infection (odds
ratio[OR],3.5).
15
Theimportanceofcontrolledbloodglucoselevelswasemphasized,as
evenpatientswithoutadiagnosisofdiabetesbutwithepisodesofhyperglycemiashowed
a higherrate ofinfection. These findingswere later supportedby Richards etal,
16
who
foundanincreasedrate ofinfectioninorthopedictraumapatientswithpoorlycontrolled
perioperative blood glucose levels. Obesity (body mass index 30–35 kg/m
2
) was also
associatedwithanincreasedriskofinfection(OR,2/2).
Preincision antibiotic prophylaxis is mandatory,and antibiotics must be given at the
appropriatetime. Wehave showna 3.4-foldincreased riskof infectionin thosepatients
whodidnotreceiveintravenouscefazolinwithin1hourofincision.Inastudyofpediatric
spinaldeformitysurgeries,Milstoneetal
17
foundasimilarrelationshipbetweeninfections
andinappropriateantibioticadministrationtiming.Thechoiceofprophylacticantibiotics
mayvarybyinstitution,butitshould consistofanantibioticwithbroad-spectrumgram-
positivecoverageof commonskinflora.At ourinstitution,prophylaxisisprovided with
cefazolin and vancomycin. In the case of penicillin or cephalosporin allergy, we use
aztreonam.Bothantibioticsaregivenwithin1houroftheskinincision,withvancomycin
startedearliertoprovideanappropriaterateofadministrationandtominimizetheriskof
red man syndrome. During surgery, we re-dose antibiotics at half the time of normal
administration. For example, cefazolin is given every 4 hours, as it is normally given
every8hours.
Intra-site antibiotics, commonly in the form of lyophilized vancomycin powder,
administered atthe time of wound closureare becoming increasingly common. Several
retrospective analyses have shown decreased rates of SSI with the institution of this
technique. Sweet et al
18
published the first report on this method, noting a decreased
prevalence from 2.6% to 0.2% with the use of intra-site vancomycin in adult spine
patients. Thisbenefit has been supportedby several otherstudiesin adult andpediatric
spinesurgeries.Therehavebeennocomplicationsdefinitivelylinkedtothe useofintra-
sitevancomycinpowder,thoughthereareconcernsaboutpseudarthrosis,anaphylaxis,and
“super-infection.”Vancomycinis acidicand changestheenvironment withinthe wound
bed,thoughnoeffectonunionrateshasbeenobserved.Vancomycinpowderiseffective
in eliminatinggram-positive contaminants, butsomeconcern over anincrease in gram-
negativeandpolymicrobialinfectionsexists.Asinglerandomizedcontrolledtrialdidnot
support the effectiveness of lyophilized vancomycin powder.
19
Nonetheless, our
experiencemirrorsthoseofothers,andwecontinuetoemploythispractice.
Weplacebothsuperficialanddeepdrainsatthetimeofwoundclosure.Thereislimited
but not strong evidence supporting their use in spinal deformity surgery. Blank et al
20
performed a randomized trial of surgical drains in patients undergoing surgery for
adolescent idiopathic scoliosis. They found increased rates of wound drainage in those
patientstreatedwithoutadrain.Thestudywasunderpoweredandthuscouldnotdetecta
differenceininfectionrates,however.Itstandstoreasonthatanadequatelypoweredstudy
wouldsupportadecreasedrateofpostoperativeinfectionwithdecreasedwounddrainage.
Postoperative drains have been associated with increased rates of perioperative blood
transfusions,andthismustbebalancedwiththepotentialbenefitofwounddrainage.
Diagnosis of spine infections can often be made with a history and physical
examination.Fevers and chillsas wellas lethargy/malaiseare common—theformer are
morefrequentwith acuteinfections,and thelatteraremorecommonwithchronic, deep
infections.In thecaseof acuteinfections, somemayshow wounderythema, fluctuance,
andwounddrainage.Thesesignsarenotubiquitous,however,andtheclinicianmusthave
somelevelofsuspicion.Inchronicinfections,asmalldrainingsinusiscommon,oranew
and enlarging fluctuant mass may be present. Upon presentation, one should draw a
complete blood count and serum C-reactive protein (CRP). We have found CRP to be
more useful than the erythrocyte sedimentation rate (ESR) in diagnosing postoperative
infections. In the immediate postoperative period, the half-life of CRP is ~ 2.5 days,
whereasthe kinetics ofESR areof littleutility.Imaging ofthe spineshould beginwith
plainradiographs,whichmay showevidenceofscrewloosening, withhalos,incasesof
chronic infection (Fig. 11.4). Following plain radiographs, CT or magnetic resonance
imaging are of limited utility, as a seroma forms in all cases, regardless of bacterial
contamination.Aspirationofaseromaandfluidanalysismaybeperformedwhenthereis
uncertaintyregardingthepresenceofaninfection.Physiciansuspicionandconcernshould
drivethedecisiontointerveneforasuspectedinfection.
Fig.11.4An11-year-oldgirlwithneuromuscularscoliosispresentedwithpain11monthsafterposteriorspinalfusion.
