Risk Estimates of Five Adverse Outcomes Following Hip and Spine Surgery Among Children with Cerebral Palsy to Inform Peri-operative Care.

BACKGROUND: Children with cerebral palsy (CP) are vulnerable to post-operative adverse outcomes following orthopaedic surgery; yet clinically usable risk estimates of these outcomes remain underreported. The number of anti-seizure medications (ASMs) may capture a child's underlying medical complexity, thus serving as a simple, easily attainable measure for risk stratification. The objective of this study was to generate post-operative risk estimates of five adverse outcomes based on the number of ASMs among children with CP undergoing hip or spine surgery.

METHODS: Using the IBM® MarketScan® Multi-State Medicaid and Commercial Databases, this retrospective cohort study accessed patient-level claims from 01/01/2009-12/31/2022 for children with CP aged 3-21 years old who underwent hip or spine surgery. The count of unique ASM prescriptions was identified during the 2-year, pre-operative period. Using logistic regression, the age- and sex-adjusted risk of 1-week respiratory failure or pulmonary collapse (RF/PC), 1-month pneumonia, 3-month surgical site infection (SSI), 3-month systemic inflammatory response syndrome (SIRS), and 6-month fracture was estimated based on exposure to 0 ASMs, 1-2 unique ASMs, or ≥3 unique ASMs during the 2-year, pre-operative period.

RESULTS: Of n = 2,378 children with CP who underwent hip surgery (mean age[SD] = 9.4[4.0] years old) and n = 2,216 who underwent spine surgery (mean age[SD] = 13.5[3.4] years old), 6.1% and 29.3% developed RF/PC, 2.9% and 5.6% developed pneumonia, 5.6% and 12.4% developed SSI, 1.4% and 5.4% developed SIRS, and 8.5% and 4.4% sustained a fracture, respectively, during each outcome's follow-up period. The age- and sex-adjusted post-operative risk estimates of each adverse outcome for each surgical cohort are reported based on ASMs. In general, having greater than or equal to 3 ASMs prescribed places you at greater risk for developing a post-operative adverse outcome.

CONCLUSIONS: This study generated clinically relevant risk estimates of adverse post-operative outcomes based on 2-year pre-operative ASMs for children with CP undergoing hip or spine surgery. This information can be used to support shared decision-making, optimize health status pre-operatively, plan for peri-operative care, and develop preventive strategies.

KEY CONCEPTS: (1)Children with cerebral palsy (CP) undergoing hip or spine surgery are at heightened risk for post-operative medical complications beyond orthopaedic issues, including pneumonia, surgical site infections, fractures, systemic inflammatory response syndrome, and respiratory failure.(2)Multidisciplinary preoperative optimization programs and standardized clinical pathways have been implemented to reduce the risk of post-operative complications in children with CP, yet clinical tools to assess individualized risk remain limited.(3)Administrative claims data provide a potential avenue for generating post-operative risk estimates by leveraging variables that serve as proxies for medical complexity, such as the number of unique anti-seizure medications (ASMs) prescribed.(4)The severity of seizure disorders, as reflected by ASM prescriptions, is closely associated with motor dysfunction and comorbidity complexity, making it a useful predictor of adverse post-operative outcomes in children with CP.(5)This study generated clinically meaningful risk estimates for post-operative complications among children with CP undergoing hip or spine surgery based on pre-operative ASM usage, informing decision-making and peri-operative care planning.

LEVEL OF EVIDENCE: Level II: Retrospective cohort study.