title: Apex of deformity for three-column osteotomy. Does it matter in the occurrence of complications?
abstract: BACKGROUND
  Posterior vertebral column resection (PVCR) is a challenging but effective technique for the correction of complex spinal deformity. However, it has a high complication rate and carries a substantial risk for neurologic injury.
  
  
  OBJECTIVE
  The aim was to test whether the apex of the deformity influences the clinical outcomes and complications in patients undergoing PVCR.
  
  
  METHODS
  A historical cohort was recruited from a single center and evaluated preoperatively, postoperatively, and at final follow-up.
  
  
  METHODS
  Ninety-eight hyperkyphotic patients undergoing PVCR were included. Inclusion criteria consisted of kyphoscoliosis and hyperkyphosis surgically treated with PVCR as a primary or revision procedure.
  
  
  METHODS
  The outcome measures included a number of neurologic complications.
  
  
  METHODS
  Receiver operator characteristic (ROC) curve analysis and Youden index (J) were used to estimate the optimum cut-off to predict neurologic complications for each potential risk factor. In three ROC analyses, we included separately body mass index (BMI), kyphosis degree, and age as independent variables and neurologic complications as the dependent variable. Logistic regression was used to estimate the odds ratios (ORs) and construct 95% confidence intervals (CIs).
  
  
  RESULTS
  Among the 98 patients, the etiologies were: post infectious (50), congenital (31), and others (17). The averages were: age 14±6.5 years, BMI 20±10 kg/m(2), American Society of Anesthesiologists 3±0.7, forced vital capacity 76±23%, fusion levels 10±3, estimated blood loss 1,319±720 mL, surgical time 375±101 minutes, and preoperative localized kyphosis 104±30°. Thirty-three patients had abnormal preoperative neurologic status. Major complications occurred in 46 patients (neurologic in 25). The apex of kyphosis was proximal thoracic T1-T5 (five patients), thoracic (TH) T6-T9 (17 patients), thoracolumbar T10-L2 (55 patients), and lumbar L3-S1 (nine patients). The level of apex and BMI were independent risk factors for neurologic complications: TH apex (OR: 101.30, 95% CI: 1.420-infinite; p=.037); BMI (OR: 1.92, 95% CI: 1.110-infinite; p=.026).
  
  
  CONCLUSIONS
  Posterior vertebral column resection for severe spine deformity is technically demanding and carries a substantial risk. The apex is a variable that influences the occurrence of neurologic complications, and the presence of a TH apex in particular could be a preoperative risk factor for neurologic complications.
authors.affiliation: Unidad de Patología Vertebral, Hospital Ruber Internacional, C/La Masó, 38 Mirasierra, 28034, Madrid, Spain. Electronic address: cristisacra@yahoo.es.
authors.forename: Cristina
authors.initials: C
authors.lastname: Sacramento-Domínguez
authors.affiliation: Department of Orthopaedic Surgery, National Hospital Organization Murayama Medical Center, Tokyo, Japan.
authors.forename: Mitsuru
authors.initials: M
authors.lastname: Yagi
authors.affiliation: FOCOS Orthopedic Hospital, Pantang, Accra, Ghana.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Ayamga
authors.affiliation: Scoliosis Service, Hospital for Special Surgery, New York, NY, USA.
authors.forename: Venu M
authors.initials: VM
authors.lastname: Nemani
authors.affiliation: FOCOS Orthopedic Hospital, Pantang, Accra, Ghana.
authors.forename: Harry
authors.initials: H
authors.lastname: Akoto
authors.affiliation: FOCOS Orthopedic Hospital, Pantang, Accra, Ghana.
authors.forename: Rufai
authors.initials: R
authors.lastname: Mahmud
authors.affiliation: FOCOS Orthopedic Hospital, Pantang, Accra, Ghana.
authors.forename: Irene A
authors.initials: IA
authors.lastname: Wulff
authors.affiliation: Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, California, USA.
authors.forename: Munish
authors.initials: M
authors.lastname: Gupta
authors.affiliation: Orthopaedic Clinic, University of Athens, Athens, Greece.
authors.forename: Elias C
authors.initials: EC
authors.lastname: Papadopoulos
authors.affiliation: Spine Unit, Servicio de COT, Hospital Vall d'Hebron, Barcelona, Spain.
authors.forename: Ferran
authors.initials: F
authors.lastname: Pellisé
authors.affiliation: Spine Unit, Department of Orthopedic Surgery, Hospital La Paz, Madrid, Spain.
authors.forename: Francisco
authors.initials: F
authors.lastname: Sánchez-Pérez-Grueso
authors.affiliation: Department of Orthopaedics, Geisinger Medical Center, Danville, Pennsylvania, USA.
authors.forename: William F
authors.initials: WF
authors.lastname: Hess
authors.affiliation: Scoliosis Service, Hospital for Special Surgery, New York, NY, USA.
authors.forename: Han Jo
authors.initials: HJ
authors.lastname: Kim
authors.affiliation: American Jewish Joint Distribution Committee, Inc., Bole, Addis Ababa, Ethiopia.
authors.forename: Richard
authors.initials: R
authors.lastname: Hodes
authors.affiliation: FOCOS Orthopedic Hospital, Pantang, Accra, Ghana.
authors.forename: Oheneba
authors.initials: O
authors.lastname: Boachie-Adjei
mesh_terms: D000293:Adolescent; D002648:Child; D005260:Female; D006801:Humans; D007738:Kyphosis / Q000473:pathology / Q000601:surgery*; D008297:Male; D010027:Osteotomy / Q000009:adverse effects* / Q000379:methods; D011183:Postoperative Complications; D013119:Spinal Cord Injuries / Q000209:etiology*
keywords: Kyphoscoliosis; Kyphosis; Neurologic complications; Pediatric deformity; Vertebral column resection osteotomy