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Avoiding PICU admission following PSF for neuromuscular scoliosis in non-ambulatory cerebral palsy managed with ERAS protocol

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Abstract

Purpose

Children with neuromuscular scoliosis (NMS) undergoing posterior spinal fusion (PSF) have historically been managed post-operatively in the pediatric intensive care unit (PICU) due to institutional tendencies. This study sought to define risk factors for PICU admission when using an enhanced recovery after surgery (ERAS) pathway.

Methods

A retrospective review of children with non-ambulatory (GMFCS 4 or 5) cerebral palsy undergoing PSF for NMS performed at two institutions by 5 surgeons. Both institutions have a pre-existing ERAS pathway for NMS patients consisting of post-surgical transfer to the hospital floor with early reinstitution of feeding and mobilization. PICU admission is used at the discretion of the surgeon and anesthesiologist rather than by institutional decree. Patient and surgical factors were assessed for risk factors of PICU admission.

Results

A total of 103 children were included (84% GMFCS 5, mean 14.52 years (± 3.4 years)). Forty children (38.8%) required postoperative PICU admission. PICU admission was associated with seizure disorder (P = 0.09), pre-existing feeding tube (P = 0.003), tracheostomy (P = 0.03), and modified GMFCS-5 subclassification (P = 0.003). Independent predictors of PICU admission include pre-existing feeding (Odd’s ratio = 2.9, P = 0.02) and length of surgery (Odd’s ratio = 2.6, P < 0.001), with surgery lasting ≥ 5.0 h having an 82.5% sensitivity and 63.5% specificity (AUC 0.8, P < 0.001) for post-operative PICU admission.

Conclusion

The majority of children with non-ambulatory cerebral palsy can be successfully managed on the hospital floor following PSF. The extent of central neuromotor impairment is significantly associated with PICU admission along with surgery lasting longer than 5 h.

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Data availability

Data is maintained by the authors and available pending institutional review and approval.

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Funding

No funding was received for the completion of this project.

Author information

Authors and Affiliations

  1. Department of Pediatric Orthopaedic Surgery, Scottish Rite for Children, Dallas, TX, USA

    K. Aaron Shaw

  2. Department of Orthopaedic Surgery, Children’s Healthcare of Atlanta, Atlanta, GA, USA

    Hilary Harris & Numera Sachwani

  3. Department of Pediatric Orthopaedic Surgery, Children’s Healthcare of Atlanta, Atlanta, GA, USA

    Tracy Ruska & Joshua S. Murphy

  4. Department of Pediatric Surgery, Children’s Healthcare of Atlanta at Emory University, Atlanta, GA, USA

    Nicholas D. Fletcher

Authors
  1. K. Aaron Shaw
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  2. Hilary Harris
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  3. Numera Sachwani
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  4. Tracy Ruska
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  5. Joshua S. Murphy
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  6. Nicholas D. Fletcher
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Contributions

KAS: study design, data analysis, data interpretation, manuscript drafting, manuscript approval, accountable. HH: study design, data analysis, data interpretation, manuscript approval, accountable. NS, TR: study design, data analysis, manuscript editing, manuscript approval, accountable. JSM: study design, data interpretation, manuscript editing, manuscript approval, accountable. NDF: study design, data analysis, manuscript editing, manuscript approval, accountable.

Corresponding author

Correspondence to Nicholas D. Fletcher.

Ethics declarations

Conflict of interest

Dr. Shaw is a committee member for NASS and AAOS; Ms Harris, Sachwani, and Ruska report nothing to disclose; Dr. Murphy reports receiving stock options from Alphatec Spine, is a consultant for Depuy and Orthopediatrics, receives research support from Epic Industries and Orthopediatrics, and is a committee member for POSNA and editorial member for Journal of Pediatric Orthopaedics and Journal of Spine Deformity; Dr. Fletcher reports is a consultant for Medtronic, is a speaker for Medrtonic, Nuvasive, Orthopediatrics, and Zimmer, and is a committee member for SRS and POSNA and an editorial member for JPOSNA.

Ethical approval

Approved by CHOA IRB: 14-030.

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Not applicable.

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Shaw, K.A., Harris, H., Sachwani, N. et al. Avoiding PICU admission following PSF for neuromuscular scoliosis in non-ambulatory cerebral palsy managed with ERAS protocol. Spine Deform 11, 671–676 (2023). https://doi.org/10.1007/s43390-022-00635-0

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  • DOI: https://doi.org/10.1007/s43390-022-00635-0

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