Spine - 2026-08-15 - Journal Article; Multicenter Study
In Adolescent Idiopathic Scoliosis, Do All Instrument-Related Complications Require Revision Surgery?
Plachta SM, Samdani AF, Pahys JM, Davuluri S, Yang MJ, Shah SA, Miyanji F, Newton PO, Hwang SW, Harms Study Group
Topics
Key Takeaway
Among 141 AIS patients with instrumentation-related complications, 54% were managed conservatively with comparable 5-year SRS-22 scores to revision surgery patients, except in the broken instrumentation subgroup where revision produced significantly higher domain scores.
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Summary
This multicenter retrospective cohort evaluated operative versus conservative management of instrumentation-related complications in AIS patients, categorizing complications as broken instrumentation, loss of fixation, prominence, or other. Of 141 patients with complications (2.7% incidence), 68 underwent revision and 77 were managed conservatively. Five-year SRS-22 scores were equivalent between groups overall, but broken instrumentation patients who underwent revision showed significantly higher domain scores (P<0.05); loss of fixation patients showed no significant radiographic or PROM differences between treatment strategies despite higher BMI, more lumbar curves, and greater pseudarthrosis rates in the revision subgroup.
Key Limitation
Non-randomized treatment allocation means sicker, more symptomatic patients selectively received revision surgery, confounding any direct outcome comparison between conservative and operative groups.
Original Abstract
STUDY DESIGN
Retrospective cohort study using a multicenter prospectively collected database.
OBJECTIVE
To evaluate outcomes of operative versus conservative management of instrumentation-related complications.
BACKGROUND
Instrumentation-related complications following AIS surgery are well described, yet limited literature exists comparing outcomes between patients treated with revision surgery and those managed conservatively.
MATERIALS AND METHODS
AIS patients with instrumentation-related complications were grouped as having broken instrumentation (BRK), loss of fixation (LOF), prominence (PRO), or other. Patients were grouped by treatment strategy: revision surgery (RS) versus conservative (nonoperative) treatment (CT).
RESULTS
Of 5144 AIS patients, 141 (2.7%) developed 148 instrumentation-related complications, with 68 (46%) undergoing revision. More than half (n=77) were managed conservatively. Pain was a strong predictor of revision in both BRK and LOF cohorts ( P <0.01). At five-year follow-up, SRS-22 scores were comparable between CT and RS groups, except for the BRK-RS subgroup, which had significantly higher domain scores ( P <0.05) except for satisfaction. These scores were collected at standardized intervals and may reflect different clinical trajectories: recovery in revision patients and stability in those treated conservatively. However, among patients with BRK complications, RS patients showed improved outcomes, suggesting that symptom severity may drive treatment. In the LOF group, RS patients had higher BMI, more lumbar curves, and greater pseudarthrosis incidence (all P <0.05), yet no significant radiographic or PROM differences were observed between the RS and CT groups at follow-up. The timing of complications varied widely (mean: 21.5 mo postoperatively, SD: ±22.6 mo).
CONCLUSION
In this multicenter cohort, many patients with instrumentation-related complications were successfully managed conservatively (CT), especially those without significant symptoms. Long-term PROMs (SRS-22) were comparable between groups (CT and RS), supporting a symptom guided, individualized approach to management. Revision surgery remains appropriate for symptomatic patients, and observation may be a safe and appropriate option in select asymptomatic individuals.
LEVEL OF EVIDENCE
Level III.