Explorationrevealedadeepwoundinfection.Notethelucencies(arrows)surroundingthemidthoracicpediclescrews.
Managementofasuperficialinfectionisoftensuccessfulwithantibioticsalone,asthis
is usually a cellulitis related to the surgical wound. Acute, deep wound infections are
treatedaggressivelyinourpractice.Thestandardofcareisirrigationanddebridement.In
thewound isgrosslycontaminated,wemay removeloosegraft. Inthe absenceofgross
contamination, graft and implants are retained. Effort should be made to achieve good
decontaminationofthewound,sothatimplantscanbe retained.Although theirpresence
asaforeignbodymightconcernsurgeons,theinstabilitycausedbyimplantremovalwill
make eradication of the infection more difficult. If there is any question regarding the
levelofcontaminationofthewound,weplaceawoundvacuum-assistedclosure(WVAC)
dressing and return to the operating room in 72 hours for repeat irrigation and
debridement, with possible WVAC change versus delayed primary closure. A chronic,
delayeddeepwound infectionis treated differently, however. Theseinfections are more
commonly associated with less virulent bacteria, such as Propionibacterium acnes or
Staphylococcusepidermidis. As these bacteria are less virulent, and grow more slowly,
intraoperativeculturesshouldbetakenandincubatedforalongerperiodthannormal,14
to28 days. Incases ofchronic, delayed infection,we removeimplants andconfirm the
arthrodesisandtheabsenceofpseudarthrosis.Patientsarefollowedforevidenceofcurve
progressionorpseudarthrosisinfollow-upandarere-instrumentedonlywhenneededfor
deformityprogression.
Whensuccessfullytreated,patientswithdeepwoundinfectionfollowingASDsurgery
can expect good outcomes, equivalent to those of patients who did not encounter this
complication.
21
ChapterSummary
Pseudarthrosisandinfectionaretwocommonreasonsforrevisionsurgeryinadultspinal
deformity. Both of these pathologies have risk factors that are modifiable by both the
patientandthesurgeon.NicotineavoidanceismandatoryinASD,giventhealreadyhigh
rate of perioperative complications associated with these surgeries. Evaluation of bone
health,withbonemineraldensitytesting,andtreatmentofosteoporosisshouldberoutine.
Appropriate management of diabetes mellitus, including tight control of perioperative
blood glucose levels, will help minimize risks of perioperative infection. Antibiotic
prophylaxis should be given within an hour of incision and be tailored to prophylaxis
againstcommonflorainthecommunity.
As techniques evolve, with concomitant improvements in implants and biologic
therapies,theratesofthesetwocomplicationswillfall.Ultimately,meticulousattentionto
detail before, during, and after surgery will maximize the likelihood of success and
minimizecomplicationsinthesepatients.
Pearls
Smokingcessationisnecessaryinadultspinaldeformitysurgery.
Evaluation for osteoporosis, withbone mineral density testing, and appropriate pharmacological intervention
shouldbeperformedinASDpatients.
Teriparatide is an anabolic agent available for management of osteoporosis and may have some benefit in
achievingarthrodesis.
Facetectomiesmustbeperformed,anddecorticationofdorsalelementsisnecessary.
Recombinanthumanbonemorphogeneticprotein-2decreasesratesofreoperationforpseudarthrosisinASD.
Informed consent specifically tailored to the use of rh-BMP2 in both on-label and off-label applications
(addressingrisksofpain,seroma,ectopicbone,andpotentialformalignancy)shouldbesoughtfromthepatient.
IliacorS2-alar-iliacscrewsshouldbeplacedroutinely,whenfusingtoS1.
High-density(≥1.8screws/level)constructsarerecommendedinASD.
Patient factors associated with surgical-site infections in ASD include high body mass index and poorly
controlleddiabetesmellitus.
Prophylactic,intravenousantibioticsmustbeadministeredwithin1hourofincision.
Prophylactic,intra-site,lyophilizedvancomycinpowdermaydecreaseratesofsurgical-siteinfection.
Aggressive managementofacute, deepwoundinfectionsofferspatientsachanceforequivalentoutcomesonce
thecomplicationhasresolved.
Pitfalls
Nicotine exposure increasesratesofpseudarthrosis. One must resistthedesire to operate onpatientswho are
usingnicotineproductsandinsistthattheybecompliantwithsmokingcessationpriortosurgery.
Implantsand osteobiologics do not compensate for poor planning and execution of technique in ASD. Poor
planningandperformanceincreaseratesofpseudarthrosisandsurgical-siteinfection.
Theuseofrh-BMP2withoutinformedconsentfromthepatientisill-advised.
Inadequatedebridementofpseudarthrosistissueincreasesthelikelihoodofrecurrentpseudarthrosis.
Prophylacticantibioticsmustbeadministeredwithin1hourofincision.Cefazolinshouldbegivenevery4hours
duringsurgery.
Poorlycontrolledpostoperativebloodglucoselevelsincreasetheriskofinfection.
References
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