Pre-operative zoledronate is safe for children with medical complexity undergoing posterior spinal fusion for neuromuscular scoliosis.

purposeDespite evidence for the safety and efficacy of zoledronate infusions in pediatric conditions (e.g., osteogenesis imperfecta), its tolerance, safety, and efficacy in medically complex children with neuromuscular scoliosis have not been established. The aim of this study was to determine adverse events associated with pre-operative zoledronate therapy in this patient population.

methodsA retrospective review was conducted of patients who had undergone pre-operative zoledronate infusions as part of pre-operative optimization at a single tertiary pediatric referral center. The protocol included three infusions with an initial 0.0125 mg/kg dose, a 0.0375 mg/kg dose at 6 weeks, and a 0.05-mg/kg dose at 6 months. Surgery was scheduled no sooner than 6 weeks after infusion.

results47 patients received at least one pre-operative zoledronate infusion, with 66% receiving three infusions of zoledronate. The most common neuromuscular conditions were cerebral palsy (57%), epileptic encephalopathy (12.8%) and Rett syndrome (10.6%). Six minor adverse events were noted, including 2 episodes of post-infusion hypocalcemia, 2 of self-limited flu-like symptoms, 1 of nephrolithiasis, and 1 of unspecified hypotension which resolved after oral fluids. There were no events requiring hospital admission or emergency department presentation related to zoledronate infusions.

conclusionNo major events were noted after pre-operative zoledronate infusions. The minor adverse events noted were self-resolving or resolved with minimal intervention. Zoledronate infusion can safely be included as part of a pre-operative optimization pathway in medically complex patients with neuromuscular scoliosis. Further research is required to optimize patient selection, infusion dose and schedule, impact on screw pull-out, and long-term complications. LEVEL OF EVIDENCE: Level IV.