Outcome of pediatric patients with severe restrictive lung disease following reconstructive spine surgery.

STUDY
DESIGN: Retrospective chart review.
OBJECTIVES: To assess outcome and complications in pediatric patients with a vital capacity < or =45% of predicted who underwent reconstructive spine surgery for severe thoracic scoliosis. SUMMARY OF BACKGROUND DATA: Despite the known sequelae of untreated spine deformity, pediatric patients with severe restrictive lung disease are frequently not considered good operative candidates for surgical treatment on the basis of their underlying lung disease. Only a few reports have examined surgical treatment in this population.
METHODS: A retrospective chart review was conducted on 21 pediatric patients with restrictive lung disease (average age 11.5 years, range 2-21 years). Eighteen patients completed pulmonary function testing, all with vital capacity < or =45%. The remaining three patients had clinical features of restrictive lung disease but could not perform pulmonary function testing. Eighteen patients underwent combined anterior and posterior spinal fusions. Before surgery, all patients were seen by the pulmonary, cardiology, pediatric, and anesthesia services, as well as neurology and gastroenterology services if indicated. Outcome variables examined were as follows: 1) days on oxygen, 2) need for tracheostomy, 3) days on ventilatory support, 4) mortality rate, 5) pulmonary complications, 6) blood loss, 7) other complications relative to the surgical procedure, and 8) length of stay.
RESULTS: For the 21 patients, the preoperative average vital capacity was 32% predicted (range 18-43%). After surgery, the median time on supplemental oxygen was 3 days (range 0-90 days). Only one patient with a vital capacity of 29%, who was successfully extubated on postoperative day 4, developed a deep wound infection, which required incision and drainage, as well as recurrent right lung collapse, and subsequently required a tracheostomy to facilitate ventilator weaning. Four patients were on assisted ventilation before the surgery and continued to require it after surgery. Two additional patients required noninvasive positive pressure ventilation for a short period of time following the surgery. Pneumonia occurred in two patients, and pleural effusion occurred in two patients. Four patients developed postoperative atelectasis. There was one reoperation for implant failure. There were no mortalities or adverse neurologic outcomes. Major thoracic scoliosis measured an average of 82 degrees (range 40-140 degrees) before surgery, with correction to an average of 35 degrees (range 6-75 degrees).
CONCLUSIONS: Reconstructive spine surgery in pediatric patients with severe restrictive lung disease and significant spinal deformity is well tolerated. Familiarity with different surgical techniques of salvage reconstruction and perioperative multidisciplinary management should be emphasized. Routine preoperative tracheostomy is not indicated.