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Surgical Risk Stratification Based on Preoperative Risk Factors in Severe Pediatric Spinal Deformity Surgery


Study design

Retrospective review.


The purpose of this study is to review the postoperative complications in pediatric patients undergoing spine surgery and to establish a preoperative classification that stratifies surgical risk and case difficulty.

Summary of Background Data

Pediatric spinal deformity (PSD) surgery can be challenging technically as well as economically. Often, a multidisciplinary approach to managing these patients is necessary. In an environment where resources are limited, such as in global outreach efforts, a method for stratifying PSD surgical cases can be useful for allocating appropriate resources and assigning appropriate skill sets in order to optimize patient outcomes and to streamline efforts.

Materials and Methods

A total of 145 consecutive PSD patients who underwent instrumented spinal fusion were reviewed. Radiographic measurements and demographic data were reviewed. A classification was established based on the curve magnitude, etiology, ASA grade, number of levels fused, the preoperative neurologic status, body mass index and type of osteotomies. Multiple regression analysis (MRA) and logistic regression analysis (LRA) were applied to indicate risk factors for complications.


The average age was 14.3 years (10—20 years). The etiology was idiopathic scoliosis (n = 71), congenital scoliosis (n = 38), infectious (n = 11), and others. 23 patients had neurologic deficits preoperatively. Twenty-three patients had a posterior vertebral column resection. Patients were classified as Level 1 (n = 5), Level 2 (n = 19), Level 3 (n = 24), Level 4 (n = 58), and Level 5 (n = 39). Intraoperative neuro-monitoring changes were observed in 46 cases. Major complications were seen in 45 cases. A major complication consisted of implant related (n = 13), deep wound infection (n = 8), neurologic deficit (n = 7), death (n = 2), and others (n = 9). MRA demonstrated a significant correlation between classified level and %EBL/TBV, operative time, and complication rate. The risk level predicted the occurrence of general (odds ratio [OR] = 1.54; 95% confidence interval [CI] = 1.08—2.21; p =.019) and neurologic (OR = 3.34; 95% CI = 1.06—17.70; p =.036) complications. Osteotomy and resection procedures were independent predictors for postoperative neurologic complications (OR = 1.7, 95% CI = 1.11-2.85; p =.015).


Corrective spine surgery for complex pediatric deformity is challenging and carries a substantial risk. No single parameter appears to independently predict postoperative complications. However, when all risk factors are considered, there is a trend toward increased intraoperative electromonitoring change and postoperative neurologic risk with the higher level score in our classification. The newly established surgical risk stratification based on patient-specific clinical and radiographic factors can guide surgeons in their preoperative planning and surgical management of severe spine deformity in order to achieve optimal outcomes.

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Author information

Correspondence to Oheneba Boachie-Adjei MD.

Additional information

Author disclosures: OBA (grants, personal fees, nonfinancial support, and other from K2M; nonfinancial support and other from DePuy Spine; grants from Medtronic; grants, personal fees and other from Baxano (Trans 1), outside the submitted work; a patent K2M with royalties paid and serves on the board of scientific advisors for K2M); MY (nonfinancial support from K2M Inc, grants from Surgical Spine Inc, other from Depuy Synthes Inc, outside the submitted work); CSD (none); HJK (none); HA (none); MEC (none); MG (none); WFH (K2M, outside the submitted work); BSL (grants from Setting Scoliosis Straight Foundation, grants from AO Spine, grants from John and Marcella Fox Fund, grants from OREF, personal fees and other from DePuy Spine, personal fees from K2M, other from Spine Search, other from Paradigm Spine, outside the submitted work); JA(none); EP (none); FSPG (none); FP (none); KJP (Complex Spine Study Group, outside the submitted work).

This study was approved by the Institutional Review Board of the hospital.

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Boachie-Adjei, O., Yagi, M., Sacramento-Dominguez, C. et al. Surgical Risk Stratification Based on Preoperative Risk Factors in Severe Pediatric Spinal Deformity Surgery. Spine Deform 2, 340–349 (2014). https://doi.org/10.1016/j.jspd.2014.05.004

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  • Scoliosis
  • Deformity
  • Congenital scoliosis
  • Idiopathic scoliosis
  • Complication